Principles of care of critically ill patients

2018 ◽  
pp. 143-150
Author(s):  
Abdullah Jibawi ◽  
Mohamed Baguneid ◽  
Arnab Bhowmick
Keyword(s):  
High Risk ◽  
Brain Stem ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Critically Ill Patients ◽  
Blood Gases ◽  
Scoring Systems ◽  
Perioperative Period ◽  
Circulatory Shock ◽  
Risk Patients

Surgeons should be competent in identifying and treating high-risk patients in the perioperative period, including ability to identify, assess, and initiate treatment for organ dysfunction and circulatory shock, obtain and interpret blood gases, use blood products and fluid composites, support nutrition, treat sepsis, and identify and diagnose brain stem death. The chapter tackles main issues in the diagnosis and treatment of such patients, defines criteria and scoring systems in use for critically ill patients, and summarize treatment principles and approaches recommendations.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients

2020 ◽  
Vol 37 (11) ◽  
pp. 890-896
Author(s):  
Carol M. Bier-Laning ◽  
Jeffrey Hotaling ◽  
W. Jeffrey Canar ◽  
Aziz A. Ansari
Keyword(s):  
General Population ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Critically Ill Patients ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Scoring Systems ◽  
Survival Outcomes ◽  
Logistic Organ Dysfunction ◽  
Failure Assessment

Objectives: To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. Methods: Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. Results: Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent ( P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS ( P = .015) and SOFA ( P = .019) scores and death within 90 days of tracheotomy. Conclusions: The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

scholarly journals Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

BMJ ◽  
2020 ◽  
pp. l6744 ◽  
Author(s):  
Ying Wang ◽  
Zhikang Ye ◽  
Long Ge ◽  
Reed A C Siemieniuk ◽  
Xin Wang ◽  
...  
Keyword(s):  
Systematic Review ◽  
High Risk ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Bleeding Prophylaxis ◽  
Risk Patients

AbstractObjectiveTo determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.DesignSystematic review and network meta-analysis.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.Eligibility criteria for selecting studies and methodsWe included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.ResultsSeventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).ConclusionsFor higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.Systematic review registrationPROSPERO CRD42019126656.

scholarly journals Intensive Care Unit Scoring Systems

2021 ◽  
Vol 41 (4) ◽  
pp. 54-64
Author(s):  
Tiffany Purcell Pellathy ◽  
Michael R. Pinsky ◽  
Marilyn Hravnak
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Critically Ill Patients ◽  
Scoring Systems ◽  
Multiple Organ Dysfunction Score ◽  
Severity Scoring ◽  
Logistic Organ Dysfunction

Background Illness severity scoring systems are commonly used in critical care. When applied to the populations for whom they were developed and validated, these tools can facilitate mortality prediction and risk stratification, optimize resource use, and improve patient outcomes. Objective To describe the characteristics and applications of the scoring systems most frequently applied to critically ill patients. Methods A literature search was performed using MEDLINE to identify original articles on intensive care unit scoring systems published in the English language from 1980 to 2020. Search terms associated with critical care scoring systems were used alone or in combination to find relevant publications. Results Two types of scoring systems are most frequently applied to critically ill patients: those that predict risk of in-hospital mortality at the time of intensive care unit admission (Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Mortality Probability Models) and those that assess and characterize current degree of organ dysfunction (Multiple Organ Dysfunction Score, Sequential Organ Failure Assessment, and Logistic Organ Dysfunction System). This article details these systems’ differing features and timing of use, score calculation, patient populations, and comparative performance data. Conclusion Critical care nurses must be aware of the strengths, limitations, and specific characteristics of severity scoring systems commonly used in intensive care unit patients to effectively employ these tools in clinical practice and critically appraise research findings based on their use.

scholarly journals Serum syndecan-1 reflects organ dysfunction in critically ill patients

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Keiko Suzuki ◽  
Hideshi Okada ◽  
Kazuyuki Sumi ◽  
Hiroyuki Tomita ◽  
Ryo Kobayashi ◽  
...  
Keyword(s):  
Risk Factor ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Critically Ill Patients ◽  
Repeated Measures ◽  
Significant Risk ◽  
Mixed Effects ◽  
Mixed Effects Models ◽  
Endothelial Glycocalyx ◽  
Outcome Variable

