Critical Care Medicine (CRIT CARE MED )

Publisher: Society of Critical Care Medicine, Lippincott, Williams & Wilkins

Description

Critical Care Medicine publishes promising research and reports on clinical breakthroughs that lead to better care of patients in life-threatening situations. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research and advances in equipment and techniques.

  • Impact factor
    6.12
    Show impact factor history
     
    Impact factor
  • 5-year impact
    6.40
  • Cited half-life
    7.20
  • Immediacy index
    2.61
  • Eigenfactor
    0.07
  • Article influence
    2.04
  • Website
    Critical Care Medicine website
  • Other titles
    Critical care medicine
  • ISSN
    0090-3493
  • OCLC
    1789720
  • Material type
    Periodical, Internet resource
  • Document type
    Journal / Magazine / Newspaper, Internet Resource

Publisher details

Lippincott, Williams & Wilkins

  • Pre-print
    • Author can archive a pre-print version
  • Post-print
    • Author cannot archive a post-print version
  • Restrictions
    • 12 months embargo
  • Conditions
    • Some journals have separate policies, please check with each journal directly
    • Pre-print must be removed upon acceptance for publication
    • Post-print may be deposited in personal website, university's institutional repository or employers intranet
    • Publisher's version/PDF cannot be used
    • Must include statement that it is not the final published version
    • Published source must be acknowledged with full citation
    • Must link to publisher version
    • NIH, Wellcome Trust and HHMI authors will have their accepted manuscripts transmitted to PubMed Central on their behalf (see policy for details)
  • Classification
    ​ yellow

Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To determine the relationship between implementation of rapid response teams and improved mortality rate using a large, uniform dataset from one state in the United States. Design: This observational cohort study included 471,062 adult patients hospitalized between 2001 and 2009. Setting: Ten acute tertiary care hospitals in Washington State. Patients or Other Participants: Hospital abstract records on adult patients (18 years old or older) were examined (n = 471,062). Patients most likely to benefit from rapid response team interventions were included and other prognostic factors of severity of illness and comorbidities were controlled. Each participating hospital provided the implementation date of their rapid response team intervention. Mortality rates in 31 months before rapid response team implementation (pre–rapid response team time period) were compared with mortality rates in 31 months following rapid response team implementation (post–rapid response team time period). Intervention(s): Implementation of a rapid response team within each acute tertiary care hospital. Measurements and Main Results: In-hospital mortality. Relative risk for in-hospital mortality improved in the post-rapid response team time period compared with the pre- rapid response team time period (relative risk = 0.76; 95% CI = 0.72–0.80; p < 0.001). Conclusions: In-hospital mortality improved in six of 10 acute tertiary care hospitals in the post-rapid response team time period when compared with the pre-rapid response team time period. Because of a long-term trend of decline in hospital mortality, these decreases could not be unambiguously attributed to rapid response team implementation. Further research should examine additional objective outcomes and optimal configuration of rapid response teams to maximize intervention effectiveness. (Crit Care Med 2014; XX:00–00)
    Critical Care Medicine 09/2014;
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    ABSTRACT: Lung contusion is a major risk factor for the development of acute respiratory distress syndrome. Hypoxia-inducible factor-1α is the primary transcription factor that is responsible for regulating the cellular response to changes in oxygen tension. We set to determine if hypoxia-inducible factor-1α plays a role in the pathogenesis of acute inflammatory response and injury in lung contusion.
    Critical Care Medicine 07/2014;
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    ABSTRACT: OBJECTIVES: To evaluate the influence of genetic polymorphisms on the susceptibility to Candida colonization and intra-abdominal candidiasis, a blood culture-negative life-threatening infection in high-risk surgical ICU patients. DESIGN: Prospective observational cohort study. SETTING: Surgical ICUs from two University hospitals of the Fungal Infection Network of Switzerland. PATIENTS: Eighty-nine patients at high risk for intra-abdominal candidiasis (68 with recurrent gastrointestinal perforation and 21 with acute necrotizing pancreatitis). MEASUREMENTS AND MAIN RESULTS: Eighteen single-nucleotide polymorphisms in 16 genes previously associated with development of fungal infections were analyzed from patient's DNA by using an Illumina Veracode genotyping platform. Candida colonization was defined by recovery of Candida species from at least one nonsterile site by twice weekly monitoring of cultures from oropharynx, stools, urine, skin, and/or respiratory tract. A corrected colonization index greater than or equal to 0.4 defined "heavy" colonization. Intra-abdominal candidiasis was defined by the presence of clinical symptoms and signs of peritonitis or intra-abdominal abscess and isolation of Candida species either in pure or mixed culture from intraoperatively collected abdominal samples. Single-nucleotide polymorphisms in three innate immune genes were associated with development of a Candida corrected colonization index greater than or equal to 0.4 (Toll-like receptor rs4986790, hazard ratio = 3.39; 95% CI, 1.45-7.93; p = 0.005) or occurrence of intra-abdominal candidiasis (tumor necrosis factor-α rs1800629, hazard ratio = 4.31; 95% CI, 1.85-10.1; p= 0.0007; β-defensin 1 rs1800972, hazard ratio = 3.21; 95% CI, 1.36-7.59; p = 0.008). CONCLUSION: We report a strong association between the promoter rs1800629 single-nucleotide polymorphism in tumor necrosis factor-α and an increased susceptibility to intra-abdominal candidiasis in a homogenous prospective cohort of high-risk surgical ICU patients. This finding highlights the relevance of the tumor necrosis factor-α functional polymorphism in immune response to fungal pathogens. Immunogenetic profiling in patients at clinical high risk followed by targeted antifungal interventions may improve the prevention or preemptive management of this life-threatening infection.
    Critical Care Medicine 04/2014; 42(4).
  • Critical Care Medicine 01/2014; 42(1):9.
  • Critical Care Medicine 12/2013;
