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Background: A non-tunneled dialysis catheter (nTDC) is often the vascular access of choice to initiate dialysis in an intensive care unit (ICU). In the absence of contraindications, if a patient remains dialysis dependent beyond 2-weeks, the options are either to replace the nTDC with another nTDC or convert to a tunneled dialysis catheter (TDC). As a standard of care, TDCs are placed under fluoroscopic guidance., Objectives: To determine if TDCs and other tunneled central venous catheters (tCVC) can be placed safely using anatomical landmark techniques without the use of fluoroscopy., Research Design: Subjects that met a predetermined selection criteria underwent placement of tunneled catheters with the use of the anatomical landmark technique. We looked at various outcomes to determine the safety and effectiveness of this technique., Subjects: One hundred eleven TDCs and other tCVCs were placed using the anatomical landmark technique in the intensive care unit., Results: All but one (110/111) of the catheters placed had recommended tip placement confirmed by at least one blinded physician. Major complications encountered were bleeding (two cases), pneumothorax (one case), and line associated blood stream infection (one case). We did find a higher-than-expected rate of "unnecessary procedures" with 18/111 lines placed in patients who did not survive beyond 7 days after placement of the catheter., Conclusions: Using the anatomical landmark technique for bedside tunneled catheter placement can be an effective approach in the right population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1 ) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2 ) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3 ) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4 ) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5 ) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Background: Acute respiratory distress syndrome (ARDS) occurs commonly in intensive care units. The reported mortality rates in studies evaluating ARDS are highly variable. Objective: To investigate mortality rates due to ARDS from before the 2009 H1N1 influenza pandemic began until the start of coronavirus disease 2019 (COVID-19) pandemic. Design: We performed a systematic search and then ran a proportional meta-analysis for mortality. We ran our analysis in three ways: for randomised controlled trials only, for observational studies only, and for randomised controlled trials and observational studies combined. Data sources: MEDLINE and Embase, using a highly sensitive criterion and limiting the search to studies published from January 2009 to December 2019. Review methods: Two of us independently screened titles and abstracts to first identify studies and then complete full text reviews of selected studies. We assessed risk of bias using the Cochrane RoB-2 (a risk-of-bias tool for randomised trials) and the Cochrane ROBINS-1 (a risk-of-bias tool for non-randomised studies of interventions). Results: We screened 5844 citations, of which 102 fully met our inclusion criteria. These included 34 randomised controlled trials and 68 observational studies, with a total of 24 158 patients. The weighted pooled mortality rate for all 102 studies published from 2009 to 2019 was 39.4% (95% CI, 37.0-41.8%). Mortality was higher in observational studies compared with randomised controlled trials (41.8% [95% CI, 38.9-44.8%] v 34.5% [95% CI, 30.6-38.5%]; P = 0.005). Conclusions: Over the past decade, mortality rates due to ARDS were high. There is a clear distinction between mortality in observational studies and in randomised controlled trials. Future studies need to report mortality for different ARDS phenotypes and closely adhere to evidence-based medicine. PROSPERO registration: CRD42020149712 (April 2020)., Competing Interests: Abhijit Duggal is a member of the Steering Committee for ALung Technologies, not related to this publication. All other authors declare that they do not have any potential conflict of interest in relation to this manuscript., (© 2022 College of Intensive Care Medicine of Australia and New Zealand.)

Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes., Objectives: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices., Design Setting and Participants: This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning., Main Outcomes and Measures: Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams., Results: Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes., Conclusions and Relevance: Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care., Competing Interests: Drs. Kashyap and Gajic have a financial conflict of interest with software platforms licensed to Ambient Clinical Analytics associated with the Checklist for Early Recognition and Treatment of Acute Illness and iNjury program. This software was not utilized for this project, and these individuals did not participate in analysis or interpretation of these study results. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Tele-critical care (TCC) adoption has been slow since its emergence in the early 2000s. The COVID-19 pandemic has renewed interest in telemedicine and may spur expansion or development of new TCC programs. This narrative addresses the Cleveland Clinic TCC service, (eHospital) to promote exchange of ideas to continually optimize the practice for current and future users. Methods: A descriptive narrative methodology is used in this report. Results: Cleveland Clinic's eHospital was established in 2014 to support nighttime critical care across system hospitals. It encompasses a tiered system of two-way audiovisual communication, telemetry, software platform that integrates the electronic health record, and a proprietary risk stratification algorithm for targeted electronic surveillance. The TCC team includes intensivists, advanced care providers, and registered nurses. Three coverage models evolved depending on onsite clinician availability. More than 133,000 patients have been served by eHospital to date, and span the typical spectrum of critical illness. Along with universal monitoring, ∼18% of patients received active interventions, the most common of which are categorized. Patterns of activity, typical workflows, and adaptations of bedside best practices are also described. Bookending the work shift are sign outs focused on pending critical issues, unstable patients, and those who can be triaged out of the intensive care unit. In between, TCC teams round periodically and interact with bedside teams. Conclusions: TCC adoption has proceeded slowly. Some acceleration is anticipated in a post-COVID-19 pandemic world. Our experience highlights operational practices that can facilitate successful TCC practice.

