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In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients., Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis., Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3)., Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

Purpose: The effects of the route of nutrition on the gut mucosa of patients with shock are unclear. Plasma citrulline concentration is a marker of enterocyte mass, and plasma intestinal fatty acid binding protein (I-FABP) concentration is a marker of enterocyte damage. We aimed to study the effect of the route of nutrition on plasma citrulline concentration measured at day 3 of nutrition., Materials and Methods: Ancillary study of the NUTRIREA-2 trial. Ventilated adults with shock were randomly assigned to receive enteral or parenteral nutrition. Enterocyte biomarkers were measured at baseline, day 3, and day 8 of nutrition., Result: A total of 165 patients from 13 French ICUs were included in the study: 85 patients in the enteral group and 80 patients in the parenteral group. At baseline, plasma citrulline was low without difference between groups (12.2 µmol L -1 vs 13.3 µmol L -1 ). At day 3, plasma citrulline concentration was higher in the enteral group than in the parenteral group (18.7 µmol L -1 vs 15.3 µmol L -1 , p = 0.01). Plasma I-FABP concentration was increased at baseline, without difference between groups (245 pg mL -1 vs 244 pg mL -1 ). Plasma I-FABP concentration was higher in the enteral group than in the parenteral group at day 3 and day 8 (158 pg mL -1 vs 50 pg mL -1 , p = 0.005 and 225 pg mL -1 vs 50 pg mL -1 , p = 0.03)., Conclusion: Plasma citrulline concentration was higher after 3 days of enteral nutrition than after 3 days of parenteral nutrition. This result raises the question of the possibility that enteral nutrition is associated with a more rapid restoration of enterocyte mass than parenteral nutrition.

Purpose: Early active mobilisation and rehabilitation in the intensive care unit (ICU) is being used to prevent the long-term functional consequences of critical illness. This review aimed to determine the effect of active mobilisation and rehabilitation in the ICU on mortality, function, mobility, muscle strength, quality of life, days alive and out of hospital to 180 days, ICU and hospital lengths of stay, duration of mechanical ventilation and discharge destination, linking outcomes with the World Health Organization International Classification of Function Framework., Methods: A PRISMA checklist-guided systematic review and meta-analysis of randomised and controlled clinical trials., Results: Fourteen studies of varying quality including a total of 1753 patients were reviewed. Active mobilisation and rehabilitation had no impact on short- or long-term mortality (p > 0.05). Meta-analysis showed that active mobilisation and rehabilitation led to greater muscle strength (body function) at ICU discharge as measured using the Medical Research Council Sum Score (mean difference 8.62 points, 95% confidence interval (CI) 1.39-15.86), greater probability of walking without assistance (activity limitation) at hospital discharge (odds ratio 2.13, 95% CI 1.19-3.83), and more days alive and out of hospital to day 180 (participation restriction) (mean difference 9.69, 95% CI 1.7-17.66). There were no consistent effects on function, quality of life, ICU or hospital length of stay, duration of mechanical ventilation or discharge destination., Conclusion: Active mobilisation and rehabilitation in the ICU has no impact on short- and long-term mortality, but may improve mobility status, muscle strength and days alive and out of hospital to 180 days., Registration of Protocol Number: CRD42015029836.

Purpose: The objective was to compare the effectiveness of repositioning every 2 or 4 h for preventing pressure ulcer development in patients in intensive care unit under mechanical ventilation (MV)., Methods: This was a pragmatic, open-label randomized clinical trial in consecutive patients on an alternating pressure air mattress (APAM) requiring invasive MV for at least 24 h in a university hospital in Spain. Eligible participants were randomly assigned to groups for repositioning every 2 (n = 165) or 4 (n = 164) h. The primary outcome was the incidence of a pressure ulcer of at least grade II during ICU stay., Results: A pressure ulcer of at least grade II developed in 10.3% (17/165) of patients turned every 2 h versus 13.4% (22/164) of those turned every 4 h (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.46-1.71, P = 0.73). The composite end point of device-related adverse events was recorded in 47.9 versus 36.6% (HR 1.50, CI 95% 1.06-2.11, P = 0.02), unplanned extubation in 11.5 versus 6.7% (HR 1.77, 95% CI 0.84-3.75, P = 0. 13), and endotracheal tube obstruction in 36.4 versus 30.5%, respectively (HR 1.44, 95% CI 0.98-2.12, P = 0.065). The median (interquartile range) daily nursing workload for manual repositioning was 21 (14-27) versus 11 min/patient (8-15) (P < 0.001)., Conclusions: A strategy aimed at increasing repositioning frequency (2 versus 4 h) in patients under MV and on an APAM did not reduce the incidence of pressure ulcers. However, it did increase device-related adverse events and daily nursing workload.