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    ABSTRACT: Objectives: To test the hypothesis that low bispectral index scores and low sedative requirements during therapeutic hypothermia predict poor neurologic outcome. Design: Observational study of a prospectively collected cohort. Setting: Cardiovascular ICU. Patients: One hundred sixty consecutive cardiac arrest patients treated with therapeutic hypothermia. Interventions: None. Measurements and Results: Eighty-four of the 141 subjects (60%) who survived hypothermia induction were discharged from the ICU with poor neurologic outcome, defined as a cerebral performance category score of 3, 4, or 5. These subjects had lower bispectral index (p < 0.001) and sedative requirements (p < 0.001) during hypothermia compared with the 57 subjects discharged with good outcome. Early prediction of neurologic recovery was best 7 hours after ICU admission, and median bispectral index scores at that time were 31 points lower in subjects discharged with poor outcome (11 [interquartile range, 4-29] vs 42 [37-49], p < 0.001). Median sedation requirements decreased by 17% (interquartile range, -50 to 0%) 7 hours after ICU admission in subjects with poor outcome but increased by 50% (interquartile range, 0-142%) in subjects with good outcome (p < 0.001). Each 10-point decrease in bispectral index was independently associated with a 59% increase in the odds of poor outcome (95% CI, 32-76%; p < 0.001). The model including bispectral index and sedative requirement correctly reclassified 15% of subjects from good to poor outcome and 1% of subjects from poor to good outcome. The model incorrectly reclassified 1% of subjects from poor to good outcome but did not incorrectly reclassify any from good to poor outcome. Conclusions: Bispectral index scores and sedative requirements early in the course of therapeutic hypothermia improve the identification of patients who will not recover from brain anoxia. The ability to accurately predict nonrecovery after cardiac arrest could facilitate discussions with families, reduce patient suffering, and limit use of ICU resources in futile cases.
    Critical Care Medicine 12/2013; EPUB.
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    ABSTRACT: Introduction: Endotracheal tube (ETT) cuff pressure must be kept less than 30 cm H2O to prevent tracheal wall pressure necrosis, but must maintain an adequate seal for ventilation. Manometry and a minimal leak test (MLT) are both well-described methods for measuring cuff pressure. Methods: During a 2 month period, we used a manometer to obtain initial ETT cuff pressure measurements on all mechanically ventilated patients in a surgery ICU. Two different physicians then separately performed a MLT for each patient and measured the corresponding cuff pressure; these were compared between the two physicians. The VAP rate per ventilator days were calculated for the two months during the study period and compared to the two months immediately prior to the study. Results: Twenty-eight patients were included for a total of 50 events. The post-MLT measured cuff pressures by the two physicians were highly consistent, with an intraclass correlation coefficient of 0.872 (95% CI). The post-MLT measured cuff pressures were greater than 30 cm H2O in only 2 cases (4%; avg 32 cm H2O). During the first half of the study, the incidence of starting cuff pressures elevated above 30 cm H2O was not significantly different than the second month (19% vs 31%, p = 0.38); however, of the patients with elevated cuff pressures, the mean and elevation above the norm were both higher (47.5 +/- 7.724 vs 38.89 +/- 5.302 cm H20 and 17.5 +/- 7.724 vs 8.89 +/- 5.302 cm H20, p = 0.037). There was no difference in VAP rate during the study compared to historical controls (2.79 vs 2.99 VAPs per 1000 ventilator days, p = 0.961). Conclusions: The incidence of ventilator-associated pneumonia is not significantly increased due to the performance of a daily MLT. The MLT is a reliable indicator of endotracheal cuff pressure, does not undergo significant inter-observer subjective variation, and produces cuff pressures consistently within the acceptable range of less than 30 cm H2O. Additionally, we suspect that by emphasizing safe cuff pressures and daily cuff measurements during the course of our study we were able to decrease unacceptably high starting endotracheal cuff pressures.(C) 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
    Critical Care Medicine 12/2013; 41(12):A92 (abstract).
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    ABSTRACT: Introduction: Patients in the ICU often experience a stress-related reduction in insulin sensitivity, necessitating insulin therapy (INSiv) to avoid hyperglycemia. Methods: We measured the plasma concentrations of C-peptide, insulin (INSpl) and blood glucose (BG) in blood samples from 9 mechanically ventilated, hyperglycemic ICU patients (ICU day 3-10, age 58 +/- 13 yrs). 7 patients were treated with INSiv including 2 type II diabetes patients. Measurements were steady-state, i.e. when nutrition and INSiv were unchanged for >1 hour up to the test. A population model of C-peptide kinetics was used to convert plasma C-peptide to C-peptide secretion rate and thereby also to pancreatic insulin secretion rate (INSpa). Results: INSpa correlated positively, but not significantly, with BG (r=0.62, p=0.08), indicating that BG drives pancreatic production of insulin. However, the correlation was moderate, and INSpa varied considerably. Even for 3 patients all with a BG of 8 mmol/l, INSpa varied 8-fold, from 11.5 mU/min to 93.5 mU/min. This implies that the patients' endogenous insulin production differ substantially independent of BG. Interestingly the insulin production (11.6 +/- 8.4 mU/min) was significantly lower (p<0.004) in the diabetes patients and in two patients over 70 years, relative to the other patients (48.5 +/- 15.2 mU/min). BG (7.9 +/- 0.9 mmol/l) was not correlated with INSpl, indicating a substantial variation in the patients' insulin sensitivity. A negative correlation (r=-0.66, p=0.05) was found between INSiv and INSpa, indicating that exogenous insulin therapy is primarily used to compensate for inadequate insulin production. Conclusions: It was confirmed that the patients had different insulin sensitivities. It was also found that BG drives the endogenous insulin production, but that there are large differences between the insulin production independent of BG. It appears that reduced insulin sensitivity and production both contribute to the need for exogenous insulin and that insulin infusions are largely used to compensate for the reduced insulin production. Possibly diabetes and high age dispose for the inability to secret endogenous insulin at adequate amounts.
