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Background. Improving estimation of long-term survival of patients with end-stage liver disease after orthotopic liver transplantation (OLT) would optimize decisions on eligibility for transplant. We aimed to externally validate previously derived Charlson Comorbity Index for OLT (CCI-OLT); subsequently, we developed a new model to predict 5-year mortality after transplant. Material and methods. This single center retrospective cohort study included 524 consecutive adult cirrhotic patients who underwent OLT in 2002-2012. External validation of CCI-OLT used Kaplan-Meier method. Derivation of the new predictive model used Cox proportional hazards regression. Results. One-, 3-, and 5-year cumulative survival after OLT was 89%, 80%, and 73%, respectively. CCI-OLT was not associated with 5-year mortality after transplant (P = 0.34). We derived and internally validated a new predictive model of 5-year mortality after OLT based on six pre-transplant characteristics of patients: age, body mass index, hepatitis C, hepatic encephalopathy, intensive care unit stay at transplant, and live donor (C-index = 0.64). We further developed a nomogram to estimate individual probability of 1-, 3-, and 5-year survival after OLT. Conclusions. In our cohort, CCI-OLT was not associated with survival following transplant. The new predictive model discriminative capacity was only modest, suggesting that pre-transplant characteristics are of limited value in predicting post-transplant outcomes in thoroughly selected patients.

Background: Little is known about the perspectives and experiences of family members of very elderly patients who are admitted to the intensive care unit. Aim: To describe family members’ perspectives about care provided to very elderly critically ill patients. Design: Multicenter, prospective, cohort study. Participants and setting: In total, 535 family members of patients aged 80 years or older admitted to 22 intensive care units for more than 24 h. Results: Family members reported that the “patient be comfortable and suffer as little as possible” was their most important value and “the belief that life should be preserved at all costs” was their least important value considered in making treatment decisions. Most family members (57.9%) preferred that life support be used for their family member, whereas 24.1% preferred comfort measures only, and 14.4% were unsure of their treatment preferences. Only 57.3% reported that a doctor had talked to them about treatment options for the patient. Overall, 29.7% of patients received life-sustaining treatments for more than 7 days and 50.3% of these died in hospital. Families were most satisfied with the skill and competency of nurses and least satisfied with being included and supported in the decision-making process and with their sense of control over the patient’s care. Conclusion: There is incongruity between family values and preferences for end-of-life care and actual care received for very elderly patients who are admitted to the intensive care unit. Deficiencies in communication and decision-making may be associated with prolonged use of life-sustaining treatments in very elderly critically ill patients, many of whom ultimately die.

Background: The effect of urinary alkalinization in cardiac surgery patients at risk of acute kidney injury (AKI) is controversial and trial findings conflicting. Accordingly, the authors performed a prospectively planned individual patient data meta-analysis of the double-blind randomized trials in this field. Methods: The authors studied 877 patients from three double-blind, randomized controlled trials enrolled to receive either 24 h of intravenous infusion of sodium bicarbonate or sodium chloride. The primary outcome measure was a postoperative increase in serum creatinine concentration of greater than 25% or 0.5 mg/dl (> 44 μm/L) within the first five postoperative days. Secondary outcomes included the raw change in serum creatinine, greater than 50% and greater than 100% rises in serum creatinine, developing AKI (Acute Kidney Injury Network criteria), initiation of renal replacement therapy, morbidity, and mortality. Results: Patients were similar in demographics, comorbidities, and cardiac procedures. Sodium bicarbonate increased plasma bicarbonate (P < 0.001) and urine pH (P < 0.001). There were no differences in the development of the primary outcome (Bicarbonate 45% [39–51%] vs. Saline 42% [36–48%], P = 0.29). This result remained unchanged when controlling for study and covariates (odds ratio [OR], 99% confidence interval [CI]: Bicarbonate vs. Control, 1.11 [0.77–1.60], P = 0.45). There was, however, a significant study-adjusted benefit in elective coronary artery bypass surgery patients in terms of renal replacement therapy (Bicarbonate vs. Control, OR: 0.38 [99% CI: 0.25–0.58], P < 0.0001) and the development of an Acute Kidney Injury Network grade = 3 (Bicarbonate vs. Control, OR: 0.45 [99% CI: 0.43–0.48], P < 0.0001). Conclusions: Urinary alkalinization using sodium bicarbonate infusion is not associated with an overall lower incidence of AKI; however, it reduces severe AKI and need for renal replacement therapy in elective coronary artery bypass patients.

Acute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim was to describe the incidence, factors, and outcomes associated with transient AKI after LTx.We performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease-Improving Global Outcome AKI stage I within 7days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function.Of 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P.001), reintubation (16.4% vs 41.9%; P.001), decreased duration of mechanical ventilation (median [interquartile range], 69 [41-142] vs 189 [63-403] hours; P.001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P.001) and 1 year (49.6% vs 66.7%, P=.01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio [OR], 0.91; 95% confidence interval, 0.85-0.98; P=.01), cyclosporine use (OR, 0.29; 0.12-0.67; P=.01), longer duration of mechanical ventilation (per hour [log transformed]; OR, 0.42; 0.21-0.81; P=.01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P.001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 [1.08-2.93]; P=.02) when compared with transient AKI (1.44 [0.93-2.19], P=.09) and no AKI (reference category), respectively.Transient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease.