Purpose: Placing patients with severe acute respiratory distress syndrome (ARDS) in the prone position has been shown to improve survival as compared to the supine position. However, a higher frequency of pressure ulcers has been reported in patients in the prone position. The objective of this study was to verify the impact of prone positioning on pressure ulcers in patients with severe ARDS., Methods: This was an ancillary study of a prospective multicentre randomised controlled trial in patients with severe ARDS in which the early application of long prone-positioning sessions was compared to supine positioning in terms of mortality. Pressure ulcers were assessed at the time of randomisation, 7 days later and on discharge from the intensive care unit (ICU), using the four-stage Pressure Ulcers Advisory Panel system. The primary end-point was the incidence (with reference to 1,000 days of invasive mechanical ventilation or 1,000 days of ICU stay) of new patients with pressure ulcers at stage 2 or higher from randomisation to ICU discharge., Results: At randomisation, of the 229 patients allocated to the supine position and the 237 patients allocated to the prone position, the number of patients with pressure ulcers was not significantly different between groups. The incidence of new patients with pressure ulcers from randomisation to ICU discharge was 20.80 and 14.26/1,000 days of invasive mechanical ventilation (P = 0.061) and 13.92 and 7.72/1,000 of ICU days (P = 0.002) in the prone and supine groups, respectively. Position group [odds ratio (OR) 1.5408, P = 0.0653], age >60 years (OR 1.5340, P = 0.0019), female gender (OR 0.5075, P = 0.019), body mass index of >28.4 kg/m(2) (OR 1.9804, P = 0.0037), and a Simplified Acute Physiology Score II at inclusion of >46 (OR 1.2765, P = 0.3158) were the covariates independently associated to the acquisition of pressure ulcers., Conclusion: In patients with severe ARDS, prone positioning was associated with a higher frequency of pressure ulcers than the supine position. Prone positioning improves survival in patients with severe ARDS and, therefore, survivors who received this intervention had a greater likelihood of having pressure ulcers documented as part of their follow-up. There are risk groups for the development of pressure ulcers in severe ARDS, and these patients need surveillance and active prevention.

Purpose: To assess physician decisions about ICU admission for life-sustaining treatments (LSTs)., Methods: Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV)., Results: The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13-0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10-0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04-3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23-0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively., Conclusions: Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.

Purpose: The study aimed to develop a gastrointestinal (GI) dysfunction score predicting 28-day mortality for adult patients needing mechanical ventilation (MV)., Methods: 377 adult patients from 40 ICUs with expected duration of MV for at least 6 h were prospectively studied. Predefined GI symptoms, intra-abdominal pressures (IAP), feeding details, organ dysfunction and treatment were documented on days 1, 2, 4 and 7., Results: The number of simultaneous GI symptoms was higher in nonsurvivors on each day. Absent bowel sounds and GI bleeding were the symptoms most significantly associated with mortality. None of the GI symptoms alone was an independent predictor of mortality, but gastrointestinal failure (GIF)--defined as three or more GI symptoms--on day 1 in ICU was independently associated with a threefold increased risk of mortality. During the first week in ICU, GIF occurred in 24 patients (6.4%) and was associated with higher 28-day mortality (62.5 vs. 28.9%, P = 0.001). Adding the created subscore for GI dysfunction (based on the number of GI symptoms) to SOFA score did not improve mortality prediction (day 1 AUROC 0.706 [95% CI 0.647-0.766] versus 0.703 [95% CI 0.643-0.762] in SOFA score alone)., Conclusions: An increasing number of GI symptoms independently predicts 28 day mortality with moderate accuracy. However, it was not possible to develop a GI dysfunction score, improving the performance of the SOFA score either due to data set limitations, definition problems, or possibly indicating that GI dysfunction is often secondary and not the primary cause of other organ failure.

The use of ultrasonography has become increasingly popular in the everyday management of critically ill patients. It has been demonstrated to be a safe and handy bedside tool that allows rapid hemodynamic assessment and visualization of the thoracic, abdominal and major vessels structures. More recently, M-mode ultrasonography has been used in the assessment of diaphragm kinetics. Ultrasounds provide a simple, non-invasive method of quantifying diaphragmatic movement in a variety of normal and pathological conditions. Ultrasonography can assess the characteristics of diaphragmatic movement such as amplitude, force and velocity of contraction, special patterns of motion and changes in diaphragmatic thickness during inspiration. These sonographic diaphragmatic parameters can provide valuable information in the assessment and follow up of patients with diaphragmatic weakness or paralysis, in terms of patient-ventilator interactions during controlled or assisted modalities of mechanical ventilation, and can potentially help to understand post-operative pulmonary dysfunction or weaning failure from mechanical ventilation. This article reviews the technique and the clinical applications of ultrasonography in the evaluation of diaphragmatic function in ICU patients.

