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Background: Acute respiratory distress syndrome (ARDS) is defined as severe hypoxemic respiratory failure resulting from diffuse lung injury and secondary to direct and indirect insults. Despite advances, mortality remains as high as 40-60%. Neuromuscular blocking agents (NMBAs) are used to facilitate mechanical ventilation in patients with ARDS and have been shown to improve arterial partial pressure of oxygen. However, the association between NMBAs and mortality is unclear. Furthermore, morbidity concerns exist, particularly regarding a putative role in intensive care unit (ICU)-acquired weakness., Objective: The purpose of this study was to compare survival in adult patients with early ARDS who were randomized to receive either a 48-hr infusion of the NMBA, cisatracurium, or a placebo., Design and Setting: This study was a multicentre double-blinded randomized controlled trial involving 20 ICUs in France from March 2006 to March 2008., Patients: Eligible patients were > 18 yr with an intubated trachea and ventilated lungs for acute hypoxemic respiratory failure. Their PaO(2)/F(i)O(2) ratio was < 150 at a tidal volume of 6-8 mL·kg(-1) ideal body weight and a positive end-expiratory pressure (PEEP) ≥ 5 cm H(2)O for < 48 hr. Additional inclusion criteria were radiographic evidence of bilateral pulmonary infiltrates and the absence of left atrial hypertension. Exclusion criteria included patients already receiving NMBA at enrolment; those who had increased intracranial pressure, severe chronic respiratory disease, or severe chronic liver disease; those who had received a bone marrow transplant or had chemotherapy-induced neutropenia; those who had a pneumothorax; and those who were expected to require mechanical ventilation for < 48 hr or were enrolled in another trial within 30 days., Intervention: Three hundred twenty-six patients were screened, and 340 of these underwent randomization in blocks of four and received either a 48-hr infusion of cisatracurium (15 mg bolus followed by 37.5 mg·hr(-1)) or a volume equivalent placebo. One hundred and seventy-eight patients received a cisatracurium infusion, and one patient withdrew leaving 177 patients included in the analysis. One hundred and sixty-two patients received the placebo infusion. Prior to either infusion, patients were sedated to a Ramsay sedation score of 6. Patients' lungs were ventilated by a volume assist-controlled mode according to the ARDS Clinical Network Mechanical Ventilation Protocol (http://www.ardsnet.org/) with the goal SpO(2) of 88-95% (or PaO(2) 55-80 mmHg) and goal plateau pressure ≤ 35 cm H(2)O. Open-label boluses of cisatracurium 20 mg (maximum of two per 24-hr period) were allowed if plateau pressures remained > 32 cm H(2)O despite increased sedation and despite decreased PEEP and decreased tidal volumes. Monitoring of paralysis via peripheral nerve stimulation was not permitted., Measurements: The primary outcome was death before hospital discharge and within 90 days of study enrolment. It was determined a priori that this would be adjusted for imbalance in key risk factors at baseline, as derived from Cox regression. Secondary outcomes included 28-day mortality, number of ventilator-free days, number of days outside of ICU, number of days without organ system failure, rate of barotrauma, and rate of ICU-acquired paresis (as defined by a Medical Research Council [MRC] score < 48) on day 28 and at ICU discharge., Main Results: With regard to the primary outcome, crude 90-day mortality was 31.6% in the cisatracurium group vs 40.7% in the placebo group. This outcome did not reach statistical significance (P = 0.08). However, post hoc analysis found a reduction in 90-day mortality in the cisatracurium group compared with placebo (95% confidence interval 0.48 to 0.98; P = 0.04). Results suggest that the reduction in 90-day mortality in the cisatracurium group was confined to those patients with a PaO(2)/F(i)O(2) ratio < 120. Additionally, 28-day mortality was significantly lower in the cisatracurium group (absolute difference -9.6%; P = 0.05). The cisatracurium group also had significantly more ventilator-free days, more days outside of the ICU, and more days free of organ-failure. Similarly, pneumothorax developed more often and earlier in the placebo group than in the cisatracurium group. The rate of ICU-acquired weakness at day 28 or at ICU discharge did not differ significantly between the two groups., Conclusions: Treatment in early severe ARDS with the NMBA, cisatracurium, for 48 hr was associated with lower adjusted 90-day mortality. It was also associated with decreased morbidity, which included increased ventilator-free days, increased ICU-free days, and increased organ failure-free days. These benefits occurred without increasing the incidence of ICU-acquired weakness.

