OA Critical Care http://www.oapublishinglondon.com/oa-critical-care OA Critical Care Cisatracurium for acute respiratory distress syndrome: review of current evidence. http://www.oapublishinglondon.com/article/344 Objective: Our aim was to review the latest available evidence whether the use of a continuous infusion of cisatracurium, a neuromuscular blocking agent (NMBA) in patients with ARDS had a beneficial effect on clinical outcomes. Methods: The following databases were searched: The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 6, 2012), MEDLINE (1950 to June 2012) and EMBASE (1980 to June 2012); the references of relevant trials and review articles identified were also searched. Only randomised controlled trials were included in the meta-analysis. In addition we have reviewed observational studies in our systematic review. Study selection and extraction of data were all performed independently. Results: We included 3 fully published randomised controlled trials containing 431 patients. The primary outcome of 28-day all cause mortality was significantly lower in the NMBA group compared to the placebo group (RR 0.68, 95% CI 0.51-0.92, I2 0%). NMBAs also had a statistically significant effect on ICU mortality (RR=0.71, 95% CI= 0.55-0.90, I2=0%), overall mortality (RR=0.73, 95% CI= 0.57-0.92, I2=0%), number of cases of new onset barotrauma (RR=0.43 ,95% CI=0.2-0.9, I2=0%) and number of ventilator-free days (MD=1.91, 95% CI= 0.28-3.55, I2=0%). However they did not show any significant effect on the duration of mechanical ventilation (RR 1.14, 95% CI= -4.07-6.35, I2=0%) or number of cases of new onset critical illness neuromyopathy (RR 1.13, 95% CI= 0.76-1.67, I2=0%). Conclusions: Our analysis showed that the early, short use of a continuous infusion of cisatracurium led to a statistically significant reduction in mortality in ARDS patients. The potential effects and drawbacks of the intervention is discussed. 08/13/2020 02:41:37 pm Challenge of intensive care unit-acquired infections and Acinetobacter baumannii in developing countries. http://www.oapublishinglondon.com/article/382   Introduction Patients in intensive care units are a significant subgroup of all hospitalised patients, accounting for about a quarter of all hospital infections. The burden of antibiotic usage is also very high in intensive care units. Nosocomial intensive care unit-acquired infections and antimicrobial resistance are global problems, and many epidemiological studies are carried out, especially from developed countries. However, available data of patient population and characteristics of intensive care units are very limited in developing countries. The prevalence of infection and mortality rates are higher in countries with limited resources associated with the quality of care. Main problems in developing countries are understaffing, poor infrastructure in intensive care units and overcrowding. Although it is difficult to solve some problems associated with financial hardship in developing countries, most solutions are simple and not resource demanding. Infection control strategies such as hand hygiene, rational antibiotic utilisation, continuous education and performance feedback demonstrated a significant reduction in the infection rates in these countries. Acinetobacter baumannii is common cause of nosocomial infections worldwide. In recent years, interest in infections caused by A. baumannii has gradually increased, and current studies indicate that this pathogen is more resistant and virulent, becoming a serious nosocomial threat. This critical review discusses the prevalence of A. baumannii and other intensive care unit-acquired infections in developing countries. Conclusion Intensive care unit-acquired infections caused by resistant organisms, prominently A. baumannii, are a global challenge. Large scale studies of intensive care unit-acquired infections in developing countries and guidelines including globally applicable infection control strategies to reduce these infections are essential. 08/13/2020 02:41:37 pm Lactate clearance as a target of therapy in sepsis: A flawed paradigm. http://www.oapublishinglondon.com/article/431   Introduction An increased blood lactate level is widely believed to be a marker of inadequate oxygen delivery and anaerobic metabolism. Furthermore, the rate of decline in lactate concentration (lactate clearance) has been recommended as an end-point of early goal-directed therapy in critical ill patients with sepsis. We provide compelling data that an elevated lactate concentration is a consequence of increased aerobic glycolysis as part of the stress response and that titrating therapy to the rate of decline in lactate concentration is a potentially harmful endeavour. Furthermore, an increased lactate concentration may be an important adaptive survival response during critical illness. Conclusion An elevated lactate concentration in patients with sepsis is a marker of disease severity and not an indication of anaerobic metabolism. Increasing oxygen delivery to treat a non-existent oxygen debt may be a harmful undertaking. ‘Lactate clearance‚ should not be used as the end-point of resuscitation in patients with sepsis. 08/13/2020 02:41:37 pm Fluid optimization strategies in critical care patients. http://www.oapublishinglondon.com/article/502 Fluid optimization is an important feature in hemodynamic resuscitation. Despite recent advances, fluid management in clinical practice remains sometimes highly empirical. Well-defined endpoints of resuscitation, not only global but also focused on the microcirculatory level, as well as the correct timing for fluids administration, always according to any of the available parameters to asses fluid responsiveness, are the essential points in order to optimize resuscitation with fluids avoiding deleterious effects. 