Purpose: To characterize the perceived utilization of physical restraint (PR) in mechanically ventilated intensive care unit (ICU) patients and to identify clinical and structural factors influencing PR use., Methods: A questionnaire was personally handed to one intensivist in 130 ICUs in France then collected on-site 2 weeks later., Results: The questionnaire was returned by 121 ICUs (response rate, 93 %), 66 % of which were medical-surgical ICUs. Median patient-to-nurse ratio was 2.8 (2.5-3.0). In 82 % of ICUs, PR is used at least once during mechanical ventilation in more than 50 % of patients. In 65 % of ICUs, PR, when used, is applied for more than 50 % of mechanical ventilation duration. Physical restraint is often used during awakening from sedation and when agitation occurs and is less commonly used in patients receiving deep sedation or neuromuscular blockers or having severe tetraparesis. In 29 % of ICUs, PR is used in more than 50 % of awake, calm and co-operative patients. PR is started without written medical order in more than 50 % of patients in 68 % of ICUs, and removed without written medical order in more than 50 % of patients in 77 % of ICUs. Only 21 % of ICUs have a written local procedure for PR use., Conclusions: This survey in a country with a relatively high patient-to-nurse ratio shows that PR is frequently used in patients receiving mechanical ventilation, with wide variations according to patient condition. The common absence of medical orders for starting or removing PR indicates that these decisions are mostly made by the nurses.

Purpose: This systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume., Methods: A systematic search strategy was used to identify studies reporting on volume-outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms., Results: A total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies., Conclusions: The results indicate that outcomes of certain subsets of ICU patients--especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis--are better in high volume centres within the constraints of risk adjustments.

Objective: To compare the effects of increasing the limit for gastric residual volume (GRV) in the adequacy of enteral nutrition. Frequency of gastrointestinal complications and outcome variables were secondary goals., Design: An open, prospective, randomized study., Setting: Twenty-eight intensive care units in Spain., Patients: Three hundred twenty-nine intubated and mechanically ventilated adult patients with enteral nutrition (EN)., Interventions: EN was administered by nasogastric tube. A protocol for management of EN-related gastrointestinal complications was used. Patients were randomized to be included in a control (GRV = 200 ml) or in study group (GRV = 500 ml)., Measurements and Results: Diet volume ratio (diet received/diet prescribed), incidence of gastrointestinal complications, ICU-acquired pneumonia, days on mechanical ventilation and ICU length of stay were the study variables. Gastrointestinal complications were higher in the control group (63.6 vs. 47.8%, P = 0.004), but the only difference was in the frequency of high GRV (42.4 vs. 26.8%, P = 0.003). The diet volume ratio was higher for the study group only during the 1st week (84.48 vs. 88.20%) (P = 0.0002). Volume ratio was similar for both groups in weeks 3 and 4. Duration of mechanical ventilation, ICU length of stay or frequency of pneumonia were similar., Conclusions: Diet volume ratio of mechanically ventilated patients treated with enteral nutrition is not affected by increasing the limit in GRV. A limit of 500 ml is not associated with adverse effects in gastrointestinal complications or in outcome variables. A value of 500 ml can be equally recommended as a normal limit for GRV.

Purpose: Neuromuscular abnormalities are common in ICU patients. We aimed to assess the incidence of clinically diagnosed ICU-acquired paresis (ICUAP) and its impact on outcome., Methods: Forty-two patients with systemic inflammatory response syndrome on mechanical ventilation for >or=48 h were prospectively studied. Diagnosis of ICUAP was defined as symmetric limb muscle weakness in at least two muscle groups at ICU discharge without other explanation. The threshold Medical Research Council (MRC) Score was set at 35 (of 50) points. Activities in daily living were scored using the Barthel Index 28 and 180 days after ICU discharge., Results: Three patients died before sedation was stopped. ICUAP was diagnosed in 13 of the 39 patients (33%). Multivariate regression analysis yielded five ICUAP-predicting variables (P < 0.05): SAPS II at ICU admission, treatment with steroids, muscle relaxants or norepinephrine, and days with sepsis. Patients with ICUAP had lower admission SAPS II scores [37 +/- 13 vs. 49 +/- 15 (P = 0.018)], lower Barthel Index at 28 days and lower survival at 180 days after ICU discharge (38 vs. 77%, P = 0.033) than patients without ICUAP. Daily TISS-28 scores were similar but cumulative TISS-28 scores were higher in patients with ICUAP (664 +/- 275) than in patients without ICUAP (417 +/- 236; P = 0.008). The only independent risk factor for death before day 180 was the presence of ICUAP., Conclusions: A clinical diagnosis of ICUAP was frequently established in this patient group. Despite lower SAPS II scores, these patients needed more resources and had high mortality and prolonged recovery periods after ICU discharge.