Human errors are the most common reason for planes to crash, and of all human errors, suboptimal communication is the number 1 issue. Mounting evidence suggests the same for errors during short-term medical care. Strong verbal communication skills are key whether for establishing a shared mental model, coordinating tasks, centralizing the flow of information, or stabilizing emotions. However, in contrast to aerospace, most medical curricula rarely address communication norms during impending crises. Therefore, this article offers practical strategies borrowed from aviation and applied to critical care medicine. These crisis communication strategies include "flying by voice," the need to combat "mitigating language," the uses of "graded assertiveness" and "5-step advocacy," and the potential role of Situation, Background, Assessment, and Recommendation communication. We also outline the "step-back method," the concept of communication "below ten thousand feet," the impetus behind "closed-loop communication," and the closely related "repeat-back method." The goal is for critical care practitioners to develop a "verbal dexterity" to match their procedural dexterity and factual expertise., (Copyright © 2011. Published by Elsevier Inc.)

Background: Undressing the chest of a cardiac arrest victim may delay the initiation of chest compressions. Furthermore, expecting laypeople to undress the chest may increase bystander reluctance to perform cardiopulmonary resuscitation (CPR). Both of these factors might conceivably decrease survival following cardiac arrest. Therefore, the aim of this study was to examine if the presence or absence of clothes affected the quality of chest compressions during CPR on a simulator manikin., Methods: Thirty laypeople and 18 firefighters were randomised to start CPR on the thorax of a manikin that was either clothed (three layers) or not. Data were obtained via recordings from the manikin and audio- and video-recordings. Measurements were: maximum compression depth; compression rate; percentage of compressions with correct hand positioning; percentage of compressions with complete release (< or = 10 mm), and percentage of compressions of the correct depth (range 40-50 mm). Laypeople were given a four-hour European Resuscitation Council standardised course in basic life support and tested immediately after. Firefighters were tested without additional training. Mock cardiac arrest scenarios consisted of three minutes of CPR separated by 15 minutes of rest., Results: No significant differences were found between CPR performed on an undressed manikin compared to a dressed manikin, for laypeople or firefighters. However, undressing the manikin was associated with a mean delay in the initiation of chest compressions by laypeople of 23 seconds (N = 15, 95% CI: 19;27)., Conclusions: In this simulator manikin study, there was no benefit gained in terms of how well CPR was performed by undressing the thorax. Furthermore, undressing the thorax delayed initiation of CPR by laypeople, which might be clinically detrimental for survival.

Non-convulsive seizures and non-convulsive status epilepticus (NCSE) are believed common in comatose patients and are suggested to worsen outcome. The purpose of this study was to prospectively evaluate outcome in patients in critical care units in whom NCSE was suspected to determine how often evidence of seizure activity existed based on an isolated standard 20 minute electroencephalogram (EEG) and to determine what clinical factors predicted outcome. We prospectively reviewed EEGs and clinical charts of patients admitted to a critical care unit at a tertiary care center who were suspected to have non-convulsive seizures. Outcomes were correlated with EEG findings, clinical factors, and acute therapies using univariate and multivariate logistic analyses. Of 189 patients, complete information was available in 169. Eighty-one (47.9%) patients died, 67 (39.6%) were discharged home, and 21 (12.4%) were discharged to long-term care. Four patients had electroencephalographic seizures, two of whom had no clinical manifestations (i.e. non-convulsive). On univariate analysis, increased age, an admitting diagnosis of cardiac arrest, a Glasgow Coma Scale (GCS) score8, and burst suppression were correlated significantly with poor outcome. A past history of seizures and unequivocal tonic-clonic convulsions were correlated significantly with a better outcome. On multivariate analysis, increased age, cardiac arrest, and a GCS score8 were associated with increased mortality (p<0.05). Clinical factors, including age, underlying etiology and GCS score are the most important predicators of outcome in coma. A standard 20 minute EEG did not correlate with a high detection rate of seizure activity. Furthermore, EEG patterns and treatment with anticonvulsant medications did not correlate with outcome., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

While medical simulation is no panacea, it offers numerous potential strategies for comprehensive and practical training, safer patient care, and for those keen to attract and retain staff. It is a technique, rather than just a technology that promotes experiential and reflective learning. It is also a key strategy to teach Crisis Resource Management skills. Simulation can benefit the individual learner, the multidisciplinary team, and the hospital as a whole. It has been described as a key driver of patient safety, and even as the patient safety laboratory of the future. As such is endorsed by many professional societies in many nations. While challenges remain (and are outlined) there are great opportunities for clinicians, administrators, and educators alike.