08/13/2020 02:41:37 pm Earlier diagnosis of acute kidney injury in critically ill patients by novel biomarkers: Moving from supportive care to targeted renoprotection? http://www.oapublishinglondon.com/article/503 Current assessments of renal function by serum creatinine or blood urea nitrogen display poor sensitivity and specificity for indicating early changes in kidney function and do not differentiate between causes of AKI. The discovery, characterization and validation of novel biomarkers specific for structural kidney damage, such as neutrophil gelatinase - associated lipocalin, kidney injury molecule-1, Interleukin -18 and liver fatty acid binding protein enable a timely diagnosis of AKI through better reflection of real time damage of AKI, promise discrimination of the underlying etiology and may enable incremental risk identification for worsening AKI, need of renal replacement and death. However, the performance of these novel biomarkers is influenced by case-mix, comorbidities, etiology of the renal insult, timing of measurements and selected thresholds for diagnosis. However, additional studies are necessary before novel biomarkers can be used in routine clinical practice. To answer the question of how to optimally utilize novel biomarkers (the right test, at the right time, on the right patient, for the right clinical setting of AKI) all promising AKI biomarkers should undergo systematic evaluation in various clinical setting of AKI in order to validate the temporal expression patterns of these biomarkers for early detection of AKI, to determine how to combine multiple biomarkers for earlier diagnosis and to discover how the temporal course relates to onset, severity, and outcome of AKI. There is a vital need that large future investigations demonstrate the association between biomarkers and hard clinical outcomes independent of serum creatinine concentrations. It needs to be shown that early renoprotective treatment for AKI based on high biomarker levels actually results in an improved outcome. Until effective renoprotective therapies are available there is little benefit from early diagnosis of AKI during critical illness. 08/13/2020 02:41:37 pm Surgical procedures in the intensive care unit: A critical review. http://www.oapublishinglondon.com/article/679 Needs to be provided by the author 08/13/2020 02:41:37 pm Arginine vasopressin and paediatric cardiovascular surgery. http://www.oapublishinglondon.com/article/680 Arginine vasopressin has become an important part of the armamentarium available to pediatric cardiac intensive care physicians managing complex infants and children recovering from cardiovascular surgery.  This therapy must be applied cautiously however, as excessive afterload from its vasoconstrictive effects could be potentially detrimental to this patient population.  Relative arginine vasopressin deficiency has been identified in some children recovering from cardiovascular surgery, and these children likely represent the ideal candidates for arginine vasopressin therapy.  Knowledge of endogenous plasma arginine vasopressin activity prior to initiation of therapy could therefore be helpful in clinical bedside decision making and should be the goal of future research. 08/13/2020 02:41:37 pm Point-of-care ultrasonography. http://www.oapublishinglondon.com/article/704 Point-of-care (POC) ultrasonography is rapidly expanding within clinical practice. POC-ultrasonography is per definition a bedside examination performed and interpreted by the treating physician. The development witnessed, in part, reflects equipment of increased quality, mobility and availability – the latter as a result of reduced costs. POC ultrasonography appears to be a safe and valuable tool supporting the physician in patient-management. It holds obvious advantages in being an easily repeatable and real-time examination that supplies images, correlating directly to the patient’s symptoms or the clinically suspected diagnosis. In terms of ABC-ultrasonography, it covers cardiac, pulmonary, abdominal and vascular ultrasound. 08/13/2020 02:41:37 pm Making sense of the pressure of arterial oxygen to fractional inspired oxygen concentration ratio in patients with acute respiratory distress syndrome. http://www.oapublishinglondon.com/article/705 The PaO2/FIO2 ratio is a commonly used indicator of lung function in critically ill patients. For many years, physicians have relied on it to define and characterize the severity of the acute respiratory distress syndrome (ARDS) and this ratio is still a central element of the new ARDS definition (Berlin definition). In addition, clinicians utilize this ratio to track change in lung conditions, to set positive end expiratory pressure (PEEP), to assess the response to different ventilatory strategies and/or to make decision regarding the need for advanced supportive treatment modalities (e.g., paralysis, prone position, ECMO). Despite having the merit of simplicity and availability, the PaO2/FIO2 is more complex to interpret than acknowledged and can at times be misleading. This risk is particularly present if one does not understand or consider the key determinant of the PaO2/FIO2 ratio in each individual patient and why this ratio may change over time. We review here the main determinants of PaO2/FIO2 ratio and discuss how the application of a few physiological key concepts can be used to optimize the management of patients with hypoxic respiratory failure. 