2009 Therapeutic hypothermia and controlled normothermia in the intensive care unit: Practical considerations, side effects, and cooling methods* [Review Article]

Critical Care Medicine:Volume 37(3)March 2009pp 1101-1120

Polderman, Kees H. MD, PhD; Herold, Ingeborg MD;
From the Department of Intensive Care, University Medical Center Utrecht, The Netherlands.

HKSCCM Chief Editor comment: A good and comprehensive review on this topic.

Abstract
Background: Hypothermia is being used with increasing frequency to prevent or mitigate various types of neurologic injury. In addition, symptomatic fever control is becoming an increasingly accepted goal of therapy in patients with neurocritical illness. However, effectively controlling fever and inducing hypothermia poses special challenges to the intensive care unit team and others involved in the care of critically ill patients.

Objective: To discuss practical aspects and pitfalls of therapeutic temperature management in critically ill patients, and to review the currently available cooling methods.

Design: Review article.

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2009 Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: A randomized controlled trial

Critical Care Medicine. 37(3):803-810, March 2009

Payen, Didier MD, PhD; Mateo, Joaquim MD; Cavaillon, Jean Marc PhD; Fraisse, Francois MD; Floriot, Christian MD; Vicaut, Eric MD, PhD; for the Hemofiltration and Sepsis Group of the College National de Reanimation et de Medecine d'Urgence des Hopitaux extra-Universitaires


From the Department of Anesthesiology and Critical Care Medicine (DPJ, JM), Lariboisiere Hospital, University Paris, Paris, France; Unit Cytokines & Inflammation (JMC), Institut Pasteur, Paris, France; Department of Intensive Care (FF), Delafontaine Hospital, Saint-Denis, France; Department of Intensive Care (CF), P. Morel Hospital, Vesoul, France; and Unite de Recherche Clinique (EV), Fernand-Widal University Hospital, Paris, France.

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2008 Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine.

Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH,
Kaufman DC; American Academy of Critical Care Medicine. Crit Care Med. 2008 Mar;36(3):953-63.

Erratum in:
    Crit Care Med. 2008 May;36(5):1699.

Harvard Medical School and Children's Hospital, Boston, MA, USA.
This email address is being protected from spambots. You need JavaScript enabled to view it.

BACKGROUND: These recommendations have been developed to improve the care of
intensive care unit (ICU) patients during the dying process. The recommendations
build on those published in 2003 and highlight recent developments in the field
from a U.S. perspective. They do not use an evidence grading system because most
of the recommendations are based on ethical and legal principles that are not
derived from empirically based evidence. PRINCIPAL FINDINGS: Family-centered
care, which emphasizes the importance of the social structure within which
patients are embedded, has emerged as a comprehensive ideal for managing
end-of-life care in the ICU. ICU clinicians should be competent in all aspects of
this care, including the practical and ethical aspects of withdrawing different
modalities of life-sustaining treatment and the use of sedatives, analgesics, and
nonpharmacologic approaches to easing the suffering of the dying process. Several
key ethical concepts play a foundational role in guiding end-of-life care,
including the distinctions between withholding and withdrawing treatments,
between actions of killing and allowing to die, and between consequences that are
intended vs. those that are merely foreseen (the doctrine of double effect).
Improved communication with the family has been shown to improve patient care and
family outcomes. Other knowledge unique to end-of-life care includes principles
for notifying families of a patient's death and compassionate approaches to
discussing options for organ donation. End-of-life care continues even after the
death of the patient, and ICUs should consider developing comprehensive
bereavement programs to support both families and the needs of the clinical
staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU
has been developed to guide research, quality improvement efforts, and
educational curricula. CONCLUSIONS: End-of-life care is emerging as a
comprehensive area of expertise in the ICU and demands the same high level of
knowledge and competence as all other areas of ICU practice.

2009 Citrate anticoagulation for continuous venovenous hemofiltration.

Crit Care Med. 2009 Dec 26.

Oudemans-van Straaten HM, Bosman RJ, Koopmans M, van der Voort PH, Wester JP, van der Spoel JI, Dijksman LM, Zandstra DF.