BACKGROUND The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear. METHODS In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was

Objective To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS). Design Inception cohort study. Setting A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom. Participants Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina). Interventions Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5-dimensional questionnaire (EQ5D). Measurements and Main Results The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes. Conclusions The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research.

Polymyxin B-immobilized hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that clears circulating endotoxin. Prior trials have shown that PMX-HP improves surrogate endpoints. We aimed to conduct an evidence synthesis to evaluate the efficacy and safety of PMX-HP in critically ill adult patients with sepsis or septic shock.We searched for randomized controlled trials (RCTs) in MEDLINE, EMBASE, the Cochrane Library, the Health Technology Assessment Database, CINAHL, "Igaku Chuo Zasshi", the National Institute of Health Clinical Trials Register, the World Health Organization International Clinical Trials Registry Platform, the University Hospital Medical Information Network Clinical Trials Registry, the reference lists of retrieved articles, and publications by manufacturers of PMX-HP. The primary outcomes were 28-day all-cause mortality, the number of patients with at least one serious adverse event, and organ dysfunction scores. The GRADE methodology for the certainty of evidence was used.Six trials (857 participants; weighted mean age 62.5 years) proved eligible. Patient-oriented primary outcomes were assessed. The pooled risk ratio (RR) for 28-day mortality associated with PMX-HP was 1.03 [95% confidence interval (CI) 0.78-1.36; IThere is currently insufficient evidence to support the routine use of PMX-HP to treat patients with sepsis or septic shock.PROSPERO International Prospective Register of Systematic Reviews (CRD42016038356).

The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years. info:eu-repo/semantics/publishedVersion

Rationale: The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear.

Background The optimal amount of protein intake in critically ill patients is uncertain. Objective In this post hoc analysis of the PermiT (Permissive Underfeeding vs. Target Enteral Feeding in Adult Critically Ill Patients) trial, we tested the hypothesis that higher total protein intake was associated with lower 90-d mortality and improved protein biomarkers in critically ill patients. Design In this post hoc analysis of the PermiT trial, we included patients who received enteral feeding for ≥3 consecutive days. Using the median protein intake of the cohort as a cutoff, patients were categorized into 2 groups: a higher-protein group (>0.80 g · kg-1 · d-1) and a lower-protein group (≤0.80 g · kg-1 · d-1). We developed a propensity score for receiving higher protein. Primary outcome was 90-d mortality. We also compared serial values of prealbumin, transferrin, 24-h urinary nitrogen, and 24-h nitrogen balance on days 1, 7, and 14. Results Among the 729 patients included in this analysis, the average protein intake was 0.8 ± 0.3 g · kg-1 · d-1 [1.0 ± 0.2 g · kg-1 · d-1 in the higher-protein group (n = 365) and 0.6 ± 0.2 g · kg-1 · d-1 in the lower-protein group (n = 364); P

To evaluate the associations between strained ICU capacity and patient outcomes.Multi-center population-based cohort study of nine integrated ICUs in Alberta, Canada. Path-analysis modeling was adopted to investigate direct and indirect associations between strain (available beds ≤1; occupancy ≥95%) and outcomes. Mixed-effects multivariate regression was used to measure the association between strain and acuity (APACHE II score), and both acuity and strain measures on ICU mortality and length of stay.12,265 admissions comprise the study cohort. Available beds ≤1 and occupancy ≥95% occurred for 22.3% and 17.0% of admissions. Lower bed availability was associated with higher APACHE II score (p0.0001). The direct effect of ≤1 available beds at ICU admission on ICU mortality was 11.6% (OR 1.116; 95% CI, 0.995-1.252). Integrating direct and indirect effects resulted in a 16.5% increased risk of ICU mortality (OR 1.165; 95% CI, 1.036-1.310), which exceeded the direct effect by 4.9%. Findings were similar with strain defined as occupancy ≥95%. Strain was associated with shorter ICU stay, primarily mediated by greater acuity.Strained capacity was associated with increased ICU mortality, partly mediated through greater illness acuity. Future work should consider both the direct and indirect relationships of strain on outcomes.