08/13/2020 02:41:37 pm State-of-the-art paediatric airway management. http://www.oapublishinglondon.com/article/755 The management of the pediatric airway has its own challenges compared to the adult airway.  Recently, new tools have become available in managing airways during diagnostic tests and/or procedures.  It is prudent for the pediatric provider to understand what the state of the art is in regards to handling the airways in children and what strategies exist to address emergent issues that arise. 08/13/2020 02:41:37 pm Tauroursodeoxycholic acid inhibits apoptosis associated with ventilator-induced lung injury in rabbits. http://www.oapublishinglondon.com/article/850 Apoptosis has been implicated in the process of lung injury. A drug that inhibits apoptosis could be very helpful to understand the role of programmed cell death in ventilator-induced lung injury (VILI). We examined whether tauroursodeoxycholic acid (TUDCA), an anti-apoptotic bile acid prevents ventilator-induced apoptosis in rabbit model of VILI. Following median thoracotomy (open chest model), rabbits (n=15) were randomly assigned. Controls were ventilated for 4 h with Pressure Control Ventilation (PCV) using a low peak pressure of 10 cm H2O (group 1). Experimental animals received PCV using a high peak pressure of 25 cm H2O (groups 2 and 3). Group 3 also received TUDCA via a 100 mg/kg bolus followed by 50 mg/kg/h maintenance dose. At the end of the protocol, the animals were euthanized, the left lung was removed for wet weight to dry weight (WW/DW) determinations and kidney/right lung samples were stored for TUNEL assay of apoptosis. Primary endpoints included apoptosis. How TUDCA affected WW/DW, PaO2/FIO2 ratios and the hemodynamics were secondary end-points.  High levels of apoptosis were seen in the lungs of group 2 but not in the kidneys of any group.  The addition of TUDCA in group 3 reduced apoptosis in the lung to a level similar to controls.There were significant differences in WW/DW and PaO2/FIO2 between the control and the 2 experimental groups but not between groups 2 and 3. TUDCA appears to reduce the rise in pulmonary vascular resistance associated with VILI and help maintain cardiac output.  In conclusion, ventilation with high pressure induced cellular apoptosis in lung but not kidneys. TUDCA significantly reduced ventilator-induced apoptosis in the lungs. This study is the first to demonstrate that the reduced cardiac output, increased pulmonary vascular resistance and apoptosis in the lungs associated with VILI is reduced by TUDCA. 08/13/2020 02:41:37 pm Well-performed interdisciplinary rounds as a strategy to increase quality of care in the intensive care unit. http://www.oapublishinglondon.com/article/917 An interdisciplinary round (IDR) is a patient-focused communication system aimed to agree to, understand and execute the appropriate plan of care for the patient by specialists from different disciplines. In the intensive care unit (ICU), IDRs are increasingly recommended because ineffective interdisciplinary communication among medical teams is a leading cause of preventable patient harm and asource ofsevere conflicts. In recent years, ICU management and staff have conducted these IDRs by bringing different disciplines in the same meeting to discuss diagnosis and disease management of the ICU patient. Nevertheless, it proves difficult to perform these meetings in an adequate way, because each profession within the ICU has a unique perspective and professional culture. Previous studies about IDRs were in particular survey studies, which described the differences between doctors and nurses regarding status/authority, gender, training and patient care responsibilities. We therefore developed performance improvements, based on 1) 60 videotaped IDRs, 2) literature reviews and 3) Delphi Rounds, aimed to support and increase quality of performed IDRs.  We discuss here the applications of these performance improvements with reference to processes of IDRs as a strategy for improving ICU care. 08/13/2020 02:41:37 pm Neurormonal and inflammatory responses during weaning trials from mechanical ventilation. http://www.oapublishinglondon.com/article/992 Introduction. Weaning from mechanical ventilation is usually accomplished with spontaneous breathing trials. The discontinuation of mechanical ventilation and the resumption of spontaneous breathing may increase oxygen demands, and patients, mainly those with limited cardiorespiratory reserve, are subject to pulmonary and cardiovascular stress. In addition, emotional distress due to agitation after interruption of sedative drugs, anxiety and other sources of discomfort potentially contributes. There is evidence of metabolic and endocrine stress response expressed as an increase in oxygen consumption and plasma concentration of catecholamines and other hormones involved in the stress system activation, in patients during the weaning process from mechanical ventilation, especiallyduring failing weaning attempts. Furthermore, extrapolating from both physical exercise and inspiratory resistive breathing data, there is evidence of immune response expressed as an increase of proinflammatory cytokine blood levels. The purpose of this review is to summarize the published information about neurormonal and inflammatory stress response during weaning from mechanical ventilation. Conclusion. The stress response during weaning trials from mechanical ventilation has  not enough been studied. Nevertheless, there is evidence that the process of weaning from mechanical ventilation incorporates hormonal, inflammatory and neuroendocrine responses, indicating that weaning might prove physically and psychologically stressful. Further studies should evaluate this stress response more thoroughly for better management of these patients. 