    Critical Care Medicine 12/2013; 41(12):A245.
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    ABSTRACT: Introduction: Hypotension during sedation with propofol is very common and well reported. The hypotension that results often leads to major interventions, which may prolong the sedation time and sometime force the procedure to be aborted.Ways to prevent the hypotension would be helpful in avoiding these complications. Methods: The study was a retrospective chart review comparing a cohort of children undergoing sedation with Propofol receiving 2XMIVF (n=100) with a prior cohort with no IVF during sedation (n=100). Study data included patient characteristics (gender, age, and weight), propofol bolus dose and infusion rate, and hemodynamic parameter measured at baseline and 5 minute intervals for the procedure duration as dictated by the sedation monitoring guidelines. Total and percent maximum decrease in systolic blood pressure (SBP) and mean arterial pressure (MAP) relative to baseline were calculated. MaxSBP and MAP decreases were also dichotomized at 25 SBP units (SBPdrop25) and 20% MAP (pctMAPdrop20). Group differences in baseline and blood pressure changes during the procedure were explored with Chi square analyses, t-tests and linear correlations. Interventions (adjusting Propofol infusion rate or administration fluid boluses) in response to decreases in arterial blood pressure and other indications during the procedure were also recorded. Results: Small but significant associations between groups were noted in procedure duration, propofol infusion and bolus. Only duration among these was also significantly associated with max SBP and MAP drops (r = -.18, p = .01). Differences in the rates of SBPdrop25 and pctMAPdrop20 were not significant comparing the IVF Group and No IVF Groups in bivariate analyses (46% versus 42% and 86% versus 83%, respectively). Logistic regression models adjusting for procedure duration. (A.O.R. 1.18, 95% CI 0.67-2.08) or pctMAPdrop20 (A.O.R. 1.12, 95% CI 0.51-2.45).A total of 22 interventions, in response to decreases in arterial blood pressure and other indications, were recorded in the No IVF group, compared to 6 in the IVF group. This difference was statistically significant (p = .001). Conclusions: The use of 2XMIVF during sedation with propofol did not show a statistically significant difference in SBP and MAP changes. However, the patients in the IVF group had less procedure interrupting interventions, including adjusting the Propofol infusion rate, and the need to give fluid boluses. The use of IVF during Propofol sedation may be justified because it results in a more efficient sedation process.
    Critical Care Medicine 12/2013; 41(12):B1-B16,A1-A377.
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    ABSTRACT: Introduction: There are concerns that fluid abstinence prior to sedation may put patients at risk for hypotension during sedation. This risk may be increased in children. Methods: This study is a retrospective chart review of 263 children who received intravenous (IV) Propofol by bolus then continuous infusion to complete magnetic resonance imaging from June 2011 through May 2013. All patients were instructed to take nothing by mouth as directed by the American Society of Anesthesiologists preoperative fasting guideline. Actual time of abstinence was documented prior to initiation of sedation. Study data included patient characteristics (gender, age, and weight), propofol bolus dose and infusion rate and hemodynamic parameters were measured at baseline and 5 minute intervals for the sedation duration which is routine per policy. IV fluid received was also recorded. Total and percent maximum decrease in systolic blood pressure (SBP) and mean arterial pressure (MAP) relative to baseline were calculated. Max SBP and MAP decreases were also dichotomized at 25 SBP units (SBPdrop25) and 20% MAP (pctMAPdrop20). Associations of hemodynamic changes with fluid abstinence and other patient characteristics were explored with linear correlation and logistic regression analyses. Results: Mean fluid abstinence time was 538.4 +/- 294.0 minutes, propofol bolus dose 2.4 +/- 0.9 mg/kg, propofol infusion rate dose 160.1 +/- 29.3 g/kg/min, and duration 51.6 +/- 24.8 minutes. Duration of procedure, baseline SBP and MAP were significantly correlated with blood pressure decreases but not with fluid abstinences time. Fluid abstinence time was not significantly correlated with maximum SBP decrease (r = 0.02, p = .727) or maximum percent MAP decrease (r = 0.08, p = .20). Logistic regression showed no significant relationships between fluid abstinence time and SBPdrop25 (O.R. 1.0, 95% C.I. 1.00 – 1.01) or pctMAPdrop20 (O.R. 1.0, 95% C.I. 1.00 – 1.01). Conclusions: In our study duration of fluid abstinence prior to sedation with Propofol is not independently associated with hemodynamic changes in children.
    Critical Care Medicine 12/2013; 41(12):B1-B16,A1-A377.
  • Critical Care Medicine 12/2013;