Background Functional status (FS) before intensive care unit (ICU) admission is associated with short-term and long-term outcomes among critically ill patients. However, measures of FS are generally not integrated into ICU-specific mortality prediction models. Methods This retrospective cohort study used prospectively collected data from 9638 consecutive patients admitted to a single ICU between 1 October 2005 and 30 September 2015. For each ICU admission, FS was prospectively determined and classified into three discrete categories based on performance of basic daily living activities (FS1 - fully independent; FS2 - partly dependent; FS3 - completely dependent). We prospectively calculated Acute Physiology and Chronic Health Evaluation (APACHE) IV predicted mortality percentage (APIV PM) for each admission and calculated observed-expected mortality ratios (OEMR), stratified by FS category and APIV PM. We calculated area under the receiver operator characteristic curve (AUC) for APIV PM and mortality for the entire cohort and the three FS categories. Results Patients had a median (IQR) age of 67 (52–80) years and mean (SD) APIV PM was 18.3% (24.3%). Of these, 7714 (80.0%) were classified as FS1, 1728 (17.9%) as FS2 and 196 (2.0%) as FS3. FS1 patients were younger, had less comorbid disease, and lower APIV PM compared to FS2 and FS3. The OEMR were significantly lower for FS1 (0.67) than FS2 (0.93) or FS3 (0.90) (p

To provide a 360-degree description of ICU-to-ward transfers.Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer.Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p 0.001) and nurses (5.0 vs. 4.4, p 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Background Providers have traditionally established priorities for quality improvement; however, patients and their family members have recently become involved in priority setting. Little is known about how to reconcile priorities of different stakeholder groups into a single prioritized list that is actionable for organizations. Objective To describe the decision-making process for establishing consensus used by a diverse panel of stakeholders to reconcile two sets of quality improvement priorities (provider/decision maker priorities n=9; patient/family priorities n=19) into a single prioritized list. Design We employed a modified Delphi process with a diverse group of panellists to reconcile priorities for improving care of critically ill patients in the intensive care unit (ICU). Proceedings were audio-recorded, transcribed and analysed using qualitative content analysis to explore the decision-making process for establishing consensus. Setting and participants Nine panellists including three providers, three decision makers and three family members of previously critically ill patients. Results Panellists rated and revised 28 priorities over three rounds of review and reached consensus on the “Top 5” priorities for quality improvement: transition of patient care from ICU to hospital ward; family presence and effective communication; delirium screening and management; early mobilization; and transition of patient care between ICU providers. Four themes were identified as important for establishing consensus: storytelling (sharing personal experiences), amalgamating priorities (negotiating priority scope), considering evaluation criteria and having a priority champion. Conclusions Our study demonstrates the feasibility of incorporating families of patients into a multistakeholder prioritization exercise. The approach described can be used to guide consensus building and reconcile priorities of diverse stakeholder groups.

Catecholamine-resistant hypotension (CRH) is characterised by inadequate response to standard doses of vasopressors, and increased mortality. Our Angiotensin II for the Treatment of High-Output Shock 3 (ATHOS-3) trial compares the efficacy and safety of angiotensin II (ANGII) versus placebo in CRH.A phase III, multicentre, randomised, placebo-controlled trial of LJPC-501 (synthetic ANGII) for CRH in up to 120 intensive care units. We have set a target of 300 critically ill patients with CRH receiving standard-of-care (SOC) vasopressor therapy (ie, catecholamine dose0.2 µg/kg/min for 6-48 hours to maintain a mean arterial pressure [MAP] of 55-70 mmHg). Calculation of a norepinephrine-equivalent vasopressor dose is critical to determining patient eligibility, as ANGII will supplement ongoing vasopressor therapy.Stable patients will be randomised 1:1 to SOC vasopressor plus continuous intravenous infusion of ANGII or placebo for 48 hours, with an aim of achieving MAP of 75 mmHg for the first 3 hours. ANGII (initiated at 20 ng/ kg/min) will be titrated according to pre-specified guidelines until 48 hours, with patients followed until Day 7. Frequent vital sign and haemodynamic monitoring will support ANGII titration, safety monitoring and efficacy assessments.The primary efficacy endpoint is MAP ≥ 75 mmHg or an increase of ≥ 10 mmHg at treatment Hour 3. Secondary endpoints include change in total and cardiovascular Sequential Organ Failure Assessment scores over 48 hours, and safety data.Our study will investigate the utility of adding ANGII to current SOC vasopressor options to increase the efficacy and safety of CRH therapy.

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Acute kidney injury (AKI) is associated with incremental risk for death and chronic kidney disease and represents a mounting clinical challenge for healthcare professionals. Renal replacement therapy (RRT) use in ICU settings is rising, likely in response to similar trends in AKI, taken together with an ageing population burdened by high prevalence of multi-morbidity and high illness acuity. Numerous features of RRT prescription and delivery are not standardized, nor are they supported from high-quality evidence derived from randomized trials. Despite the publication of rigorous clinical practice guidelines focused on RRT for AKI that are intended to optimize the quality and reliability of RRT in ICU settings, practice patterns and outcomes continue to show significant variability. In this concise review, we aim to summarize new knowledge and recent advances for the provision of RRT for critically ill patients with AKI.