Background: Respiratory intensive care units (RICU) dedicated to weaning could be suitable facilities for clinical management of "post-ICU" patients., Methods: We retrospectively analyzed the time course of patients' characteristics, clinical outcomes and medical staff utilization in five Italian RICUs by comparing three periods of 5 consecutive years (from 1991 to 2005)., Results: A total of 3,106 patients (age 76 +/- 4 years; 72% males) were analyzed. The number of co-morbidities per patient (from 1.8 to 3.0, p = 0.05) and the previous intensive care unit (ICU) stay (from 25 to 32 days, p = 0.002) increased over time. The doctor-to-patient ratio significantly decreased over time (from 1:3 to 1:5, p < 0.01), whereas the physiotherapist-to-patient ratio mildly increased (from 1:6 to 1:4.5, p < 0.05). The overall weaning success rate decreased (from 87 to 66%, p < 0.001), and the discharge destination changed (p < 0.001) over time; fewer patients were discharged to home (from 22 to 10%), and more patients to nursing home (from 3 to 6%), acute hospitals (from 6 to 10%) and rehabilitative units (from 70 to 75%). The mortality rate increased over time (from 9 to 15%). Significant correlations between the doctor-to-patient ratio and the rates of weaning success (r = 0.679, p = 0.005), home discharge (r = 0.722, p = 0.002) and the RICU length of stay (LOS) (r = -0.683, p = 0.005) were observed., Conclusions: The clinical outcomes of our units worsened over 15 years, likely as consequence of admitting more severely ill patients. The potential further negative influence of reduced medical staff availability on weaning success, home discharge and LOS warrants future prospective investigations.

Background: A considerable number of patients admitted to the intensive care unit (ICU) die following withdrawal of mechanical ventilation. After discontinuation of ventilation without proper preparation, excessive respiratory secretion is common, resulting in a 'death rattle'. Post-extubation stridor can give rise to the relatives' perception that the patient is choking and suffering. Existing protocols lack adequate anticipatory preparation to respond to all distressing symptoms., Methods: We analyzed existing treatment strategies in distressing symptoms after discontinuation of mechanical ventilation., Conclusion: The actual period of discontinuation of mechanical ventilation can be very short, but thoughtful anticipation of distressing symptoms takes time. There is an ethical responsibility to anticipate and treat (iatrogenic) symptoms such as pain, dyspnea-associated respiratory distress, anxiety, delirium, post-extubation stridor, and excessive broncho-pulmonary secretions. This makes withdrawal of mechanical ventilation in ICU patients a thoughtful process, taking palliative actions instead of fast terminal actions. We developed a flowchart covering all possible distressing symptoms that can occur after withdrawal of mechanical ventilation and extubation. We recommend a two-phase process. Six hours before extubation, enteral feeding should be stopped and parenteral fluids reduced, overhydrated patients should be dehydrated with furosemide, administration of sedatives (for distress) and opioids (for pain and/or dyspnea) should be continued or started and methylprednisolone should be given in anticipation of stridor after extubation. Thirty minutes before extubation, Butylscopolamine should be given and methylprednisolone repeated. After this the patient should be extubated to secure a dying process as natural as possible with the lowest burden due to distress.

Objective: Mechanically ventilated patients in the intensive care unit cannot cooperate to perform the Valsalva maneuver during echocardiography for detection of patent foramen ovale. We evaluated the effectiveness of the end-inspiratory occlusion maneuver to enhance detection of patent foramen ovale in this patient population., Design: Prospective interventional study., Setting: The 40-bed intensive care unit of a university hospital., Patients and Participants: Twenty five sedated and mechanically ventilated intensive care unit patients referred by their attending physician for bedside transesophageal echocardiography and agitated saline contrast study for detection of patent foramen ovale., Intervention: Agitated saline contrast study with end-inspiratory occlusion maneuver., Measurements and Results: All patients underwent a complete transesophageal echocardiographic study without any complications. Reduction in right atrial cross-sectional area (from 15.80 +/- 6.08 cm2 to 12.40 +/- 4.63 cm2; p < 0.001) and interatrial septum deviation during the maneuver were recorded in all patients. Microbubbles imaged in the left atrium within three cardiac cycles after injection of agitated saline diagnosed patent foramen ovale in three patients. When end-inspiratory occlusion maneuver was added, patent foramen ovale was diagnosed in seven patients (McNemar chi2 = 9.33, p = 0.0023)., Conclusions: The end-inspiratory occlusion maneuver enhances the sensitivity of transesophageal echocardiography with agitated saline contrast study for diagnosing intermittent patent foramen ovale in critically ill mechanically ventilated patients.

Objective: To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU., Design and Setting: The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit., Patients: Adult mechanically ventilated patients were selected consecutively (n=322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group., Intervention: An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy., Measurements and Results: The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P=0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P=0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used., Conclusions: The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.

