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Purpose of Review: Nosocomial pneumonia is a frequent and severe nosocomial infection divided in two distinct groups: hospital-acquired pneumonia and ventilator-associated pneumonia (VAP). In this context, the VAP is notoriously difficult to diagnose clinically, resulting from the lack of a 'gold standard' method of diagnosis., Recent Findings: The use of biomarkers may potentially improve the early diagnosis of infections allowing earlier and better identification and treatment. An exhausting list of biomarkers has been studied and although far from perfect, procalcitonin (PCT) and C-reactive protein (CRP) are the most studied biomarkers used in clinical practice. Data coming from literature suggests the use of PCT for VAP prognosis and as a based algorithm tool for the reduction of duration of pneumonia therapy, as well as, the use of the CRP dynamics to the early prediction of VAP and the response to the antibiotics., Summary: The evidence for the use of biomarkers to diagnose nosocomial pneumonia as a stand-alone tool is low to moderate. Improved performance for both PCT and CRP can be obtained by using them in association with clinical features or scoring systems but prospective studies are still needed to validate this hypothesis.

Objective: To describe the Epimed Monitor Database®, a Brazilian intensive care unit quality improvement database., Methods: We described the Epimed Monitor® Database, including its structure and core data. We presented aggregated informative data from intensive care unit admissions from 2010 to 2016 using descriptive statistics. We also described the expansion and growth of the database along with the geographical distribution of participating units in Brazil., Results: The core data from the database includes demographic, administrative and physiological parameters, as well as specific report forms used to gather detailed data regarding the use of intensive care unit resources, infectious episodes, adverse events and checklists for adherence to best clinical practices. As of the end of 2016, 598 adult intensive care units in 318 hospitals totaling 8,160 intensive care unit beds were participating in the database. Most units were located at private hospitals in the southeastern region of the country. The number of yearly admissions rose during this period and included a predominance of medical admissions. The proportion of admissions due to cardiovascular disease declined, while admissions due to sepsis or infections became more common. Illness severity (Simplified Acute Physiology Score - SAPS 3 - 62 points), patient age (mean = 62 years) and hospital mortality (approximately 17%) remained reasonably stable during this time period., Conclusion: A large private database of critically ill patients is feasible and may provide relevant nationwide epidemiological data for quality improvement and benchmarking purposes among the participating intensive care units. This database is useful not only for administrative reasons but also for the improvement of daily care by facilitating the adoption of best practices and use for clinical research.

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

Background: Subsyndromal delirium (SSD) is a frequent condition and has been commonly described as an intermediate stage between delirium and normal cognition. However, the true frequency of SSD and its impact on clinically relevant outcomes in the intensive care unit (ICU) remains unclear., Methods: We performed a systematic search in PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 October 2016 to identify publications that evaluated SSD in ICU patients., Results: The six eligible studies were evaluated. SSD was present in 950 (36%) patients. Four studies evaluated only surgical patients. Four studies used the Intensive Care Delirium Screening Checklist (ICDSC) and two used the Confusion Assessment Method (CAM) score to diagnose SSD. The meta-analysis showed an increased hospital length of stay (LOS) in SSD patients (0.31, 0.12-0.51, p = 0.002; I 2  = 34%). Hospital mortality was described in two studies but it was not significant (hazard ratio 0.97, 0.61-1.55, p = 0.90 and 5% vs 9%, p = 0.05). The use of antipsychotics in SSD patients to prevent delirium was evaluated in two studies but it did not modify ICU LOS (6.5 (4-8) vs 7 (4-9) days, p = 0.66 and 2 (2-3) vs 3 (2-3) days, p = 0.517) or mortality (9 (26.5%) vs 7 (20.6%), p = 0.55)., Conclusions: SSD occurs in one-third of the ICU patients and has limited impact on the outcomes. The current literature concerning SSD is composed of small-sample studies with methodological differences, impairing a clear conclusion about the association between SSD and progression to delirium or worse ICU clinical outcomes.

Background: Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs., Patients and Methods: Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality., Results: Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge., Conclusions: ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option., (© The Author 2014. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support., Methods: This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality., Results: Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes., Conclusions: Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Introduction: Coagulation abnormalities are frequent in patients with severe infections. However, the predictive value of d-dimer and of the presence of associated coagulation derangements in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of coagulation parameters in patients with severe CAP admitted to the intensive care unit., Methods: d-Dimer, antithrombin, International Society of Thrombosis and Hemostasis score, clinical variables, Sequential Organ Failure Assessment (SOFA), The Acute Physiology and Chronic Health Evaluation II (APACHE II) and the CURB-65 score were measured in the first 24 hours. Results are shown as median (25%-75% interquartile range). The main outcome measure was hospital mortality., Results: Ninety patients with severe CAP admitted to the intensive care unit were evaluated. Overall hospital mortality was 15.5%. d-Dimer levels in nonsurvivors were higher than those in survivors. In the univariate analysis, d-dimer, SOFA, and APACHE II scores were predictors of death. The discriminative ability of d-dimer (area under receiver operating curve = 0.75 [95% confidence interval, 0.64-0.83]; best cutoff for d-dimer was 1798 ng/mL) for in-hospital mortality was comparable with APACHE II and SOFA and better than C-reactive protein. Moreover, the addition of d-dimer to APACHE II or SOFA score increased the discriminative ability of both scores (area under the receiver operating curve = 0.82 [0.72-0.89] and 0.84 [0.75-0.91], respectively)., Conclusions: d-Dimer levels are good predictors of outcome in severe CAP and may augment the predictive ability of scoring systems as APACHE II and SOFA., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The prognostic effect of neutropenia in cancer patients admitted to intensive care units (ICUs) was addressed exclusively in cohort studies with conflicting results. Our aim was to address this question using a matched case-control study., Patients and Methods: Ninety-four neutropenic patients and 94 non-neutropenic controls were matched for age, cancer type, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment score, and need for mechanical ventilation and vasopressors. Conditional logistic regression was used to identify factors associated with hospital mortality., Results: The ICU (66% versus 66%, P = 0.999) and hospital (73% versus 78%, P = 0.611) mortality rates were similar in neutropenic and non-neutropenic patients. Adjusting for the type of admission and length of hospital stay before ICU admission, the characteristics associated with increased mortality were the severity of acute disease and organ failures, compromised performance status and sepsis diagnosis. The impact of both previous chemotherapy and neutropenia on the outcomes was not significant., Conclusions: Using a matched case-control study design, our results provide additional evidence that the presence of neutropenia is no longer associated with worse outcomes in critically ill patients with cancer. Moreover, our results also corroborate that recent exposure to chemotherapy is not associated with increased risk for death.