Background. Electronic alerts (e-alerts) for acute kidney injury (AKI) in hospitalized patients are increasingly being implemented; however, their impact on outcomes remains uncertain. Methods. We performed a systematic review. Electronic databases and grey literature were searched for original studies published between 1990 and 2016. Randomized, quasi-randomized, observational and before-and-after studies that included hospitalized patients, implemented e-alerts for AKI and described their impact on one of care processes, patient-centred outcomes or resource utilization measures were included. Results. Our search yielded six studies (n = 10 165 patients). E-alerts were generally automated, triggered through electronic health records and not linked to clinical decision support. In pooled analysis, e-alerts did not improve mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI), 0.84–1.31; n = 3 studies; n = 3425 patients; I2 = 0%] or reduce renal replacement therapy (RRT) use (OR 1.20; 95% CI, 0.91–1.57; n = 2 studies; n = 3236 patients; I2 = 0%). Isolated studies reported improvements in selected care processes. Pooled analysis found no significant differences in prescribed fluid therapy. Conclusions. In the available studies, e-alerts for AKI do not improve survival or reduce RRT utilization. The impact of e-alerts on processes of care was variable. Additional research is needed to understand those aspects of e-alerts that are most likely to improve care processes and outcomes.

Contains fulltext : 182590.pdf (Publisher’s version ) (Closed access) Acute kidney injury (AKI) is a common complication in the critically ill. Current standard of care mainly relies on identification of patients at risk, haemodynamic optimization, avoidance of nephrotoxicity and the use of renal replacement therapy (RRT) in established AKI. The detection of early biomarkers of renal tissue damage is a recent development that allows amending the late and insensitive diagnosis with current AKI criteria. Increasing evidence suggests that the consequences of an episode of AKI extend long beyond the acute hospitalization. Citrate has been established as the anticoagulant of choice for continuous RRT. Conflicting results have been published on the optimal timing of RRT and on the renoprotective effect of remote ischaemic preconditioning. Recent research has contradicted that acute tubular necrosis is the common pathology in AKI, that septic AKI is due to global kidney hypoperfusion, that aggressive fluid therapy benefits the kidney, that vasopressor therapy harms the kidney and that high doses of RRT improve outcome. Remaining uncertainties include the impact of aetiology and clinical context on pathophysiology, therapy and prognosis, the clinical benefit of biomarker-driven interventions, the optimal mode of RRT to improve short- and long-term patient and kidney outcomes, the contribution of AKI to failure of other organs and the optimal approach for assessing and promoting renal recovery. Based on the established gaps in current knowledge the trials that must have priority in the coming 10 years are proposed together with the definition of appropriate clinical endpoints.

Intensive care unit (ICU) readmission negatively impacts patients' outcomes. We aimed to characterize and determine risk factors for ICU readmission within the initial hospital stay after liver transplant (LT).The reference cohort included 369 LT recipients from a Canadian center between 2005 and 2012. One control was randomly selected per each case of ICU readmission within the initial hospital stay after LT. Survival analysis used the Kaplan-Meier method. Associations were studied by conditional logistic regression.Fifty-two (14%) LT recipients were readmitted to the ICU within the initial hospital stay after LT; they had longer first hospital stay (P.001) and lower 1-month to 2-year cumulative survival (P.001). Respiratory failure was the major cause of ICU readmission (61%). Respiratory rate at discharge from the first ICU stay after LT was an independent risk factor for ICU readmission (odds ratio = 1.24). The cutoff point more than 20 breaths per minute prognosticated ICU readmission with a specificity of 90% and a positive predictive value of 80%.Intensive care unit readmission within the initial hospital stay after LT negatively impacts LT recipients' outcomes. Monitoring respiratory rate at discharge from the first ICU stay after LT is important to prevent readmission.

Recovery of kidney function following an episode of acute kidney injury (AKI) is now acknowledged as a vital patient-centered outcome with clear health economic implications. In approximately 5-8% of critically ill patients with more severe forms of AKI, support with renal replacement therapy (RRT) is provided. Recent data have suggested that rates of RRT utilization in AKI are increasing. Despite advances in our understanding of how best to prescribe acute RRT in critically ill patients with AKI, additional aspects remain uncertain, predisposing to suboptimal delivery and variation in practice. Importantly, if, when, how, and by what principles we apply acute RRT for AKI are all treatment decision-related factors that are modifiable and may interact with recovery of kidney function. Limited data, mostly from observational studies and secondary analyses, have explored the specific association between acute RRT and recovery. Available data are not able to clarify whether providing any RRT in otherwise eligible patients with AKI impacts recovery. They are also unable to inform whether the timing or circumstance under which RRT is started impacts recovery. No studies have evaluated whether there is an optimal time to start RRT to maximize the probability of recovery. Accumulated evidence, mostly derived from observational studies, suggests initial therapy in critically ill patients with AKI with continuous RRT, compared with intermittent modalities, improves the probability of recovery to dialysis independence. Evidence from high-quality randomized trials failed to show any association between delivered dose intensity of RRT and recovery. The use of biocompatible membranes for acute RRT may improve recovery in AKI; however, data are inconsistent. Limited data have evaluated the impact of membrane flux properties on recovery. Preliminary data have suggested that circuit anticoagulation with citrate, which results in a reduction in membrane-induced oxidative stress and leukocyte activation, may be associated with improved recovery; however, further corroborative data are needed. Additional evidence, ideally from randomized trials, is clearly needed to inform best practice in the delivery of acute RRT to optimize probability of recovery of kidney function for survivors of AKI.

