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Objectives: The coronavirus disease 2019 pandemic has disrupted critical care services across the world. In anticipation of surges in the need for critical care services, governments implemented "lockdown" measures to preserve and create added critical care capacity. Herein, we describe the impact of lockdown measures on the utilization of critical care services and patient outcomes compared with nonlockdown epochs in a large integrated health region.Design: This was a population-based retrospective cohort study.Setting: Seventeen adult ICUs across 14 acute care hospitals in Alberta, Canada.Patients: All adult (age ≥ 15 yr) patients admitted to any study ICU.Interventions: None.Measurements and Main Results: The main exposure was ICU admission during "lockdown" occurring between March 16, 2020, and June 30, 2020. This period was compared with two nonpandemic control periods: "year prior" (March 16, 2019, to June 30, 2019) and "pre lockdown" immediately prior (November 30, 2019, to March 15, 2020). The primary outcome was the number of ICU admissions. Secondary outcomes included the following: daily measures of ICU utilization, ICU duration of stay, avoidable delay in ICU discharge, and occupancy; and patient outcomes. Mixed multilevel negative binomial regression and interrupted time series regression were used to compare rates of ICU admissions between periods. Multivariable regressions were used to compare patient outcomes between periods. During the lockdown, there were 3,649 ICU admissions (34.1 [8.0] ICU admissions/d), compared with 4,125 (38.6 [9.3]) during the prelockdown period and 3,919 (36.6 [8.7]) during the year prior. Mean bed occupancy declined significantly during the lockdown compared with the nonpandemic periods (78.7%, 95.9%, and 96.4%; p < 0.001). Avoidable ICU discharge delay also decreased significantly (42.0%, 53.2%, and 58.3%; p < 0.001). During the lockdown, patients were younger, had fewer comorbid diseases, had higher acuity, and were more likely to be medical admissions compared with the nonpandemic periods. Adjusted ICU and hospital mortality and ICU and hospital lengths of stay were significantly lower during the lockdown compared with nonpandemic periods.Conclusions: The coronavirus disease 2019 lockdown resulted in substantial changes to ICU utilization, including a reduction in admissions, occupancy, patient lengths of stay, and mortality. [ABSTRACT FROM AUTHOR]

Objective: To describe the occurrence of recurrent clinical deterioration and repeat medical emergency team activation and assess its effect on processes and outcomes of care. Design: Retrospective cohort study. Setting: Two community hospitals and two tertiary care hospitals, Alberta, Canada. Patients: Consecutive hospitalized adult patients with sudden clinical deterioration and medical emergency team activation without admission to ICU. Intervention: None. Measurement and Main Results: We compared ICU admission rates (admissions > 2 hr following index medical emergency team), hospital length of stay, and hospital mortality for a cohort of 3,200 patients with and without recurrent clinical deterioration following medical emergency team activation adjusting for patient, provider, and hospital characteristics. The cohort consisted of 3,200 patients. Ten percent of patients (n = 337) experienced recurrent clinical deterioration and repeat medical emergency team activation during their hospital stay. Patients more likely to experience recurrent clinical deterioration and repeat medical emergency team activation included those with chronic liver disease (odds ratio, 1.75; 95% Cl, 1.14-2.69) or who received airway suctioning (odds ratio, 1.66; 95% Cl, 1.23-2.25), noninvasive mechanical ventilation (odds ratio, 1.67; 95% Cl, 0.94-2.94), or central IV catheter insertion (odds ratio, 1.81; 95% Cl, 1.02-3.21) during the index medical emergency team activation. Patients with recurrent clinical deterioration were more likely than patients without recurrent clinical deterioration to be subsequently admitted to ICU (43% vs 13%; odds ratio, 6.11; 95% Cl, 4.67-8.00; p < 0.01), to have longer lengths of hospital stay (median, 31 d vs 13 d; p<0.01), and to die during their hospital stay (34% vs 23%; odds ratio, 1.98; 95% Cl, 1.47-2.67; p < 0.01). Conclusions: Recurrent clinical deterioration and repeat medical emergency team activation are common and associated with increased risk of subsequent ICU admission, increased length of hospital stay, and increased hospital mortality. It may be possible to identify patients at risk of recurrent clinical deterioration following medical emergency team activation and target interventions to improve patient care. [ABSTRACT FROM AUTHOR]

The article presents a study that aims to examine temporal trends in blood glucose (BG) control and identify their association with hospital mortality in critically ill patients from Australia. It mentions that 24 intensive care units (ICU) across Australia are considered in the study. It identifies that there was no significant change in early glycemic control from 2000 to 2005 and that high and early low BG levels were associated with hospital mortality.

The article provides a systematic review of randomized trials comparing intermittent renal replacement therapy (IRRT) and continuous RRT (CRRT) modality for critically-ill patients with acute kidney injury (AKI). The review's objectives were to evaluate whether modality influences mortality, renal recovery, treatment-related complications and physiologic outcomes. The study found no difference in mortality or renal recovery to RRT independence.

