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The article offers information on a study which emphasizes the delay in oseltamivir administration as a major risk factor for in-hospital mortality. Topics discussed include need for influenza-infected patient management in intensive care unit (ICUs); information on hospitalizations in intensive care units (ICUs) because of influenza; and information on efficacy of oseltamivir to reduce the duration of symptoms, respiratory tract complications, and hospital admittance.

The article focuses on the ventilated patient, patients with artificial respiration. Topics mentioned include the respiratory control system (RCS), the importance of patients care management, and the breathing measurement. Also mentioned are the irregular patterns of heart beat, the pressure-control ventilation, and the activation of inspiratory muscles.

Purpose: Pleural and abdominal pressure are clinically estimated by measuring the esophageal and bladder or intragastric pressure (IGP), respectively. A new nasogastric polyfunctional catheter is now commercially available, equipped with two balloons in the lower and distal part; this catheter allows simultaneous esophageal pressure (Pes) and IGP measurements and can be also used to feed the patient. We compared the Pes and IGP measured using this new device with those obtained with a standard balloon catheter taken as gold standard. Methods: Twenty-four intubated patients requiring ventilator support (mean age 64.3 ± 16.8 years, body mass index 25.3 ± 3.0 kg/m, and PaO/FiO 280.8 ± 123.4 mmHg) were enrolled. Esophageal pressure and IGP were measured with the new nasogastric polyfunctional catheter (Nutrivent, Sidam, Italy) and with a standard balloon catheter (Smart Cath Viasys, USA). The Smart Cath was first inserted in the stomach and then retracted to the esophagus to measure IGP and Pes, respectively. In each patient two paired measurements were averaged. Results: In the Bland-Altman analysis, the bias and agreement bands for Pes, ΔPes (computed as the difference of esophageal pressure between end-inspiration and expiration), and IGP were −0.25 (−2.65 to +2.15), 0.0 (−0.9 to +0.9), and −0.45 (−2.85 to + 1.95) cmHO, respectively. No side effects or complications were recorded. Conclusions: The new polyfunctional catheter showed a clinically acceptable validity in recording esophageal and intragastric pressure. This device should help physicians to better individualize the clinical patient management. [ABSTRACT FROM AUTHOR]

The article focuses on bacterial causes of sepsis and septic shock. Topics discussed include increased use of combination therapy and broad spectrum antibiotics risks increasing antimicrobial resistance, enhanced surveillance necessitates better collaboration between stakeholders and improved microbiological facilities, and improving management of individual patients by providing high-quality epidemiological data.

A letter to the editor is presented that discusses the guidelines that intensivists follow for managing primary spontaneous pneumothorax in healthy patients.

The author reflects on the challenges and potential solutions in obtaining consent from patients who will participate in clinical research in the intensive care unit (ICU). He explains that challenges in obtaining consent from respondents arises due to the issue in providing substitute decision maker (SDM) in patients who are critically ill. The author also argues that SDM can sometimes fail to offer the accurate wishes of patients.

Acute kidney injury (AKI) is associated with significantly increased morbidity and mortality. To provide a uniformly accepted definition, the RIFLE classification was introduced by the Acute Dialysis Quality Initiative, recently modified by the Acute Kidney Injury Network (AKIN), suggesting staging of AKI based on dynamic changes within 48 h. This study compares these two classification systems with regard to outcome. Cohort analysis of SAPS 3 database. Sixteen thousand seven hundred and eighty-four ICU patients from 303 ICUs were analysed. Classification was performed according to RIFLE (Risk, Injury, Failure) or according to AKIN (stage 1, 2, 3) without including a requirement of renal replacement therapy in the analysis. Changes of serum creatinine as well as urinary output were assessed for both AKIN and RIFLE during the first 48 h of ICU admission. Primary endpoint was hospital mortality. Incidence of AKI in our population of critically ill patients was found to range between 28.5 and 35.5% when applying AKIN and RIFLE criteria, respectively, associated with increased hospital mortality averaging 36.4%. Observed-to-expected mortality ratios revealed excess mortality conferred by any degree of AKI increasing from 0.81 for patients classified as non-AKI up to 1.31 and 1.23 with AKIN stage 3 or RIFLE Failure, respectively. AKIN misclassified 1,504 patients as non-AKI compared to RIFLE which misclassified 504 patients. Acute kidney injury classified by either RIFLE or AKIN is associated with increased hospital mortality. Despite presumed increased sensitivity by the AKIN classification, RIFLE shows better robustness and a higher detection rate of AKI during the first 48 h of ICU admission. [ABSTRACT FROM AUTHOR]