Background and objectives No data on the development of conventional indications for RRT (refractory acidosis, hyperkalemia, uremia, oliguria/anuria, and volume overload) related to timing of RRT exist. The prevalence of conventional indications among critically ill patients on RRT for AKI was evaluated, and patients manifesting indications versus patients without indications were compared in terms of crude and adjusted 90-day mortality. Design, setting, participants, & measurements In this substudy of the Finnish Acute Kidney Injury study conducted in 2011 and 2012 in 17 intensive care units with 2901 patients, patients were classified as pre-emptive (no conventional indications) and classic (one or more indications) RRT recipients. Patients with classic RRT were divided into classic-urgent (RRT initiated ≤12 hours from manifesting indications) and classic-delayed (RRT >12 hours from first indication). Additionally, 2450 patients treated without RRT were matched to patients with pre-emptive RRT. Results Of 239 patients treated with RRT, 134 (56.1%; 95% confidence interval [95% CI], 49.8% to 62.4%) fulfilled at least one conventional indication before commencing RRT. Crude 90-day mortality of 134 patients with classic RRT was 48.5% (95% CI, 40.0% to 57.0%), and it was 29.5% (95% CI, 20.8% to 38.2%) for the 105 patients with pre-emptive RRT. Classic RRT was associated with a higher risk for mortality (adjusted odds ratio, 2.05; 95% CI, 1.03 to 4.09). Forty-four patients with classic–delayed RRT showed higher crude mortality (68.2%; 95% CI, 54.4% to 82.0%) compared with patients with classic–urgent RRT, and this association persisted after adjustment for known confounders (odds ratio, 3.85; 95% CI, 1.48 to 10.22). Crude 90-day mortality of 67 1:1 matched patients with pre-emptive RRT was 26.9% (95% CI, 6.3% to 37.5%), and it was 49.3% (95% CI, 37.3% to 61.2%; P=0.01) for their non-RRT matches. Conclusions Patients on RRT after one or more conventional indications had both higher crude and adjusted 90-day mortality compared with patients without conventional indications. These findings require confirmation in an adequately powered, multicenter, randomized controlled trial.

To provide an update on the recent publications for the management and prognostication of critically ill cirrhotic patients before and after liver transplant.The CLIF Acute-oN-ChrONicLIver Failure in Cirrhosis (CANONIC) study recently derived an evidence-based definition of acute-on-chronic liver failure (ACLF): hepatic decompensation; organ failure [predefined by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA)]; and high 28-day mortality rate. Although Sequential Organ Failure Assessment (SOFA) appears to be more accurate in predicting ICU and hospital mortality in ACLF patients, CLIF-SOFA has been derived specifically for critically ill cirrhotic patients, including those not receiving mechanical ventilation. Recent data suggest that a lower transfusion target in esophageal variceal bleeding (7 g/l) is safe. Newly defined 'cirrhosis-associated acute kidney injury (AKI)' correlates with mortality, organ failure and length of hospital stay. Although the SOFA score appears to perform better than liver-specific scoring systems [Model for End-stage Liver Disease (MELD) and Child-Pugh scores], neither MELD nor SOFA appears to independently predict posttransplant survival; however, correlated with lengths of ICU and hospital stay. For patients declined for liver transplant, palliative care referral and appropriate goals of care are rarely achieved.New definitions for ACLF, cirrhosis-associated AKI and the CLIF-SOFA may improve the discrimination between survivors and nonsurvivors with ACLF. Predicting futility postliver transplant based on preliver transplant severity of illness still poses significant challenges.

Objective:Among critically ill patients with acute kidney injury, the impact of renal replacement therapy modality on long-term kidney function is unknown. Compared with conventional intermittent hemodialysis, continuous renal replacement therapy may promote kidney recovery by conferring greater hem

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Acute kidney injury (AKI) is a widespread problem of epidemic status. Compelling evidence indicates that the incidence of AKI is rapidly increasing, particularly among hospitalized patients with acute illness and those undergoing major surgery. This increase might be partially attributable to greater recognition of AKI, improved ascertainment in administrative data and greater sensitivity of consensus diagnostic and classification schemes. Other causes could be an ageing population, increasing incidences of cardiovascular disease, diabetes mellitus and chronic kidney disease (CKD), and an expanding characterization of modifiable risk factors, such as sepsis, administration of contrast media and exposure to nephrotoxins. The sequelae of AKI are severe and characterized by increased risk of short-term and long-term mortality, incident CKD and accelerated progression to end-stage renal disease. AKI-associated mortality is decreasing, but remains unacceptably high. Moreover, the absolute number of patients dying as a result of AKI is increasing as the incidence of the disorder increases, and few proven effective preventative or therapeutic interventions exist. Survivors of AKI, particularly those who remain on renal replacement therapy, often have reduced quality of life and consume substantially greater health-care resources than the general population as a result of longer hospitalizations, unplanned intensive care unit admissions and rehospitalizations.