Background: Acute hypoxemic respiratory failure (ARF) is characterized by both lower arterial oxygen and carbon dioxide tensions in the blood. First line treatment for ARF includes oxygen therapy - intially administered non invasively using nasal prongs, high flow nasal cannulae (HFNC) or masks. Invasive mechanical ventilation (IMV) is usually reserved for patients who are unable to maintain their airway, those with worsening hypoxemia, or those who develop respiratory muscle fatigue and consequent hypercapnia. Inhaled nitric oxide (iNO) gas is known to improve oxygenation in patients with ARF by manipulating ventilation-perfusion matching. Addition of iNO may potentially alleviate the need for IMV in selected patients., Case Summary: In this article we report our preliminary experience of using HFNC to deliver oxygen and nitric oxide gas in patients with hypoxemic ARF as a strategy to potentially avoid IMV in selected patients., Conclusion: This article demonstrates the feasibility of this technique based on our experience of patients with hypoxemic ARF and generates hypothesis for future studies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature., Main: RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy., Conclusion: The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.

Background: Treatments for ARDS that improve patient outcomes include use of lung-protective ventilation, prone ventilation, and conservative fluid management. Implementation of ARDS protocols via educational programs might improve adherence and outcomes. The objective of this study was to investigate the effects of an ARDS protocol implementation on outcomes and adherence with ARDS guidelines., Methods: This was a single-center, interventional, comparative study before and after protocol implementation. Staff education for the ARDS protocol was implemented between June 2014 and May 2015. A retrospective cohort analysis was conducted during between January 2012 and May 2014 (pre-protocol) and between June 2015 and June 2017 (post-protocol). A total of 450 subjects with ARDS were included. After propensity score matching, 432 subjects were analyzed. Of those, 330 subjects were treated after protocol implementation., Results: The median (interquartile range [IQR]) plateau pressure and tidal volume over the first 3 d decreased significantly after protocol implementation (30.5 [IQR 24.2-33] vs 25.5 [IQR 21.7-30], P = .01 and 7.65 vs 7.4 mL/kg predicted body weight, P = .032, respectively). The percentage of subjects with unsafe tidal volume (> 10 mL/kg predicted body weight) decreased (14.4% vs 5.8%, P = .02). The percentage of subjects with safe plateau pressure (≤ 30 cm H 2 O) increased (47.4% vs 76.5%, P < .001). PEEP deviation from the ARDSNet PEEP/[Formula: see text] table was significantly lower after the implementation. Mortality at 28 and 90 days improved after implementation (53.9% vs 41.8% and 61.8% vs 48.2%, respectively). Adjusted odds ratios for 28-d and 90-d mortality were 0.47 (95% CI 0.28-0.78) and 0.45 (95% CI 0.27-0.76), respectively., Conclusions: ARDS protocol implementation was associated with improved survival and rate of adherence., Competing Interests: The authors have disclosed no conflicts of interest. Supplementary material related to this paper is available at http://www.rcjournal.com., (Copyright © 2021 by Daedalus Enterprises.)

Background: Obese subjects are at higher risk of development and progression of ARDS. There are limited data regarding mechanical ventilation practices and use of adjunctive therapies in subjects with ARDS across different obesity classes. We hypothesized that the adherence to lung-protective ventilation would be worse with rising body mass index class in patients with ARDS., Methods: We conducted a retrospective observational study of subjects with ARDS. We evaluated the differences in ventilator settings, airway pressures, gas exchange, use of rescue therapies, length of hospital stay, and mortality among subjects based on the obesity classes of the WHO., Results: The study included 613 subjects with ARDS: 21.4% were normal weight, 25% were overweight, and 53.7% were obese; 33.3% of the obese subjects met criteria for class I-II obesity, while 20.4% were class III obese (morbid obesity). On day 1, 53% of subjects with class III obesity had tidal volumes > 8 mL/kg, compared to 26% of the subjects with normal weight. In addition, 48% of the morbidly obese subjects received at least one rescue therapy as compared to 37% of normal weight subjects and 36% of overweight subjects. There were significant differences in the use of rescue therapies among the groups. In a multivariable model, subjects with class III obesity were significantly more likely to receive tidal volume > 8 mL/kg predicted body weight on day 1 when compared with subjects with normal weight (odds ratio 3.14, 95% CI 1.78-5.57). There was no difference in length of stay in ICU or hospital, duration of mechanical ventilation, or adjusted ICU or hospital mortality among the 4 groups., Conclusions: In this study, the risk of exposure to higher tidal volumes and the need for specific rescue therapies rose with higher classes of obesity in subjects with ARDS. More research is needed to identify how to better implement lung-protective ventilation in patients with obesity., Competing Interests: Mr Chatburn has disclosed relationships with IngMar Medical, Drive/DeVilbiss, and imtmedical. The remaining authors have disclosed no conflicts of interest., (Copyright © 2020 by Daedalus Enterprises.)