From the Department of Intensive Care Medicine (HMO-vS, RJB, MK, PHJvdV, JPJW, JIvdS, DFZ); and Teaching Hospital (LMD), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

OBJECTIVE:: Continuous venovenous hemofiltration (CVVH) is applied in critically ill patients with acute renal failure for renal replacement. Heparins used to prevent circuit clotting may cause bleeding. Regional anticoagulation with citrate reduces bleeding, but has metabolic risks. To compare the safety and efficacy of the two. DESIGN:: Randomized, nonblinded, controlled single-center trial. SETTING:: General intensive care unit of a teaching hospital. PATIENTS:: Adult critically ill patients needing CVVH for acute renal failure and without an increased bleeding risk. INTERVENTIONS:: Regional anticoagulation with citrate or systemic anticoagulation with the low-molecular weight heparin nadroparin. MEASUREMENTS AND MAIN RESULTS:: End points were adverse events necessitating discontinuation of study anticoagulant, transfusion, metabolic and clinical outcomes, and circuit survival. Of the 215 randomized patients, 200 received CVVH per protocol (97 citrate and 103 nadroparin). Adverse events required discontinuation of citrate in two patients (accumulation and clotting) of nadroparin in 20 (bleeding and thrombocytopenia) (p < 0.001). Bleeding occurred in 6 of 16 patients (p = 0.08). The median number of red blood cell units transfused per CVVH day was 0.27 (interquartile range, 0.0-0.63) for citrate, 0.36 (interquartile range, 0-0.83) for nadroparin (p = 0.31). Citrate conferred less metabolic alkalosis (p = 0.001) and lower plasma calcium (p < 0.001). Circuit survival was similar. Three-month mortality on intention-to-treat was 48% (citrate) and 63% (nadroparin) (p = 0.03), per protocol 45% and 62% (p = 0.02). Citrate reduced mortality in surgical patients (p = 0.007), sepsis (p = 0.01), higher Sepsis-Related Organ Failure Assessment score (p = 0.006), and lower age (p = 0.009). CONCLUSIONS:: The efficacy of citrate and nadroparin anticoagulation for CVVH was similar, however, citrate was safer. Unexpectedly, citrate reduced mortality. Less bleeding could only partly explain this benefit, less clotting could not. Post hoc citrate appeared particularly beneficial after surgery, in sepsis and severe multiple organ failure, suggesting interference with inflammation.


Comment: This is the first study showing mortality benefit when using citrate as anticoagulant for CVVH.

2009 Furosemide does not improve renal recovery after hemofiltration for acute renal failure in critically ill patients: A double blind randomized controlled trial

Crit Care Med. 2009 Dec 26. [Epub ahead of print]

van der Voort PH, Boerma EC, Koopmans M, Zandberg M, de Ruiter J, Gerritsen RT, Egbers PH, Kingma WP, Kuiper MA.

From the Department of Intensive Care (PHJvdV, MK), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; and Department of Intensive Care, (PHJvdV, ECB, MK, MZ, JdR, RTG, PHME, WPK, MAK) Medical Center Leeuwarden, Amsterdam, The Netherlands.

OBJECTIVE:: To study the potential beneficial role of furosemide in resolving renal failure after hemofiltration in mechanically ventilated critically ill patients. DESIGN:: Single-center randomized, double blind, placebo-controlled study. SETTING:: A 13-bed mixed intensive care unit (ICU) in a teaching hospital. PATIENTS:: Patients who had been treated with continuous venovenous hemofiltration were included. INTERVENTIONS:: After the end of continuous venovenous hemofiltration, the urine of the first 4 hours was collected for measuring creatinine clearance. Patients were subsequently randomized for furosemide (0.5 mg/kg/hr) or placebo by continuous infusion. To prevent hypovolemia, the rate of fluid infusion was adapted every hour and was set as the urinary production of the previous hour. MEASUREMENTS AND MAIN RESULTS:: End points were renal recovery (creatinine clearance more than 30 mL/min or stable serum creatinine without renal replacement therapy) in the ICU and in the hospital. Seventy-two patients were included and 71 were eligible for the analysis. The 36 furosemide-treated patients had a significantly increased urinary volume compared with the 35 placebo-treated patients (median 247 mL/hr (interquartile range [IQR] 774 mL/hr) vs. 117 mL/hr (IQR 158 mL/hr), p = 0.003) and greater sodium excretion (median 73 mmol/L (IQR 48) vs. 37 (IQR 48) mmol/L, p = 0.001). In the furosemide group 25 patients and in the placebo group 27 patients showed recovery of renal function at ICU discharge (p = 0.46). Two patients of the furosemide group needed long-term dialysis dependency (p = 0.23). CONCLUSION:: Furosemide by continuous infusion in the recovery phase of hemofiltration-dependent acute kidney failure did increase urinary volume and sodium excretion but did not lead to a shorter duration of renal failure or more frequent renal recovery.