The epidemiologic characteristics of children and young adults with acute kidney injury have been described in single-center and retrospective studies. We conducted a multinational, prospective study involving patients admitted to pediatric intensive care units to define the incremental risk of death and complications associated with severe acute kidney injury.We used the Kidney Disease: Improving Global Outcomes criteria to define acute kidney injury. Severe acute kidney injury was defined as stage 2 or 3 acute kidney injury (plasma creatinine level ≥2 times the baseline level or urine output0.5 ml per kilogram of body weight per hour for ≥12 hours) and was assessed for the first 7 days of intensive care. All patients 3 months to 25 years of age who were admitted to 1 of 32 participating units were screened during 3 consecutive months. The primary outcome was 28-day mortality.A total of 4683 patients were evaluated; acute kidney injury developed in 1261 patients (26.9%; 95% confidence interval [CI], 25.6 to 28.2), and severe acute kidney injury developed in 543 patients (11.6%; 95% CI, 10.7 to 12.5). Severe acute kidney injury conferred an increased risk of death by day 28 after adjustment for 16 covariates (adjusted odds ratio, 1.77; 95% CI, 1.17 to 2.68); death occurred in 60 of the 543 patients (11.0%) with severe acute kidney injury versus 105 of the 4140 patients (2.5%) without severe acute kidney injury (P0.001). Severe acute kidney injury was associated with increased use of mechanical ventilation and renal-replacement therapy. A stepwise increase in 28-day mortality was associated with worsening severity of acute kidney injury (P0.001 by log-rank test). Assessment of acute kidney injury according to the plasma creatinine level alone failed to identify acute kidney injury in 67.2% of the patients with low urine output.Acute kidney injury is common and is associated with poor outcomes, including increased mortality, among critically ill children and young adults. (Funded by the Pediatric Nephrology Center of Excellence at Cincinnati Children's Hospital Medical Center and others; AWARE ClinicalTrials.gov number, NCT01987921 .).

Purpose.The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality.Materials and Methods.Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality.Results.Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm3(30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16;p<0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73;p=0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13;p=0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13;p=0.01). CD4 count and PVL were not associated with mortality.Conclusions.Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.

Owing to an oversight by the authors, Figure 2 in this article was not the version intended for publication. The correct Figure 2, reproduced here, features footnote symbols and Figure 2b includes three studies as described in the main text.

ObjectiveTo compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices.Design(1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers.SettingData were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers.ParticipantsParticipants included 6946 ICU admissions and 309 healthcare providers from the same ICUs.Main outcome measures(1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices.ResultsLMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively).ConclusionsDespite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.

IntroductionPredicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines.Methods and analysisWe will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics.Ethics and disseminationOur review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required.PROSPERO registration numberCRD42018087474.

IntroductionDelirium is a common complication of critical illness, associated with negative patient outcomes. Preventive or therapeutic interventions are mostly ineffective. Although relaxation-inducing approaches may benefit critically ill patients, no well-designed studies target delirium prevention as a primary outcome. The objective of this study is to assess feasibility and treatment effect estimates of a multimodal integrative intervention incorporating relaxation, guided imagery and moderate pressure touch massage for prevention of critical illness delirium and for related outcomes.Methods and analysisRandomised, controlled, single-blinded trial with two parallel groups (1:1 allocation: intervention and standard care) and stratified randomisation (age (18–64 years and ≥65 years) and presence of trauma) with blocking, involving 104 patients with Intensive Care Delirium Screening Checklist (ICDSC): 0–3 recruited from two academic intensive care units (ICUs). Intervention group participants receive the intervention in addition to standard care for up to five consecutive days (or until transfer/discharge); control group participants receive standard care and a sham intervention. We will assess predefined feasibility outcomes, that is, recruitment rates and protocol adherence. The primary clinical outcome is incidence of delirium (ICDSC ≥4). Secondary outcomes include pain scores, inflammatory biomarkers, heart rate variability, stress and quality of life (6 weeks and 4 months) post-ICU discharge. Feasibility measures will be analysed descriptively, and outcomes will be analysed longitudinally. Estimates of effects will be calculated.Ethics and disseminationThe study has received approval from the Human Research Ethics Board, University of Alberta. Results will inform the design of a future multicentre trial.Trial registration numberNCT02905812; Pre-results.

Background: Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care. Methods: We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life. Results: The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%–37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09–3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28–2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01–2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03–4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22–3.23) in the 12 months following enrolment. Interpretation: Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.

PURPOSE OF REVIEW Frailty is a multidimensional syndrome characterized by loss of physiologic reserves that gives rise to vulnerability to adverse events. RECENT FINDINGS Frailty has been described in older patients undergoing geriatric assessment and in noncardiac and cardiac surgical settings, in which it closely correlates with heightened risk for major morbidity including functional decline, postoperative complications, institutionalization, and short-term and long-term mortality. Critically ill patients may represent a population with similar vulnerabilities to older frail patients. Prior data have described the association with less favorable outcomes and poor premorbid functional status (i.e., activities of daily living, cognitive impairment, body mass index), used perhaps as a surrogate for frailty. Preliminary epidemiologic data suggest the prevalence of frailty (and intermediate frail states) among critically ill patients is high and likely to increase with the greater demand placed on ICU resources associated with population demographic transition. SUMMARY The concept of frailty, as a marker of biologic age and physiologic reserve, may have direct relevance to critical care, and clearly identifies a population at greater risk of adverse events, morbidity, and mortality. Its recognition in critical care settings may enable improved prognostication and shared decision-making and identify vulnerable subgroups with specific needs who might benefit from targeted follow-up.