Although medical simulation has not been shown to directly save lives, mounting evidence highlights its ability to decrease clinical protocol violations, increase adherence to guidelines, decrease time to competence, enhance team performance, and increase patient safety. These clinical insights suggest that simulation might offer similar improvements in the design, enrollment, and execution of complex phase 3 clinical research trials. This article provides a theoretical outline of why and how this could be done. Matching the simulation technique with the specific trial uses well-established principles from adult education and process engineering. The goal is to give participants the experiential and emotional involvement that fosters complex thought. Simulation can facilitate "dry runs," role playing, analysis of videos, and "what-if" discussions. Simulated interviews with actors might help with obtaining informed consent and thereby boost enrollment. Simulated phone calls might help with reporting adverse outcomes. Full-body mannequins might be used to confirm that teams can coordinate multiple complex steps. Overall, the goal of simulation in clinical trials is to maximize realism while minimizing logistics and cost. While increased study is needed, this technique has considerable potential to decrease the risk to enrolled patients and to increase the accuracy of study data. Simulation provides an effective tool for immersive, interactive and reflective experiences. Overall, if simulation represents a "revolution in healthcare" then clinicians, patients, and now researchers, all stand to gain.

Background: A patient presented with severe acidosis and a point-of-care lactate measurement of 42 mmol/L. Mesenteric ischemia was suspected, with a potential need for laparotomy; however, plasma lactate measurements were below 4 mmol/L. Ethylene glycol ingestion was subsequently diagnosed. We therefore wished to determine why discrepancies in lactate measurements occur and whether this "lactate gap" could be clinically useful., Methods: We phlebotomized blood, added various concentrations of metabolites of ethylene glycol, and tested the resulting samples with the 5 most common lactate analyzers., Results: With the Radiometer 700 point-of-care analyzer, glycolate addition resulted in an artifactual, massive lactate elevation, even at low glycolate concentrations. Another major ethylene glycol metabolite, glyoxylate (but not oxalate or formate), caused similar elevations. The i-STAT and Bayer point-of-care analyzers and the Beckman and Vitros laboratory analyzers reported minimal lactate elevations. Lactate gap was determined by comparing the Radiometer result with the corresponding result from any of the other analyzers., Interpretation: We demonstrated how inappropriate laparotomy or delayed therapy might occur if clinicians are unaware of this phenomenon or have access to only a single analyzer. We also showed that lactate gap can be exploited to expedite treatment, diagnose late ethylene-glycol ingestion and terminate dialysis. By comparing lactate results from the iSTAT or Bayer devices with that from the Radiometer, ethylene-glycol ingestion can be diagnosed at the point of care. This can expedite diagnosis and treatment by hours, compared with waiting for laboratory results for plasma ethylene glycol.

There are a number of causes of raised intracranial pressure (ICP) following aneurysm rupture. These include primary and diffuse hypoxic brain injury, intracranial hematomas, cerebral ischemia or infarction, and obstructive hydrocephalus. More localized brain swelling can also occur: the result of vasogenic and cytotoxic edema resulting from overlying bleeding in the subarachnoid spaces. In the case of rupture of an anterior communicating artery (ACommA) aneurysm and interhemispheric subarachnoid hemorrhage (SAH), this swelling can occur in both frontal lobes and when extensive, and the resulting intracranial hypertension can be difficult to manage with ventricular drainage and medical treatment. We describe two patients in whom decompressive bifrontal craniectomy was associated with successful ICP management and good clinical outcomes.

Purpose: Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication following cerebral revascularization. Management of CHS requires aggressive blood pressure control to prevent stroke and intracerebral hemorrhage. This case report documents a severe case of CHS, and outlines a successful outcome associated with aggressive blood pressure control., Clinical Features: A 67-yr-old gentleman, nine days post left carotid endarterectomy, required tracheal intubation and intensive care unit admission following seizures and acute right-sided weakness. A computed tomography scan and magnetic resonance imaging revealed significant vasogenic edema in the left middle cerebral artery territory, without evidence of infarction. The history and radiographic findings suggested CHS. As such, a systolic blood pressure target was set at 90-140 mmHg. This blood pressure parameter was lower than typically targeted following acute ischemic or hemorrhagic stroke. Rapid clinical improvements were seen by day five, and tight blood pressure control was maintained throughout. Repeat computed tomography and magnetic resonance imaging revealed improved edema and no evidence of infarct or hemorrhage., Conclusion: Cerebral hyperperfusion syndrome is believed to occur following restoration of blood flow to a brain with impaired autoregulation due to chronic hypoperfusion. Massive brain edema and hemorrhage can result from higher pressures. Clinicians should be aware of this potential complication following cerebral revascularization procedures, and the importance of establishing blood pressure targets which are considerably lower than for other patients with similar clinical presentations.