AbstractSyndecan-1 (SDC-1) is found in the endothelial glycocalyx and shed into the blood during systemic inflammatory conditions. We investigated organ dysfunction associated with changing serum SDC-1 levels for early detection of organ dysfunction in critically ill patients. To evaluate the effect of SDC-1 on laboratory parameters measured the day after SDC-1 measurement with consideration for repeated measures, linear mixed effects models were constructed with each parameter as an outcome variable. A total of 94 patients were enrolled, and 831 samples were obtained. Analysis using mixed effects models for repeated measures with adjustment for age and sex showed that serum SDC-1 levels measured the day before significantly affected several outcomes, including aspartate aminotransferase (AST), alanine transaminase (ALT), creatinine (CRE), blood urea nitrogen (BUN), antithrombin III, fibrin degradation products, and D-dimer. Moreover, serum SDC-1 levels of the prior day significantly modified the effect between time and several outcomes, including AST, ALT, CRE, and BUN. Additionally, increasing serum SDC-1 level was a significant risk factor for mortality. Serum SDC-1 may be a useful biomarker for daily monitoring to detect early signs of kidney, liver and coagulation system dysfunction, and may be an important risk factor for mortality in critically ill patients.

scholarly journals Haloperidol prophylaxis in critically ill patients with a high risk for delirium

Critical Care ◽  
2013 ◽  
Vol 17 (1) ◽  
pp. R9 ◽  
Author(s):  
Mark van den Boogaard ◽  
Lisette Schoonhoven ◽  
Theo van Achterberg ◽  
Johannes G van der Hoeven ◽  
Peter Pickkers
Keyword(s):  
High Risk ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Haloperidol Prophylaxis

scholarly journals Current use of inotropes in circulatory shock

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Thomas W. L. Scheeren ◽  
Jan Bakker ◽  
Thomas Kaufmann ◽  
Djillali Annane ◽  
Pierre Asfar ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Clinical Signs ◽  
Left Ventricular ◽  
Additional Treatment ◽  
Circulatory Shock ◽  
Left Ventricular Ejection ◽  
First Line ◽  
Ventricular Ejection Fraction

Abstract Background Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. Results A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81–90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). Conclusion Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.

scholarly journals Risk Potential for Organ Dysfunction Associated with Sodium Bicarbonate Therapy (SBT) in Critically Ill Patients with Hemodynamic Worsening

2021 ◽  
Author(s):  
Tiehua Wang ◽  
Lingxian Yi ◽  
Hua Zhang ◽  
Tianhao Wang ◽  
Jingjing Xi ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Metabolic Acidosis ◽  
Sodium Bicarbonate ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Critically Ill Patients ◽  
Control Group ◽  
Increased Risk ◽  
Bicarbonate Therapy ◽  
Risk Potential

Abstract Background: The role of sodium bicarbonate therapy (SBT) remains controversial. This study aimed to investigate whether hemodynamic status before SBT contributed to the heterogeneous outcomes associated with SBT in acute critically ill patients.Methods: We obtained data from patients with metabolic acidosis from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score matching (PSM) was applied to match the SBT group with the control group. Logistic regression and Cox regression were used to analyze a composite of newly “developed or exacerbated organ dysfunction” (d/eOD) within 7 days of ICU admission and 28-day mortality associated with SBT for metabolic acidosis.Results: A total of 1765 patients with metabolic acidosis were enrolled, and 332 pairs obtained by PSM were applied to the final analyses in the study. An increased incidence of newly d/eOD was observed in the SB group compared with the control group (54.8% vs 44.6%, p<0.01). Multivariable logistic regression indicated that the adjusted OR of SBT for this composite outcome was no longer significant [OR (95% CI): 1.39 (0.9, 1.85); p=0.164]. This effect of SBT did not change with the quintiles stratified by pH. Interestingly, SBT was associated with an increased risk of the composite of newly d/eOD in the subgroup of patients with worsening hemodynamics before SBT [adjusted OR (95% CI): 3.6 (1.84, 7.22), p< 0.001]. Moreover, the risk potential for this composite of outcomes was significantly increased in patients characterized by both worsening [adjusted OR (95% CI): 2.91 (1.54, 5.47), p< 0.001] and unchanged hemodynamics [adjusted OR (95% CI): 1.94 (1.01, 3.72), p=0.046) compared to patients with improved hemodynamics before SBT. Our study failed to demonstrate an association between SBT and 28-day mortality in acute critically ill patients with metabolic acidosis.Conclusions: Our findings suggested that SBT for metabolic acidosis was associated with an increased risk potential for subsequent d/eOD, while the hemodynamic status remained unstable during the acute phase of critical illness.

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