Purpose of review We discuss the formulation of a prescription for intravenous (i.v.) fluid therapy (a 'volume prescription') for critically ill patients: pros/cons of different fluid types; accurate dosing; and qualitative and quantitative toxicities. Updated physiologic concepts are invoked and results of recent major clinical trials on i.v. fluid therapy in the acutely ill are interpreted. Recent findings Context is vital and any fluid can be harmful if dosed incorrectly. When contrasting 'crystalloid versus colloid', differences in efficacy are modest, but differences in safety are significant. Differences in chloride load and strong ion difference appear to be clinically important. Quantitative toxicity is mitigated when dosing is based on dynamic parameters that predict volume responsiveness. Qualitative toxicity for colloids (even with newer hydroxyethyl starch 130/0.4 solutions) and isotonic saline remain a concern. Summary Similar to any drug used in acutely ill patients, clinicians ordering a volume prescription must recognize that context is crucial. Physiologically balanced crystalloids may be the 'default' fluid for acutely ill patients, and the role for colloids is unclear. Optimal dosing involves assessment of volume responsiveness.

Patients with acute myeloid leukemia (AML) are at risk for sudden clinical deterioration. We aimed to describe the incidence of medical emergency team (MET) activation, intensive care unit (ICU) admissions and outcomes for patients with AML. We performed a 5-year retrospective cohort study of patients hospitalized with AML. One hundred and seventy patients were divided into three groups: (1) MET activated (n = 34); (2) MET criteria present but MET not activated (n = 17); and (3) all other patients with AML (n = 119). MET activation incidence was 200 calls/1000 admissions (95% confidence interval [CI], 138-279), compared with a hospital-wide rate of 29.3 calls/1000 admissions (95% CI, 28.2-30.4) (relative risk 6.90; 95% CI, 4.77-9.67, p0.0001). Some 77% (n = 26) were triaged to the ICU. Hospital mortality was higher in MET activated and MET fulfilled without activation groups compared with all others (27% vs. 12% vs. 7%, p = 0.007). Changes to goals of care were more common with MET activation. Patients with AML commonly receive MET activation. Approximately one in 10 fulfill MET criteria, however do not receive MET activation.

Introduction Polymyxin-B immobilised haemoperfusion (PMX-HP) is a promising adjuvant strategy for the treatment of sepsis and septic shock. PMX-HP therapy works by clearing circulating endotoxin through binding to polymyxin-immobilised fibres during haemoperfusion. Small clinical trials have shown that PMX-HP therapy is associated with improved haemodynamic profile, oxygenation and survival. However, clear inferences have been largely inconclusive due to limitations in study design (eg, small, unblinded) and generalisability. We therefore propose to perform an up-to-date systematic review and evidence synthesis to describe the efficacy, safety and effectiveness of PMX-HP for adult patients with sepsis or septic shock. Methods and analysis We will search the following databases from 1946 to 2016 MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, Health Technology Assessment Database (HTA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and ‘Igaku Chuo Zasshi’ (ICHUSHI) for randomised controlled trials of PMX-HP in critically ill patients with sepsis or septic shock. There will be no language restrictions in the electronic search for studies. Two reviewers will extract data and appraise the quality of each study independently. The primary outcome will be the pooled risk ratio of 28-day all-cause mortality. Serious adverse events and changes in organ dysfunction scores will also be evaluated. The secondary outcomes will be 90-day all-cause mortality, changes in haemodynamic profile and endotoxin levels, and health services use. Ethics and dissemination Our systematic review will synthesise the evidence on use of the PMX-HP as an adjuvant therapy in sepsis/septic shock to improve patient-centred, physiological and health services outcomes. Research ethics is not required for this review. The study will be disseminated by peer-reviewed publication and conference presentation. Trial registration number CRD42016038356.

The dilemma of whether and when to start renal replacement therapy among critically ill patients with acute kidney injury in the absence of conventional indications has long been a vexing challenge for clinicians. The lack of high-quality evidence has undoubtedly contributed decisional uncertainty and unnecessary practice variation. Recently, two randomized trials (ELAIN and AKIKI) reported specifically on the issue of the timing of initiation of renal replacement therapy in critically ill patients with acute kidney injury. In this commentary, their fundamental differences in trial design, sample size, and widely discrepant findings are considered in context. While both trials are important contributions towards informing practice on this issue, additional evidence from large multicenter randomized trials is needed.