Objective: To investigate the relationship between memory and intensive care sedation., Design and Setting: Prospective cohort study over 18[Symbol: see text]months in two general intensive care units (ICUs) in district university hospitals., Patients: 313 intubated mechanically ventilated adults admitted for more than 24 h, 250 of whom completed the study., Measurements: Patients (n=250) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool. Patient characteristics, doses of sedative and analgesic agents, and sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview., Results: Patients with no recall (18%) were significantly older, had higher baseline severity of illness, and experienced fewer periods of wakefulness (median proportion of MAAS score 3; 0.37 vs. 0.70) than those who had memories of the ICU (82%). Multivariate analyses showed that increasing proportion of MAAS 0-2 and older age were significantly associated with having no recall. Patients with delusional memories (34%) had significantly longer ICU stay (median 6.6 vs. 2.2 days), higher baseline severity of illness, higher proportions of MAAS scores 4-6, and more administration of midazolam than those with recall of the ICU without delusional memories., Conclusions: Heavy sedation increases the risk of having no recall, and longer ICU stay increases the risk of delusional memories. The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU.

Objective: To evaluate a blind 'active' technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus., Design and Setting: An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital., Patients: 20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route., Interventions: Previously described insertion technique-the Corpak 10-10-10 protocol-for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening., Measurements and Results: A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3-55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage., Conclusions: The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.

Objective: Bispectral index (BIS) is being evaluated as a monitor of consciousness, yet it is unclear what components of consciousness (i.e., arousal vs. content of consciousness) the BIS measures. This study compared BIS levels to well-validated clinical measures of arousal and the presence or absence of delirium., Design: A prospective, blinded, observational cohort study., Patients: 124 mechanically ventilated, adult, medical ICU patients., Measurements and Results: Using BIS 3.4 and BIS-XP 4.0 algorithms, BIS values were calculated immediately prior to clinical assessments. The clinical assessments included the Richmond Agitation-Sedation Scale (RASS) and presence or absence of delirium using the Confusion Assessment Method for the ICU. A total of 484 assessments were collected among 124 patients. BIS-XP values demonstrated greater correlation with RASS than BIS 3.4 ( R(2)=0.36 vs. 0.20), although considerable overlap of BIS-XP scores remained across RASS levels. Median BIS-XP values for delirious and nondelirious observations were 74 and 96, respectively, while BIS 3.4 values were 91 and 96, respectively. However, neither BIS 3.4 nor BIS-XP were significantly associated with delirium after controlling for RASS value., Conclusions: In comparison with clinical measures of arousal in mechanically ventilated patients, BIS-XP algorithm demonstrated stronger correlation with RASS levels than did BIS 3.4, yet marked overlap across different levels of arousal persist using both algorithms. After controlling for level of arousal, neither BIS-XP nor BIS 3.4 algorithms distinguished between the presence and absence of delirium.

Abnormalities of sleep are extremely common in critically ill patients, but the mechanisms are poorly understood. About half of total sleep time occurs during the daytime, and circadian rhythm is markedly diminished or lost. Judgments based on inspection consistently overestimate sleep time and do not detect sleep disruption. Accordingly, reliable polygraphic recordings are needed to measure sleep quantity and quality in critically ill patients. Critically ill patients exhibit more frequent arousals and awakenings than is normal, and decreases in rapid eye movement and slow wave sleep. The degree of sleep fragmentation is at least equivalent to that seen in patients with obstructive sleep apnea. About 20% of arousals and awakenings are related to noise, 10% are related to patient care activities, and the cause for the remainder is not known; severity of underlying disease is likely an important factor. Mechanical ventilation can cause sleep disruption, but the precise mechanism has not been defined. Sleep disruption can induce sympathetic activation and elevation of blood pressure, which may contribute to patient morbidity. In healthy subjects, sleep deprivation can decrease immune function and promote negative nitrogen balance. Measures to improve the quantity and quality of sleep in critically ill patients include careful attention to mode of mechanical ventilation, decreasing noise, and sedative agents (although the latter are double-edged swords).

Objective: To assess the frequency, timing, technique, and follow-up of tracheostomy for long-term ventilated patients in different intensive care units (ICUs) in The Netherlands., Design and Setting: Postal questionnaire, survey on retrospective data. A questionnaire was sent to all ( n=63) ICUs with six or more beds suitable for mechanical ventilation and officially recognized by The Netherlands Intensive Care Society. Pediatric ICUs were excluded., Measurements and Results: There was an 87% ( n=55) response rate of contacted ICUs. The number of tracheostomies per year per unit varied widely (range 1-75), most ICUs (42%) performing between 11 and 25 tracheostomies per year. In 44% of ICUs ( n=24) tracheostomy was not performed on a routine basis. In 25% of ICUs ( n=14) tracheostomies were performed during the second week of ventilation. Surgical tracheostomy and percutaneous procedures were technique of first choice in 38% and 62% of ICUs, respectively. In only 7% of units were late follow-up protocols in use. Thirty-two units (58%) reported a total of 56 major complications., Conclusions: Timing and technique of tracheostomy varies widely in Dutch ICUs. The percutaneous technique is the procedure of choice for tracheostomy in most of these units. Late follow-up protocols are rarely in use.