2009 Adverse outcomes associated with the use of drotrecogin alfa (activated) in patients with severe sepsis and baseline bleeding precautions

Gentry CA, Gross KB, Sud B, Drevets DA. Crit Care Med. 2009 Jan;37(1):19-25.

Pharmacy Service, Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA. This email address is being protected from spambots. You need JavaScript enabled to view it.

BACKGROUND: Key clinical trials involving drotrecogin alfa (activated) (or recombinant human activated protein C) excluded patients with specific baseline bleeding precautions. However, not all such precautions are considered contraindications to treatment with recombinant human activated protein C in current product labeling. OBJECTIVE: To compare outcomes of patients receiving
recombinant human activated protein C with or without baseline bleeding precautions as defined by the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial. DESIGN: Retrospective medical record review. SETTING: Two tertiary care institutions: An academic medical center and an affiliated Veterans Affairs Medical Center. PATIENTS: All patients receiving
recombinant human activated protein C for treatment of sepsis. INTERVENTIONS: Demographic information, characteristics associated with inclusion and exclusion criteria of the PROWESS trial, and 30-day postdischarge outcomes. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients received recombinant human activated protein C. Serious bleeding events occurred in 7 of 20 patients (35%) with any baseline bleeding precaution vs. only 2 of 53 patients (3.8%) without any bleeding precautions (p < 0.0001). More patients with a baseline bleeding precaution died compared with patients without any bleeding precautions (65% vs. 24.5%, p = 0.0015). Patients with a baseline bleeding precaution had a higher mean Acute Physiology and Chronic Health Evaluation II score (27.5 vs. 22.7, p = 0.015). Multivariate analysis demonstrated that the presence of a baseline bleeding precaution was the only independent variable associated with occurrence of serious bleeding events. The presence of a baseline bleeding precaution, increased Acute Physiology and Chronic Health Evaluation II score, and the presence of bloodstream infection were independent variables associated with mortality. CONCLUSIONS: Patients with severe sepsis who received recombinant human activated protein C with baseline bleeding precautions as defined by product labeling had significantly higher rates of both serious bleeding events and deaths compared with those without bleeding precautions. These data suggest that strict adherence to PROWESS trial exclusion criteria would further limit serious bleeding events associated with the use of recombinant human activated protein C.

2008 American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine

Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.

Erratum in: Crit Care Med. 2008 May;36(5):1699.

Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al; American Academy of Critical Care Medicine. Recommendations for
end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008

Harvard Medical School and Children's Hospital, Boston, MA, USA. This email address is being protected from spambots. You need JavaScript enabled to view it.



BACKGROUND: These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. PRINCIPAL FINDINGS: Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. CONCLUSIONS: End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

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2008 Eye Care in the Intensive Care Unit: Narrative Review and Meta-analysis

Jamie B. Rosenberg, MD; Lewis A. Eisen, MD, Crit Care Med.  2008;36(12):3151-3155.  ©2008 Lippincott Williams & Wilkins 

Abstract

Background: Patients in the intensive care unit are at increased risk of exposure keratopathy. Untreated, this may progress to microbial keratitis and visual loss.


Data Synthesis: A total of 20% to 42% of patients in the intensive care unit develop exposure keratopathy. The epidemiology of this underappreciated problem is reviewed. The pathophysiology of microbial keratitis is reviewed with special attention to the multiple risk factors unique to intensive care unit patients. The clinical presentation of exposure keratopathy is reviewed with tips for recognition for the practicing clinician, including suggestions for when ophthalmologic consultation is warranted. Studies and case series of screening and prevention are reviewed in detail. Two of the most studied methods of prevention, moisture chambers and lubricating ointments, are formally compared in a meta-analysis. Eight of 113 (7.1%) patients in the moisture chamber group vs. 32 of 151 (21.2%) patients in the lubrication group developed exposure keratopathy, with a summary odds ratio of 0.208 (95% confidence interval 0.090-0.479, p < 0.001).


Conclusion: With application of simple protocols, exposure keratopathy can be prevented, thus improving patient care in the intensive care unit.