Most antiviral or immunomodulatory therapies investigated for use in patients with COVID-19 have failed to show any mortality benefit. Similar to the previous pandemics caused by respiratory viruses, the role and benefit of corticosteroids has been under debate in COVID-19-related pulmonary disease. In this consult, we discuss the evidence regarding the efficacy of corticosteroid use in hospitalized patients with COVID-19, including data from the first randomized controlled trial on this subject., (Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.)

Shock is common in critically ill patients with COVID-19, developing in up to 67% of patients in intensive care (5% to 10% overall) and is associated with high mortality. Optimal management requires prompt recognition with precise evaluation and differentiation. Correcting hypoperfusion and treating the underlying process are fundamental aspects of treatment. Undifferentiated shock may be treated initially with norepinephrine to optimize perfusion while additional evaluation is performed to categorize the shock pathophysiology. Physical examination, bedside echocardiography, hemodynamic monitoring, lactate and venous oxygen saturation are important components of the patient evaluation., (Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.)

Rationale: Survival in patients with cystic fibrosis (CF) is improving over time. Traditionally, there has been concern about high mortality in individuals with CF requiring invasive mechanical ventilation (IMV) for respiratory failure. Objectives: We hypothesized that mortality has decreased over time in this population because of improvements in disease-specific therapies. Methods: The U.S. Nationwide Healthcare Cost and Utilization Project database was used to identify adult patients with CF undergoing IMV between 2002 and 2014. Patients with nonurgent/nonemergent admissions, pregnancy, and encounters related to lung transplantation were excluded. Demographic, geographic, and comorbidities were analyzed. The Cochran-Armitage trend test was used to examine trends in mortality over time. Multivariate mixed effects logistic regression was used to account for possible differences in hospital mortality patterns. Results: We identified 58,799 CF admissions from 2002 to 2014, with 3,727 (6.3%) undergoing IMV. After exclusions, 1,711 admissions remained. In 762 (44.5%) of adult hospitalizations, the patient died. Annual mortality per hospitalization ranged from 29.9 to 55.3%. The Cochran-Armitage trend test suggested an increased probability of survival over time. Factors significantly associated with mortality in multivariate analysis included female sex (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.09), acute renal failure (OR, 1.99; 95% CI, 1.32-3.01), and malnutrition (OR, 1.44; 95% CI, 1.01-2.06). IMV greater than 96 hours was associated with increased mortality in univariate analysis (OR, 1.51; 95% CI, 1.14-1.98); however, after adjustment for potential confounders, the association was no longer statistically significant (OR, 1.05; 95% CI, 0.77-1.43). Conclusions: Mortality per hospitalization in adults with CF who are not bridging to lung transplant and require emergent IMV is 44.5%, suggesting IMV is not futile. Furthermore, mortality decreased over the study period. These finding may help providers, families, and patients with CF weigh the risks and benefits of IMV for respiratory failure.

Objectives: The purpose of this study was to determine the prevalence and scope of point-of-care ultrasound (US) education in internal medicine, pediatric, and medicine-pediatric residency programs nationwide., Methods: Program directors were surveyed between January and June 2016 with a 15-item online questionnaire to assess the state of point-of-care US training in their programs. The survey aimed to identify whether programs had an established point-of-care US curriculum and, if not, what reasons may have existed for a lack of point-of-care US training in their programs., Results: The survey was distributed to 685 program directors, and the response rate was 19.2%. Only 31.5% of respondents reported having a formal point-of-care US curriculum in their program, and in 12.4% of programs, there was no US training at all. The presence of point-of-care US training as reported by internal medicine (n = 64) and medicine-pediatric (n = 24) respondents showed formal point-of-care US curriculum rates of 37.5% and 43.5%, respectively. Pediatric programs (n = 24) reported limited point-of-care US training, with formal curriculum in only 12.4% of programs and 27.3% having no point-of-care US training at all. The most common reasons for lack of a point-of-care US curriculum among program directors were lack of trained faculty/instructors (70.4%), lack of guidelines/standards by governing societies (44.4%), and lack of the necessary technology (33.3%)., Conclusions: Less than half of residents with internal medicine training will have trained at a program with a point-of-care US curriculum, and point-of-care US training in pediatrics is even more limited. The major reason for the lack of point-of-care US education is a lack of trained faculty or instructors., (© 2018 by the American Institute of Ultrasound in Medicine.)