Renal replacement therapy (RRT) is increasingly utilized to support critically ill patients with severe acute kidney injury (AKI). The question of whether and when to start RRT for a critically ill patient with AKI has long troubled clinicians. When severe complications of AKI develop, the need to commence RRT is unambiguous. In the absence of such complications but in the presence of severe AKI, the optimal time and thresholds for starting RRT are uncertain. The majority of existing data have largely been derived from observational studies. These have been limited due to confounding by indication, considerable heterogeneity in case mix and illness severity, and variably applied definitions for both AKI and for how "timing" was anchored relative to starting RRT. It is unclear whether a preemptive or earlier strategy of RRT initiation aimed largely at avoiding complications related to AKI or a more conservative strategy where RRT is started in response to developing complications leads to better patient-centered outcomes and health services use. This question has been the focus of 2 recently completed randomized trials. In this review, we provide an appraisal of available evidence, discuss existing knowledge gaps, and provide perspective on future research that will better inform the optimal timing of RRT initiation in AKI.

OBJECTIVES: Evidence to guide fluid resuscitation evidence in sepsis continues to evolve. We conducted a multicountry survey of emergency and critical care physicians to describe current stated practice and practice variation related to the quantity, rapidity and type of resuscitation fluid administered in early septic shock to inform the design of future septic shock fluid resuscitation trials.METHODS: Using a web-based survey tool, we invited critical care and emergency physicians in Canada, the UK, Scandinavia and Saudi Arabia to complete a self-administered electronic survey.RESULTS: A total of 1097 physicians' responses were included. 1 L was the most frequent quantity of resuscitation fluid physicians indicated they would administer at a time (46.9%, n=499). Most (63.0%, n=671) stated that they would administer the fluid challenges as quickly as possible. Overall, normal saline and Ringer's solutions were the preferred crystalloid fluids used 'often' or 'always' in 53.1% (n=556) and 60.5% (n=632) of instances, respectively. However, emergency physicians indicated that they would use normal saline 'often' or 'always' in 83.9% (n=376) of instances, while critical care physicians said that they would use saline 'often' or 'always' in 27.9% (n=150) of instances. Only 1.0% (n=10) of respondents indicated that they would use hydroxyethyl starch 'often' or 'always'; use of 5% (5.6% (n=59)) or 20-25% albumin (1.3% (n=14)) was also infrequent. The majority (88.4%, n=896) of respondents indicated that a large randomised controlled trial comparing 5% albumin to a crystalloid fluid in early septic shock was important to conduct.CONCLUSIONS: Critical care and emergency physicians stated that they rapidly infuse volumes of 500-1000 mL of resuscitation fluid in early septic shock. Colloid use, specifically the use of albumin, was infrequently reported. Our survey identifies the need to conduct a trial on the efficacy of albumin and crystalloids on 90-day mortality in patients with early septic shock.

Author details Division of Critical Care Medicine (University of Alberta Hospital), Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440-112 Street NW, Edmonton, AB T6G 2B7, Canada. Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-112 Clinical Sciences Building, 8440-112 Street, Edmonton, AB T6G 2B7, Canada. Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 13-103 Clinical Sciences Building, 8440-112 Street, Edmonton, AB T6G 2B7, Canada. Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada. Department of Medicine, Faculty of Medicine and Dentistry, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada. Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1 N4, Canada.

Very elderly (over 80 yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study is to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers. This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge. There were 1,671 patients evaluated in this study. Patient demographics included a mean age of 84.5 yr, baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22.4, baseline Sequential Organ Failure Assessment (SOFA) score of 5.3, overall ICU mortality of 21.8%, and overall hospital mortality of 35.0%. Medical patient median ICU length of stay was 4.1 days, hospital length of stay was 16.2 days, ICU mortality was 26.5%, and hospital mortality was 41.5%. Surgical patient median ICU length of stay was 3.8 days, hospital length of stay was 20.1 days, ICU mortality was 18.7%, and hospital mortality was 31.6%. Only 45.0% of medical patients and 41.6% of surgical emergency patients were able to return home to live. In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

Purpose: The purpose of the study is to understand what clinicians believe defines fluid bolus therapy (FBT) and the expected response to such intervention. Methods: We asked intensive care specialists in 30 countries to participate in an electronic questionnaire of their practice, definition, and expectations of FBT. Results: We obtained 3138 responses. Despite much variation, more than 80% of respondents felt that more than 250 mL of either colloid or crystalloid fluid given over less than 30 minutes defined FBT, with crystalloids most acceptable. The most acceptable crystalloid and colloid for use as FBT were 0.9% saline and 4% albumin solution, respectively. Most respondents believed that one or more of the following physiological changes indicates a response to FBT: a mean arterial pressure increase greater than 10 mm Hg, a heart rate decrease greater than 10 beats per minute, an increase in urinary output by more than 10 mL/h, an increase in central venous oxygen saturation greater than 4%, or a lactate decrease greater than 1 mmol/L. Conclusions: Despite wide variability between individuals and countries, clear majority views emerged to describe practice, define FBT, and identify a response to it. Further investigation is now required to describe actual FBT practice and to identify the magnitude and duration of the physiological response to FBT and its relationship to patient-centered outcomes., Facultad de Ciencias Médicas