Objective: To understand the national utilization pattern of heat and moisture exchangers (HME) and heated humidifiers (HH) in mechanically ventilated ICU patients., Design: Cross-sectional survey., Population: ICU directors in French and Canadian university-affiliated hospitals. Response rate was 89%., Measurements: We asked respondents whether they primarily used HME or HH. We recorded whether HME were used in all patients and for how long, how often they were changed, for whom, and why they were not used., Results: HME were used more often in France HH in Canada. HME were more likely to be used for all patients in France than in Canada (63% vs. 13% and for any duration of ventilation (93% vs. 35%). Short-term use of HME was more common in Canada than in France (59% vs. 7%). HME were primarily changed every day in both countries. The patients for whom HME were not used and reasons for nonutilization were similar in France and Canada. The variable of country was the strongest predictor of HME utilization for every patient (France vs. Canada, odds ratio 11) and utilization for periods of 5 days or less (Canada vs. France, odds ratio 22)., Conclusions: HME were reportedly used more in often in France than in Canada for the entire duration of mechanical ventilation. This survey highlights perceptions and practices related to the determinants and consequences of airway humidification and suggests differences in the cost of mechanical ventilation between countries

Objective: To determine the value of the bispectral index (BIS) in assessing the depth of sedation in sedated and mechanically ventilated ICU patients, compared with clinical sedation scores., Design and Setting: Prospective convenience sample in a 12-bed anesthesiological-surgical ICU of a university hospital., Patients: 19 consecutive patients without any central neurological diseases requiring mechanical ventilation for more than 24 h., Measurements: BIS version 3.12 and clinical depth of sedation assessed by the modified Observers's Assessment of Alertness/Sedation Scale, modified Glasgow Coma Scale, modified Ramsay Scale, Cook Scale, and Sedation-Agitation Scale were measured twice daily while patients were intubated and once daily after extubation until discharged from ICU., Results: there was a moderate correlation between BIS and each sedation score in 11 patients (58%, "BIS patients") and no correlation in 8 patients (42%, "non-BIS patients"). We found no parameters distinguishing between these two groups. On average eight measurements were necessary to establish a statistical correlation. In the BIS patients the slopes of the linear regression curves showed significant differences for all BIS score combinations with increasing scattering at deeper sedation levels., Conclusions: BIS is correlated only in some ICU patients with the clinical assessment of their sedation level as based on various scores. At deeper sedation levels the interindividual differences increase. There were no criteria found to distinguish patients with and without correlation. This suggests that the BIS is not suitable for monitoring the sedation in a heterogeneous group of surgical ICU patients.

Objective: To document the changes in patterns of airway accidents in intubated patients., Design: Prospective recording of all airway accidents over two periods: 1994-1997 and 1998-1999., Patients: Ventilated patients (5,046) intubated for 9,289 days over 4 years (1994-1997) and 2,932 ventilated patients intubated for 6,339 days over 2 years (1998-1999)., Measurements: The incidence and pattern of airway accidents over a 2-year period were compared to an earlier similar analysis done in the previous 4 years., Results: The total accident rate in the 1994-1997 period was 36 in 5,046 patients over 9,289 intubated-patient days. The total accident rate in the period 1998-1999 was 20 in 2,932 patients over 6,339 intubated-patient days. The frequency of blocked tracheal tube increased to equal that of unplanned extubation (UE) of endotracheal tube (ETT) as the commonest airway accident. There were nine episodes of blocked tracheal tube in the two current years compared to four in the previous 4 years and there were nine episodes of UE in the two current years compared to 15 in the previous 4 years. There were a total of 18 ETT accidents in 2,930 patients over 5,309 ETT days compared to a total of two tracheostomy accidents in 67 patients over 1,030 tracheostomy days., Conclusions: We noted a change of the pattern of airway accidents. We noted an increasing trend in the incidence of blocked tracheal tubes, associated with an increased duration of heat and moisture exchanger-filters use. We also noted that the incidence of tracheostomy tube accidents was similar to that of ETT accidents in the current study, unlike the earlier study where tracheostomy tube accidents were more frequent than ETT accidents. This was due to the elimination of tracheostomy tube displacements during the later study period. We associated this with the use of adjustable tracheostomy length tubes.

Objectives: Invasive pulmonary aspergillosis (IPA) is increasingly recognized as a cause of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD) treated with corticosteroids. For these patients admission in intensive care unit (ICU) is often required for life-support and mechanical ventilation. Whether this approach improves outcome is unknown., Design and Setting: Retrospective study in a university hospital intensive care unit., Patients: Between November 1993 and December 1997, 23 COPD patients were admitted in our ICU and received antifungal agents for possible IPA., Interventions: None., Measurements and Results: The clinical features and the outcome were reviewed. Diagnosis of IPA was classified as confirmed (positive lung tissue biopsy and/or autopsy) or probable (repeated isolation of Aspergillus from the airways with consistent clinical and radiological findings). Among the 23 patients treated for Aspergillus, 16 fulfilling these criteria for IPA were studied. Steroids had been administered at home to all patients but one and were increased during hospitalization in all. Twelve patients suffered a worsening of their bronchospasm precipitating acute respiratory failure. During ICU stay all patients required mechanical ventilation for acute respiratory failure. Although amphotericin B deoxycholate was started when IPA was suspected (0.5-1.5 mg/kg per day), all patients died in septic shock (n = 5) or in multiple-organ failure., Conclusions: The poor prognosis of intubated COPD patients with IPA, in spite of antifungal treatment suggests that further studies are required to define the limits and indications for ICU management of these patients.