Most critically ill patients are incapable of providing informed consent for research. We sought to determine patients’ preferences for different consent frameworks for enrolling incapable patients into critical-care trials. Prospective observational and structured interview study. Five university-affiliated hospitals in Ontario. Two-hundred and forty consecutive capable and consenting survivors of critical illness. Participants considered four frameworks for enrolling incapable patients into clinical trials using a baseline scenario and three permutations for: risk (very low vs. high), treatment type (new vs. currently available), and availability of substitute decision-maker (yes vs. no). For each scenario, patients chose their preferred framework and rated the acceptability of each framework using a seven-point Likert scale. Most (180/240; 76%) patients selected “consent by substitute prior to enrolment” as their preferred framework; this also received the highest baseline acceptability ratings (“acceptable” or “highly acceptable” 207/240; 87%). Modifying risk or treatment type did not substantially change these ratings. A minority of patients rated delayed consent as unacceptable or highly unacceptable in both the baseline scenario (48/240, 20% delayed to substitute; 57/240, 24% delayed to patient) and when a substitute was unavailable (34/240; 15%). Most survivors of critical illness found the usual practice of obtaining informed consent from a substitute decision-maker prior to enrolment in a clinical trial to be acceptable. Nearly half of patients considered foregoing informed consent to be unacceptable, whereas a minority considered enrolment followed by delayed consent to be unacceptable even when a substitute was unavailable. These approaches should, therefore, only be considered when deviating from the usual practice of obtaining consent from a substitute decision-maker is truly justified, such as where treatments being tested need to be delivered as soon as possible in order to be effective. [ABSTRACT FROM AUTHOR]

To evaluate the incidence of unintended tube, line, and drain removals (UTRs) in our ICU, to identify system factors associated with UTRs, and to evaluate interventions designed to decrease UTR occurrence. Interventional study in the 18-bed medical ICU of a French general university hospital. We prospectively determined the incidence and circumstances of UTRs in our ICU over a 2-year period. Demographic and clinical data were collected for consecutively admitted patients, and additional information was recorded about patients experiencing UTRs. Investigators analyzed UTR data twice a month to identify possible causes and developed interventions to decrease UTRs (mainly securing tubes and sedation protocol). Conditional logistic regression stratified on length of stay was used to identify risk factors for UTRs and segmented linear regression analysis to test the effects of interventions. Of 2,007 admitted patients (12,256 patient days), 193 (9.6%) experienced 270 UTRs (22/1,000 patient days). Clinical or therapeutic consequences occurred for 17% of UTRs. Three factors were independently associated with UTR; two were risk factors, namely, admission for coma [OR, 2.68; 95% CI (1.87; 3.84); P < 0.0001] and mechanical ventilation in over 65% of all ICU patients [OR = 1.65 (1.19; 2.29); P = 0.003], and one was protective, namely, mean SAPS II >45 in all ICU patients [OR, 0.54; 95% CI (0.39; 0.75); P = 0.0003]. Segmented regression analysis showed a 67.4% drop [95% CI (17.2%; 117.3%); P = 0.009] in the UTR rate after the first intervention was introduced. System factors played a major role in UTR occurrence. UTRs are common. A continuous quality-improvement program can reduce UTR rates in the ICU. [ABSTRACT FROM AUTHOR]