08/13/2020 02:41:37 pm Prediction of acute Kidney injury during sepsis: Unsolved mystery yet. http://www.oapublishinglondon.com/article/993 Introduction: Acute kidney injury (AKI), the most common part of the multiple organ dysfunction syndrome, is the most frequent cause of death in septic patients admitted to intensive care units. The pathogenesis of sepsis induced AKI is a controversy area. Whether pre-renal transit AKI or direct tubular injury is the determinant factor for development of permanent renal AKI during sepsis, remain a matter of debt.  In addition, the renal hemodynamic changes during sepsis is another unanswered question. Conclusion: Full understand of the mechanism of AKI is an essential step for development of ideal biomarker or tool, which is one of the research priority today. The aims of this review are to discuss briefly the recent suggested mechanisms of AKI, and to outline the current development in AKI predictive tool and marker during septic shock. 08/13/2020 02:41:37 pm Compliance with the Surviving Sepsis Guidelines: A prospective cohort study of critical care in lesser developed countries. http://www.oapublishinglondon.com/article/1299 The article has been forwarded to the production team. The processing may take few weeks. Then the proof will be forwarded to the corresponding author. The final PDF and HTML files will be uploaded when the corrections to the proof are returned by the corresponding author. 08/13/2020 02:41:37 pm Sodium disorders in critically ill neurologic patients: A focus on pharmacologic management. http://www.oapublishinglondon.com/article/1300 The article has been forwarded to the production team. The processing may take few weeks. Then the proof will be forwarded to the corresponding author. The final PDF and HTML files will be uploaded when the corrections to the proof are returned by the corresponding author. 08/13/2020 02:41:37 pm ICU Delirium: Is prevention better than cure? http://www.oapublishinglondon.com/article/1301 The article has been forwarded to the production team. The processing may take few weeks. Then the proof will be forwarded to the corresponding author. The final PDF and HTML files will be uploaded when the corrections to the proof are returned by the corresponding author. 08/13/2020 02:41:37 pm Role of thrombolytics in the management of sub-massive pulmonary embolism. http://www.oapublishinglondon.com/article/1302 The article has been forwarded to the production team. The processing may take few weeks. Then the proof will be forwarded to the corresponding author. The final PDF and HTML files will be uploaded when the corrections to the proof are returned by the corresponding author. 08/13/2020 02:41:37 pm The administration of Botulinum Toxin in a case of generalised tetanus. http://www.oapublishinglondon.com/article/1518 Tetanus is a serious infectious disease that is associated with high morbidity and mortality. The treatment of tetanus has many implications for anesthesiologists and critical care physicians, but most physicians in developed countries lack experience in dealind with such cases. The aim of this  report was to present a case whose foot was injured in the field and who developed serious generalized tetanus due to delay in referral with fatal outcome. In this case, botulinum toxin was administered to most intensively involved muscle groups for treatment. 08/13/2020 02:41:37 pm Theraputic hypothermia and hemodynamics after cardiac arrest: From animal to human studies. http://www.oapublishinglondon.com/article/1552 Data on the  hemodynamic and cardiovascular effects of therapeutic hypothermia (TH)  in patients after cardiac arrest (CA)are scarce , even if nearly half of thesepatients are hemodynamically unstable and quite often require vasopressor agents.           The present manuscript is aimed at summarizing the available evidence on the hemodynamic effects of  hypothermia after cardiac arrest in experimental studies and in investigations performed in humans.            In the temperature recommended for therapeutic hypothermia (32-34°C),  in animal models, hypothermia has an inotropic effects most likely acts by sensitizing the myofilaments of calcium.           In cardiac arrest patients, therapeutic hypothermia  is associated with a reduction in heart rate and an increase in systemic vascular resistance.                Despite scarcity of data, TH seems to be feasible and well tolerated in CA patients with hemodynamic instability who presented a comparable incidence of complications in respect to stable patients and a good neurological outcome.                Despite the fact the hemodynamic management is crucial in post-arrest care, concrete data to guide clinical treatment decisions are so far scarce andno consensus exist on the hemodynamic goals that a clinical should reach in the management of CA patients submitted to TH.  There is the clinical need of implementation investigations which could provide sufficient details which could be agreed upon by a consensus group of experts in post-arrest care. 08/13/2020 02:41:37 pm