Background: High cortisol levels are frequent in patients with severe infections. However, the predictive value of total cortisol and of the presence of critical illness-related corticosteroid insufficiency (CIRCI) in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of adrenal response in patients with severe CAP admitted to the ICU., Methods: Baseline and postcorticotropin cortisol levels C-reactive protein (CRP), d-dimer, clinical variables, sequential organ failure assessment (SOFA), APACHE (acute physiology and chronic health evaluation) II, and CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age > or = 65 years) scores were measured in the first 24 h. Results are shown as median (interquartile range [IQR]). The major outcome measure was hospital mortality., Results: Seventy-two patients with severe CAP admitted to the ICU were evaluated. Baseline cortisol levels were 18.1 microg/dL (IQR, 14.4 to 26.7 microg/dL), and the difference between baseline and postcorticotropin cortisol after 250 microg of corticotropin was 19 microg/dL (IQR, 12.8 to 27 microg/dL). Baseline cortisol levels presented positive correlations with scores of disease severity, including CURB-65, APACHE II, and SOFA (p < 0.05). Cortisol levels in nonsurvivors were higher than in survivors. CIRCI was diagnosed in 29 patients (40.8%). In univariate analysis, baseline cortisol, CURB-65, and APACHE II were predictors of death. The discriminative ability of baseline cortisol (area under receiver operating characteristic curve, 0.77; 95% confidence interval, 0.65 to 0.90; best cutoff for cortisol, 25.7 microg/dL) for in-hospital mortality was better than APACHE II, CURB-65, SOFA, d-dimer, or CRP., Conclusions: Baseline cortisol levels are better predictors of severity and outcome in severe CAP than postcorticotropin cortisol or routinely measured laboratory parameters or scores as APACHE II, SOFA, and CURB-65.

Background: Data on patients with cancer who have a prolonged length of stay (LOS) in the ICU are scarce. The aim of the present study was to evaluate the characteristics and the outcomes of cancer patients with life-threatening complications with an ICU stay > or = 21 days., Methods: A cohort study performed at a 10-bed oncology medical-surgical ICU from May 2000 to December 2005. Prolonged ICU LOS was defined as an ICU stay > or = 21 days., Results: During the period, 1,090 patients were admitted to the ICU and 163 patients (15%) had a prolonged ICU LOS. These patients, however, accounted for 48% (5,828/12,224) of the total ICU bed-days. The hospital and 6-month mortality rates were 50% and 60%, respectively, and similar to patients with ICU LOS < 21 days (51% and 61%, respectively). ICU-acquired events and complications were common, and the most frequent were infections (90%), mechanical ventilation (99%), and need for vasopressors (88%). The number of organ failures, older age, and poor performance status were the main outcome predictors. The median long-term follow-up after hospital discharge was 537 days (range, 193 to 1,119 days), and 29 patients (18%) were alive., Conclusions: Fifteen percent of critically ill patients with cancer had a prolonged ICU LOS. Short- and long-term survival rates were reasonable, and the prognosis was better than expected a priori. In our opinion, the length of ICU admission per se should not be used in the clinical decisions regarding the continuation of treatment in these patients.

Background: The management of patients with lung cancer has improved recently, and many of them will require admission to the ICU. The aims of this study were to determine hospital mortality and to identify risk factors for death in a large cohort of critically ill patients., Methods: Cohort study in two ICUs specialized in the management of patients with cancer, in France and Brazil., Results: Of the 143 patients (mean age, 61.6 +/- 9.9 years [+/- SD]), 25 patients (17%) had small cell lung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICU admission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) was used in 100 patients (70%), including 38 patients in whom lung cancer was considered a reason for MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariate logistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancer recurrence or progression, and severity of comorbidities were associated with increased mortality., Conclusions: The improved survival previously reported in patients with cancer admitted to the ICU seems to extend to patients with lung cancer, including those who need MV. Mortality increased with the number of organ failures, severity of comorbidities, and presence of respiratory failure due to cancer progression. The type of the cancer per se was not associated with mortality and, therefore, should not be factored into ICU triage decisions.