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    ABSTRACT: Introduction: Hypotension during sedation with Propofol is common. Multiple factors have been hypothesized to cause this, one of which is the length of sedation that might be expected to exacerbate blood pressure changes specifically in the pediatric population Methods: This study is a retrospective chart review of 263 children who received intravenous (IV) Propofol infusion for sedation to complete magnetic resonance imaging from June 2011 through May 2013. Study data included patient characteristics (gender, age, and weight), Propofol bolus dose and infusion rate, sedation duration and hemodynamic parameters measured at baseline and 5 minute intervals for the sedation duration which is routine per policy. Intravenous fluid received was also recorded. Total and percent maximum decreases in systolic blood pressure (SBP) and Mean arterial pressure (MAP) relative to baseline were calculated. Max SBP and MAP decreases were also dichotomized at 25 SBP units and 20% MAP. Associations of hemodynamic changes with sedation duration and other patient characteristics were explored with linear correlation and linear regression analyses Results: Mean sedation duration was 51.6 +/- 24.8 minutes. Forty-one percent of patients had one or more SBP measurements lower than 25 points relative to baseline and 73% had at least one MAP value decreased by 25%. Sedation duration was significantly correlated with maximum SBP drop (r = -.125, p = .043) but not max MAP drop (r = -.048, p = .436). Max SBP drop and max MAP drop were also significantly correlated with baseline SBP (r = .770, p < .001 and r = -.687, p <.001) and baseline HR (r=.179, p =.004 and r=0.234, p < .001). Multiple linear regression analysis indicated that baseline SBP, baseline HR and sedation duration are all significant independent predictors of max SBP drop (all p <.001) Conclusions: Max SBP drop during sedation with Propofol is significantly directly associated with sedation duration, baseline SBP and baseline HR. A multivariate model found that each of these is a significant independent predictor.
    Critical Care Medicine 12/2013; 41(12):B1-B16,A1-A377.
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    ABSTRACT: Introduction: Multi drug resistant organisms are problematic to treat due to resistance but attributable mortality data is sparse. The issue of whether a patient is dying with septicemia or due to the septicemia is usually question that clinicians ponder. Septicemia's attributable mortality is usually associated with the presence of systemic inflammatory response syndrome[ SIRS}. We hypothesize that MDROs found in blood culture are not only resistant but add significant mortality risk with and without SIRS. Methods: we retrospectively analyzed 283 blood culture samples in 202 patients. We collected demographic data, laboratory [clinical and microbiologic] data and survival data. MDROs were defined as any bacteria with resistance to greater than 2 antibiotics on the sensitivity panel. Data were analyzed by one-way analysis of variance [ANOVA] Results: Survival was significantly lower in patients with MDROs than patients with non-drug resistant organisms [65.0 +/- 3.6% versus 80.5 +/- 3.8%, p=0.001] In the presence of SIRS the survival dropped to 51.5 +/- 4.2%. When evaluating the effect of SIRS on mortality, the presence of SIRS reduced survival from 91.0 +/- 3.9 % to 60.0 +/- 3.2%, p=0.001. Gram negative organisms had significantly greater mortality than gram positive organisms. Conclusions: Septicemia with MDROs has a higher mortality than with non-MDROs and this mortality rate rises significantly higher in the presence of SIRS.(C) 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
    Critical Care Medicine 12/2013; 41(12):786.
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    ABSTRACT: OBJECTIVE:: We investigated the epidemiology of ventilator-associated pneumonia in elderly ICU patients. More precisely, we assessed prevalence, risk factors, signs and symptoms, causative bacterial pathogens, and associated outcomes. DESIGN:: Secondary analysis of a multicenter prospective cohort (EU-VAP project). SETTING:: Twenty-seven European ICUs. PATIENTS:: Patients who were mechanically ventilated for greater than or equal to 48 hours. We compared middle-aged (45-64 yr; n = 670), old (65-74 yr; n = 549), and very old patients (≥ 75 yr; n = 516). MEASUREMENTS AND MAIN RESULTS:: Ventilator-associated pneumonia occurred in 103 middle-aged (14.6%), 104 old (17.0%), and 73 very old patients (12.8%). The prevalence (n ventilator-associated pneumonia/1,000 ventilation days) was 13.7 in middle-aged patients, 16.6 in old patients, and 13.0 in very old patients. Logistic regression analysis could not demonstrate older age as a risk factor for ventilator-associated pneumonia. Ventilator-associated pneumonia in elderly patients was more frequently caused by Enterobacteriaceae (24% in middle-aged, 32% in old, and 43% in very old patients; p = 0.042). Regarding clinical signs and symptoms at ventilator-associated pneumonia onset, new temperature rise was less frequent among very old patients (59% vs 76% and 74% for middle-aged and old patients, respectively; p = 0.035). Mortality among patients with ventilator-associated pneumonia was higher among elderly patients: 35% in middle-aged patients versus 51% in old and very old patients (p = 0.036). Logistic regression analysis confirmed the importance of older age in the risk of death (adjusted odds ratio for old age, 2.1; 95% CI, 1.2-3.9 and adjusted odds ratio for very old age, 2.3; 95% CI, 1.2-4.4). Other risk factors for mortality in ventilator-associated pneumonia were diabetes mellitus, septic shock, and a high-risk pathogen as causative agent. CONCLUSIONS:: In this multicenter cohort study, ventilator-associated pneumonia did not occur more frequently among elderly, but the associated mortality in these patients was higher. New temperature rise was less common in elderly patients with ventilator-associated pneumonia, whereas more episodes among elderly patients were caused by Enterobacteriaceae. PMID: 24158167 [PubMed - as supplied by publisher]
    Critical Care Medicine 10/2013;

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