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs). To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making. Retrospective, observational. Consecutive patients admitted to a 12-bed closed medical-surgical ICU. Patients with EOLD discharged home or transferred to another hospital. Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group. Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens. [ABSTRACT FROM AUTHOR]

To study the diurnal variation of melatonin and cortisol in critically ill patients and to assess whether the severity of organ dysfunction, sedation and sympathetic activity correlate with the production of these hormones. Prospective clinical study. Surgical intensive care unit in a university hospital. Forty non-septic patients without brain injury and treatment with adrenergic agonists or corticosteroids. Twenty-five of the patients were sedated with benzodiazepines. None. The pattern of melatonin production was monitored by the determination of 6-sulphatoxymelatonin (aMT6s) in urine. The 12-h aMT6s excretions at nights (11.8 ± 8.9 μg, mean ± SD) were higher than in the daytime (6.8 ± 7.5 μg; P < 0.0001), and benzodiazepine treatment did not abolish the diurnal periodicity of aMT6s excretion during the entire 3-day study period. Serum cortisol concentrations at noon (524 ± 276 nmol/l, mean ± SD) were higher than at midnight (415 ± 172 nmol/l; P < 0.0001), and the decrease at midnight was significant also in the patients treated with benzodiazepines. Sympathetic activity was monitored with urine vanillylmandelic acid (VMA). The 12-h VMA excretions did not show a diurnal variation, but a significant positive relationship between the 12-h VMA and aMT6s excretions was observed. The severity of organ dysfunction did not correlate either with the aMT6s and VMA excretion or with serum cortisol concentration. The diurnal variation of melatonin and cortisol is maintained in non-septic intensive care unit patients. Benzodiazepines do not impair the diurnal variation of melatonin and cortisol. [ABSTRACT FROM AUTHOR]

Monitoring end-expiratory lung volume (EELV) is a valuable tool to optimize respiratory settings that could be of particular importance in mechanically ventilated pediatric patients. We evaluated the feasibility and precision of an intensive care unit (ICU) ventilator with an in-built nitrogen washout/washin technique in mechanically ventilated pediatric patients. Duplicate EELV measurements were performed in 30 patients between 5 kg and 43 kg after cardiac surgery (age, median + range: 26, 3–141 months). All measurements were taken during pressure-controlled ventilation at 0 cm H2O of positive end-expiratory pressure (PEEP). Linear regression between duplicate measurements was excellent ( R2 = 0.99). Also, there was good agreement between duplicate measurements, bias ± SD: −0.3% (−1.5 mL) ± 5.9% (19.2 mL). Mean EELV ± SD was 19.6 ± 5.1 mL/kg at 0 cm H2O PEEP. EELV correlated with age ( p < 0.001, r = 0.92, R2 = 0.78), body weight ( p < 0.001, r = 0.91, R2 = 0.82) and height ( p < 0.001, r = 0.94, R2 = 0.75). This ICU ventilator with an in-built nitrogen washout/washin EELV technique can measure EELV with precision, and can easily be used for mechanically ventilated pediatric patients. [ABSTRACT FROM AUTHOR]