Objective: The aim of the study was to compare caffeine and paraxanthine concentrations in venous blood of pregnant women and in the umbilical cord blood of their newborns., Materials and Methods: Pregnant women who gave birth at the Clinic of Obstetrics, Gynecology and Oncology 2nd Faculty of Medicine, Medical University of Warsaw were included in the study Caffeine and paraxanthine concentrations were analyzed in 30 samples of venous blood serum drawn from the women before delivery and 30 samples of umbilical cord blood serum of their newborns. Caffeine intake in the last 24 hours before delivery was estimated using a questionnaire. Statistical analysis employed a linear logistic regression model, Wilcoxon rank sum test and a non-parametric Spearman's rank correlation coefficient., Results: No difference was found between caffeine concentration in maternal venous blood and neonatal umbilical cord blood. However; paraxanthine level in venous blood was higher than in umbilical cord blood (p = 0.04)., Conclusions: Caffeine consumed by a pregnant woman passes through the placenta to the fetus freely.

Background: There is currently many over the counter products on the market that exert nutritional or physiological effects on the human body. The differences between dietary supplements and non-prescription drugs are however poorly understood by the average consumer and may thus affect their expectations as to the desired effect produced on the body., Objectives: To evaluate patients' knowledge and attitudes towards dietary supplements as compared to non-prescription drugs., Materials and Methods: Subjects were 335 patients of the Mazowiecki Voivodeship Hospital in Warsaw, Poland. The data were collected from a face-to-face interview using a single and multiple choice questionnaire with 10 questions on dietary supplements. Statistical analysis used the Chi-square (χ2) test., Results: The majority of respondents were found to be familiar with the term 'dietary supplements', but had difficulties in classifying these products into appropriate categories. Over 55% do not consider dietary supplements to be foodstuffs and more than 40% considered such products to be drugs. Most respondents thought that the main purpose of taking dietary supplements is to improve nutrition, but over one third expected them to also treat disease. Over 70% declared taking notice to which category the non-prescription products they bought belongs to ie. whether non-prescription drugs (medicinal products) or dietary supplements., Conclusions: Many patients mistakenly believe that dietary supplements are drugs and can be used to treat disease and health disorders., Key Words: dietary supplements, opinion on dietary supplements, nutrition, dietary supplement vs. medicinal product.

Objective: Estimation of the maternal caffeine intake during pregnancy and its influence on pregnancy duration, birthweight and Apgar score of the newborn., Study Design: The research was conducted on pregnant women who gave birth at the Clinic of Obstetrics, Gynaecology and Oncology, 2nd Faculty of Medicine, Medical University of Warsaw. It covered unifetal pregnancies without diseases (N=509). Research data were collected by direct questionnaire supplemented with data from patients' records. Statistical analysis employed a multivariate logistic regression model and a non-parametric Spearman's rank correlation coefficient., Results: 98.4% of pregnant women consume no more than 300 mg of caffeine per day. Pregnant women who smoke and older women consume more caffeine than non-smokers and younger women [β 1.95 (95% CI: 1.02-2.88)] and [β 0.68 (95% CI: 0.05-1.3)] respectively. There is no association between maternal caffeine intake during pregnancy and the risk of premature birth, the birthweight or the Apgar score of newborns., Conclusion: Caffeine intake of no more than 300 mg per day during pregnancy does not affect pregnancy duration and the condition of the newborn., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Aim: To examine if dietary and socio-economic factors contribute to Helicobacter pylori (H pylori) re-infection., Methods: The population of patients consisted of subjects in whom H pylori infection had been successfully treated in the past. Patients were divided into two groups: I-examined group (111 persons with H pylori re-infection) and II-control group (175 persons who had not been re-infected). The respondents were interviewed retrospectively on their dietary habits and socio-economic factors., Results: A statistically significant lower frequency of fermented dairy products (P < 0.0001), vegetables (P = 0.02), and fruit (P = 0.008) consumption was noted among patients with H pylori re-infection as compared to those who had not been re-infected., Conclusion: High dietary intake of probiotic bacteria, mainly Lactobacillus, and antioxidants, mainly vitamin C (contained in fruit and vegetables), might decrease the risk of H pylori re-infection.