Objective: Hepatorenal syndrome (HRS) is associated with high rates of morbidity and mortality. Evidence examining commonly used drug treatments remains uncertain. We assessed the comparative effectiveness of inpatient treatments for HRS by performing a network meta-analysis of randomized clinical trials (RCTs).Data Sources: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Medline In-Process & Other Non-Indexed Citations, Scopus, and Web of Science from inception.Study Selection and Data Extraction: Pairs of reviewers independently identified eligible RCTs that enrolled patients with type 1 or 2 HRS. Pairs of reviewers independently extracted data.Data Synthesis: We assessed risk of bias using the Cochrane tool for RCTs and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach. Our main outcomes are all-cause mortality, HRS reversal, and serious adverse events. Of 3,079 citations, we included 26 RCTs examining 1,736 patients. Based on pooled analysis, terlipressin increases HRS reversal compared with placebo (142 reversals per 1,000 [95% CI, >87.7 to >210.9]; high certainty). Norepinephrine (112.7 reversals per 1,000 [95% CI, 52.6 to >192.3]) may increase HRS reversal compared with placebo (low certainty). The effect of midodrine+octreotide (67.8 reversals per 1,000 [95% CI, <2.8 to >177.4]; very low) on HRS reversal is uncertain. Terlipressin may reduce mortality compared with placebo (93.7 fewer deaths [95% CI, 168.7 to <12.5]; low certainty). Terlipressin probably increases the risk of serious adverse events compared with placebo (20.4 more events per 1,000 [95% CI, <5.1 to >51]; moderate certainty).Conclusions: Terlipressin increases HRS reversal compared with placebo. Terlipressin may reduce mortality. Until access to terlipressin improves, initial norepinephrine administration may be more appropriate than initial trial with midodrine+octreotide. Our review has the potential to inform future guideline and practice in the treatment of HRS. [ABSTRACT FROM AUTHOR]

Objectives: The optimal time to initiate renal replacement therapy in critically ill patients with acute kidney injury is controversial. We investigated the effect of such earlier versus later initiation of renal replacement therapy on the primary outcome of 28-day mortality and other patient-centered secondary outcomes.Design: We searched MEDLINE (via PubMed), EMBASE, and Cochrane databases to July 17, 2020, and included randomized controlled trials comparing earlier versus later renal replacement therapy.Setting: Multiple centers involved in eight trials.Patients: Total of 4,588 trial participants.Intervention: Two independents investigators screened and extracted data using a predefined form. We selected randomized controlled trials in critically ill adult patients with acute kidney injury and compared of earlier versus later initiation of renal replacement therapy regardless of modality.Measurements and Main Results: Overall, 28-day mortality was similar between earlier and later renal replacement therapy initiation (38.43% vs 38.06%, respectively; risk ratio, 1.01; [95% CI, 0.94-1.09]; I2 = 0%). Earlier renal replacement therapy, however, shortened hospital length of stay (mean difference, -2.14 d; [95% CI, -4.13 to -0.14]) and ICU length of stay (mean difference, -1.18 d; [95% CI, -1.95 to -0.42]). In contrast, later renal replacement therapy decreased the use of renal replacement therapy (relative risk, 0.69; [95% CI, 0.58-0.82]) and lowered the risk of catheter-related blood stream infection (risk ratio, 0.50, [95% CI, 0.29-0.86). Among survivors, renal replacement therapy dependence at day 28 was similar between earlier and later renal replacement therapy initiation (risk ratio, 0.98; [95% CI, 0.66-1.40]).Conclusions: Earlier or later initiation of renal replacement therapy did not affect mortality. However, earlier renal replacement therapy was associated with significantly shorter ICU and hospital length of stay, whereas later renal replacement therapy was associated with decreased use of renal replacement therapy and decreased risk of catheter-related blood stream infection. These findings can be used to guide the management of critically ill patients with acute kidney injury. [ABSTRACT FROM AUTHOR]

Objectives: The optimum duration of antimicrobial treatment for patients with bacteremia is unknown. Our objectives were to determine duration of antimicrobial treatment provided to patients who have bacteremia in ICUs, to assess pathogen/patient factors related to treatment duration, and to assess the relationship between treatment duration and survival.Design: Retrospective cohort study.Settings: Fourteen ICUs across Canada.Patients: Patients with bacteremia and were present in the ICU at the time culture reported positive.Interventions: Duration of antimicrobial treatment for patients who had bacteremia in ICU.Measurements and Main Results: Among 1,202 ICU patients with bacteremia, the median duration of treatment was 14 days, but with wide variability (interquartile range, 9-17.5). Most patient characteristics were not associated with treatment duration. Coagulase-negative staphylococci were the only pathogens associated with shorter treatment (odds ratio, 2.82; 95% CI, 1.51-5.26). The urinary tract was the only source of infection associated with a trend toward lower likelihood of shorter treatment (odds ratio, 0.67; 95% CI, 0.42-1.08); an unknown source of infection was associated with a greater likelihood of shorter treatment (odds ratio, 2.14; 95% CI, 1.17-3.91). The association of treatment duration and survival was unstable when analyzed based on timing of death.Conclusions: Critically ill patients who have bacteremia typically receive long courses of antimicrobials. Most patient/pathogen characteristics are not associated with treatment duration; survivor bias precludes a valid assessment of the association between treatment duration and survival. A definitive randomized controlled trial is needed to compare shorter versus longer antimicrobial treatment in patients who have bacteremia. [ABSTRACT FROM AUTHOR]