Ventilator-associated pneumonia caused by Pseudomonas aeruginosa with impaired sensitivity to ceftazidime is frequent in critically ill patients. The aim of the study was to compare lung tissue deposition and antibacterial efficiency between nebulized and intravenous administrations of ceftazidime in ventilated piglets with pneumonia caused by Pseudomonas aeruginosa with impaired sensitivity to ceftazidime. Ceftazidime was administered 24 h following the intra-bronchial inoculation of Pseudomonas aeruginosa (minimum inhibitory concentration = 16 μg ml−1), either by nebulization (25 mg kg−1 every 3 h, n = 6) or by continuous intravenous infusion (90 mg kg−1 over 24 h after an initial rapid infusion of 30 mg kg−1, n = 6). Four non-treated inoculated animals served as controls. All piglets were killed 48 h (intravenous and control groups) or 51 h (aerosol group) after inoculation. Lung tissue concentrations and lung bacterial burden were assessed on multiple post-mortem sub-pleural lung specimens [(lower limit of quantitation = 102 colony forming unit (cfu g−1)]. Ceftazidime trough lung tissue concentrations following nebulization were greater than steady-state lung tissue concentrations following continuous intravenous infusion [median and interquartile range, 24.8 (12.6–59.6) μg g−1 vs. 6.1 (4.6–10.8) μg g−1] ( p < 0.001). After 24 h of ceftazidime administration, 83% of pulmonary segments had bacterial counts <102 cfu g−1 following nebulization and only 30% following intravenous administration ( p < 0.001). In control animals, 10% of lung segments had bacterial counts <102 cfu g−1 48 h following bronchial inoculation. Nebulized ceftazidime provides more efficient bacterial killing in ventilated piglets with pneumonia caused by Pseudomonas aeruginosa with impaired sensitivity to ceftazidime. [ABSTRACT FROM AUTHOR]

During neurally adjusted ventilatory assist (NAVA) the ventilator is driven by the patients electrical activation of the diaphragm (EAdi), detected by a special esophageal catheter. A reliable positioning of the EAdi-catheter is mandatory to trace a representative EAdi signal. We aimed to determine whether a formula that is based on the measurement from nose to ear lobe to xiphoid process of the sternum (NEX distance) modified for EAdi-catheter placement (NEXmod) is sufficient for predicting the accurate catheter position. Twenty-six patients were enrolled in this study. The optimal EAdi-catheter position (OPT) was defined by: (1) stable EAdi signal, (2) electrical activity highlighted in central leads of the catheter positioning tool, and (3) absence of p-wave in distal lead. Afterwards NEXmod was calculated and compared to the OPT finding. At NEXmod the EAdi signal was suitable for running NAVA in 18 out of 25 patients (72%). NEXmod was identical with OPT in four patients (16%). NAVA was possible in all patients at OPT. Median OPT position was 2 cm caudal of the NEXmod ranging from 3 cm too cranial to a position 12 cm too caudal ( P < 0.01). In one patient excluded from further analysis EAdi-catheter placement led to the diagnosis of bilateral injury of the phrenic nerves. EAdi-catheter placement based on the NEXmod formula allows running NAVA in about two-thirds of all patients. The additional tools provided are efficient and facilitate the correct positioning of the EAdi-catheter for neurally adjusted ventilatory assist. [ABSTRACT FROM AUTHOR]

The author reflects on the issue concerning the proper way of administering and managing patients suffering from progressive hemorrhage. He argues that the issue arises due to the debate which medical intervention should be used between oxygenation and making early resuscitation. However, the author explains that studies revealed that both interventions are used in hospitals.

The article offers information on a study about patient management and the evidence that closed intensive care units (ICU) are associated with better outcomes and better quality of care for patients and families. It also discusses the benefits of closed-format ICU on patient outcomes and positive effects on other aspects such as staff and family satisfaction.

The author reflects on the findings of the study on the prevalence of post-traumatic stress disorder (PTSD) in patients inside the intensive care unit (ICU). The author explains that this study is an important step on how to handle these patients in a timely and objective manner while they are treated with their diseases. The author suggests those attending the patients should pray for a good and health minds of personnel responsible for the patients' care.

The author reflects on the assessment and review made by Dr. S. Gorman and his colleagues on the 24 critical care medical guidelines for intensive care medicine. It says that the Appraisal of Guidelines, Research and Evaluation (AGREE) Collaboration tool was used in the evaluation of the methodologic quality of the 24 guidelines. The authors emphasize the need for a more detailed and well-formulated guideline and recommendations essential in effective management of critically ill patients.