Objectives: To assess the relevance of current monitoring alarms as a warning system in the adult ICU., Design: Prospective, observational study., Settings: Two university hospital, and three general hospital, ICUs., Patients: Hundred thirty-one patients, ventilated at admission, from different shifts (morning, evening, night) combined with different stages of stay, early (0-3 days), intermediate (4-6 days) and late (> 6 days)., Interventions: Experienced nurses were asked to record the patient's characteristics and, for each alarm event, the reason, type and consequence., Measurements and Main Results: The mean age of the patients included was 59.8 +/- 16.4 and SAPS1 was 15.9 +/- 7.4. We recorded 1971 h of care. The shift distribution was 78 mornings, 85 evenings and 83 nights; the stage distribution was 88 early, 78 intermediate and 80 late. There were 3188 alarms, an average of one alarm every 37 min: 23.7% were due to staff manipulation, 17.5% to technical problems and 58.8% to the patients. Alarms originated from ventilators (37.8%), cardiovascular monitors (32.7%), pulse oximeters (14.9%) and capnography (13.5%). Of the alarms, 25.8% had a consequence such as sensor repositioning, suction, modification of the therapy (drug or ventilation). Only 5.9% of the alarms led to a physician's being called. The positive predictive value of an alarm was 27% and its negative predictive value was 99%. The sensitivity was 97% and the specificity 58%., Conclusions: The study confirms that the level of monitoring in ICUs generates a great number of false-positive alarms.

Objective: Intensivists generally view patients with hematological malignancies as poor candidates for intensive care. Nevertheless, hematologists have recently developed more aggressive treatment protocols capable of achieving prolonged complete remissions in many of these patients. This change mandates a reappraisal of indications for ICU admission in each type of hematological disease. Improved knowledge of the prognosis is of assistance in making treatment decisions., Patients and Methods: The records of 75 myeloma patients consecutively admitted to our ICU between 1992 and 1998 were reviewed retrospectively and predictors of 30-day mortality were identified using stepwise logistic regression., Results: The median age was 56 years (37-84). Chronic health status (Knaus scale) was C or D in 39 cases. Fifty-five patients (73%) had stage III disease and 17 had a complete or partial remission. Autologous bone marrow transplantation had been performed in 28 patients (37%). ICU admission occurred between 1992 and 1995 in 41 patients (54.7%), and between 1996 and 1998 in 34 patients (45.3%). The median SAPS II and LOD scores were 60 (23-107) and 7 (0-21), respectively. Reasons for ICU admission were acute respiratory failure in 39 patients (52%) and shock in 31 (41%). Forty-six patients (61%) required mechanical ventilation. Fifty patients (66%) received vasopressors and 24 dialysis. Thirty-day mortality was 57%. Only five parameters were independently associated with 30-day mortality in the multivariate model: female gender (OR = 5.12), mechanical ventilation (OR = 16.7) and use of vasopressor agents (OR = 5.67) were associated with a higher mortality rate, whereas disease remission (OR = 0.16) and ICU admission between 1996 and 1998 (OR = 0.09) were associated with a lower one., Conclusion: The prognosis for myeloma patients in the ICU is improving over time. This may reflect either recent therapeutic changes in hematological departments and ICUs or changes in patient selection for ICU admission. Hematologists and intensivists should work closely together to select hematological patients likely to benefit from ICU admission.

Objective: To assess the use of sedatives, analgesics and neuromuscular blocking agents (NMBAs) in patients requiring mechanical ventilation in Danish Intensive Care Units (ICUs)., Design: Questionnaires were mailed in December 1996 to all Departments of Anaesthesiology listed in the Annual Directory of Danish Hospitals. The questionnaires asked about the use of sedatives, analgesics and NMBAs in patients on mechanical ventilation in the ICU., Results: Forty-nine questionnaires were received from a possible 53 ICUs with ventilators (response rate 92.5%). Sedatives and analgesics were given to patients on mechanical ventilation at virtually all the ICUs surveyed (60% used the combination routinely). The frequency of use was influenced by both the level of ventilatory support and the type of underlying disease. Opioids, benzodiazepines and propofol were employed most commonly, in particular by continuous infusion. NMBAs were used in 65% of the ICUs surveyed in less than 20% of the total number of patients in the respective ICU. Overall 98% of the ICUs reported the occurrence of some kind of side effect secondary to the sedative treatment, but in most ICUs they were reported to occur in less than 20% of the patients., Conclusion: Sedatives and analgesics are widely used in patients requiring mechanical ventilation in Danish ICUs. NMBAs are only used in a few patients. The frequency of use is correlated to the level of ventilatory support required and to the kind of respiratory disease.