Objectives: Nosocomial Gram-negative bacteremia in the critically ill is associated with significant morbidity and mortality. This study provides epidemiological and antimicrobial susceptibility data for nosocomial Gram-negative bacteremia in a general intensive care unit (ICU) over a five-year period., Methods: Positive blood cultures from January 1, 1999 to December 31, 2003 were reviewed for microbial etiology and susceptibilities. Patient charts were reviewed to determine the source of infection and outcome., Results: Forty-five nosocomial Gram-negative bacteremias occurred in 44 patients. Infection rates of 6.9/1000 admissions and 11.3/10,000 patient days remained stable. Admitting diagnoses included respiratory failure, solid organ transplant, post-surgery, and multi-trauma. Seven bacterial species were identified; Pseudomonas aeruginosa and Enterobacter spp were most common. Sources of bacteremia included pneumonia (48.9%), and central venous catheterization (22.2%). Antimicrobial susceptibilities were highest for imipenem, gentamicin, tobramycin, ceftazidime, and piperacillin-tazobactam. Ciprofloxacin susceptibility was inferior to imipenem, gentamicin, and tobramycin (p < 0.05). Mortality rates were 53.3% in the ICU, and 60% for overall hospitalization. Average length of ICU stay was 50.5 days compared to 6.13 days for all-comers., Conclusions: Nosocomial Gram-negative bacteremia is associated with marked morbidity and mortality in critically ill patients. Significant resistance to ciprofloxacin was demonstrated. Empiric treatment regimens should be based on unit-specific data.

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.

Purpose: To propose a strategy for the management of patients admitted to critical care units after resuscitation from cardiac arrest., Source: Prior to the conference relevant studies were identified via literature searches and brief reviews circulated on the following topics: glucose and blood pressure management; therapeutic hypothermia; prearrest outcome prediction; post-arrest outcome prediction; and management of myocardial ischemia. Two days were devoted to assessing evidence and developing a management strategy at the conference. Consensus opinion of conference participants [intensive care unit (ICU) physicians] was used when high grade evidence was unavailable. Additional literature searches and data grading were performed post-conference., Principal Findings: High grade evidence was lacking in most areas. Specific goals of treatment were proposed for: general care; neurologic care; respiratory care; cardiac care; and gastrointestinal care. There was adequate evidence to recommend therapeutic hypothermia for comatose patients who had witnessed ventricular fibrillation or ventricular tachycardia arrests. Conference participants supported extending therapeutic hypothermia to other presenting rhythms in selected circumstances. Additional goals included mean arterial pressure 80 to 100 mmHg, glucose 5 to 8 mmol.L(-1) using insulin infusions, and PaO(2) > 100 mmHg for the first 24 hr. Absent withdrawal to pain 72 hr after resuscitation should prompt consideration of palliative care. The level of evidence for other recommendations was low., Conclusions: The proposed management strategy represents an approach to manage patients in the ICU following resuscitation from cardiac arrest. Most of the recommendations are based on low grade evidence. Additional research is needed to improve the evidence base. A standard post-arrest management strategy could help facilitate future research.

Although Ca2+ is an important regulator of energy metabolism, the effects of increasing extracellular [Ca2+] on energy substrate preference are not clear. We determined the relationship between [Ca2+], fatty acids, and ischemia on rates of glycolysis, glucose oxidation, and palmitate oxidation in isolated working rat hearts. Hearts were perfused with Krebs-Henseleit buffer containing 11 mM glucose, 100 microU/mL insulin, and either 1.25 or 2.5 mM Ca2+, in the presence or absence of 1.2 mM palmitate. Rates of glycolysis and glucose oxidation or palmitate oxidation were measured in the hearts using [5-3H,14C(U)]glucose or [1-14C]palmitate, respectively. In the absence of fatty acids, glycolysis and glucose oxidation rates were similar, regardless of whether [Ca2+ was 1.25 or 2.5 mM. Addition of 1.2 mM palmitate to the perfusate of hearts perfused with 1.25 mM Ca2+ significantly decreased rates of both glycolysis (from 4623 +/- 438 to 1378 +/- 238 nmol.min-1.g-1 dry weight) and glucose oxidation (from 1392 +/- 219 to 114 +/- 22 nmol.min-1.g-1 dry weight). When [Ca2+] was increased from 1.25 to 2.5 mM in hearts perfused with 1.2 mM palmitate, glycolysis and glucose oxidation increased by 164 and 271%, respectively, with no change in palmitate oxidation rates. Increasing [Ca2+] from 1.25 to 2.5 mM increased the contribution of glucose to ATP production from 9.3 to 18.7%. When hearts were subjected to low-flow ischemia (by reducing coronary flow to 0.5 mL.min-1) oxidative metabolism was essentially abolished. Under these conditions, glycolytic rates were not dependent on either [Ca2+] or the presence or absence of fatty acids. These results demonstrate that perfusate [Ca2+] is an important determinant of myocardial glucose metabolism in aerobic hearts, and that glycolysis and glucose oxidation are more responsive to changes in [Ca2+] than is fatty acid oxidation.