Data acquired prospectively from 134 patients with acute renal failure requiring dialysis in a medical intensive care unit (ICU) were analysed in order to derive indicators predicting ICU-survival. Mortality in the ICU was 56.7%. Linear discriminant analysis correctly predicted outcome in 79.9% at the start of dialysis, and 84.7% at 48 h after the first dialysis. The most important predictive variables were mechanical ventilation and low blood pressure. On the other hand, the total correct classification rates achieved by a standardised system for scoring ICU-patients (APACHE II) did not exceed 58.2%. It is concluded that outcome prediction by APACHE II and even by the discriminant functions is too inaccurate to become the basis for clinical decisions either concerning the initiation or the continuation of dialysis treatment in ARF.

A survey of sedation techniques for ventilated patients was performed by visiting 34 Intensive Care Units in Great Britain and Northern Ireland. The opiates in frequent used were phenoperidine (21 units - 62% of units), papaveretum (11 - 32%) and morphine (9-26%). Many units used more than one opiate. Levorphanol, buprenorphine, pethidine, fentanyl and codeine were little used. Frequent use of diazepam was found in 22 units (64%), of lorazepam in 11 (32%) and of Althesin in four (12%). Other sedative drugs, droperidol, chlormethiazole, chlorpromazine and ketamine were sued on an occasional basis. Continuous sedation using nitrous oxide was employed in nine (26%) of units-for more than 24 h in six (18%). All units used pancuronium - 31 (91%) used in frequently. Curare was in frequent use in five units (15%). There was wide variation in the way in which the drugs were used. A compromise between the ideal and the practicable method was common, depending more upon shortage of trained nursing staff than upon lack of funds for equipment or expensive drugs. The depth of sedation thought to be ideal depended on the state of the patient as well as the usual practice in the ICU - however a majority (23 = 67%) of units aimed to keep most patients well sedated and detached from the ICU environment. The use of very large doses of opiate to obtain the stress response was thought helpful in only six units (18%) and then in a minority of patients.

Analgesia and sedation for patients in intensive care units (ICU) who require mechanical ventilation are most commonly provided by intermittent i.v. injections of opiates and benzodiazepines. However, the technique has a number of disadvantages. Also, in many cases these drugs are inadequate, even in large doses, and muscle relaxants may be necessary for patient respirator coordination. The analgesic effect of epidural and intrathecal morphine was studied in 24 ICU patients requiring controlled ventilation. In spite of large doses of phenoperidine, diazepam and a number of other analgesics and sedatives, all patients were restless, agitated and coordinated poorly with the respirator. Through an indwelling epidural catheter morphine (4 mg) was injected intermittently as required in 11 patients and as a continuous infusion (20-40 mg/day) in five patients. In eight patients morphine (2-4 mg) was injected intrathecally as a single injection. Both epidural and intrathecal morphine gave potent analgesia and good patient respirator coordination. The duration of analgesia was shortest after intermittent injections of epidural morphine and longest after intrathecal morphine. However, continuous infusion of morphine in the epidural catheter appears to be the most practical method. In patients with multiple trauma and in patients where frequent assessment of the level of consciousness is important this technique is superior to parenteral analgesic sedative combinations. Intrathecal morphine may be indicated in patients in a compromised position. The daily analgesic requirement can be reduced by about 10-100 times by the use of epidural and intrathecal morphine respectively.

The efficacy of selective decontamination of the oral cavity and GI-tract in the treatment of established gram-negative pneumonia in critically ill patients was evaluated in a prospective open trial. 25 patients with pneumonia caused by Enterobacteriaceae or Pseudomonadaceae were studied. All patients were mechanically ventilated (range 2-60 days). Non-absorbable antibiotics (polymyxin E 100 mg, tobramycin 80 mg, amphotericin B 500 mg) were administered through the nasogastric tube four times a day. The oral cavity was decontaminated with an ointment containing 2% of the same antibiotics, applied to the buccal mucosa four times a day. For systemic therapy a combination of tobramycin (3-6 mg X kg-1) with either cefotaxim (50-100 mg X kg-1) or ceftazidime (100 mg X kg-1) was given both intravenously and by aerosol (50% IV dose/5 ml saline) four times a day. Eradication of pathogens from the respiratory tract was achieved in 24 patients within 9 days (median 5 days). The cure rate was 96%. Two patients had a relapse. Neither recolonization with resistant organisms nor supra-infections were found for the remaining period of mechanical ventilation (up to 60 days), also after systemic/aerosol therapy had been discontinued. Only 3 patients died (12%).

Purpose: Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods: A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results: A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion: Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. [ABSTRACT FROM AUTHOR]