Publications

Metabolic alterations in the critically ill have been studied for more than a century, but the heterogeneity of the critically ill patient population, the varying duration and severity of the acute phase of illness, and the many confounding factors have hindered progress in the field. These factors may explain why management of metabolic alterations and related conditions in critically ill patients has for many years been guided by recommendations based essentially on expert opinion. Over the last decade, a number of randomized controlled trials have been conducted, providing us with important population-level evidence that refutes several longstanding paradigms. However, between-patient variation means there is still substantial uncertainty when translating population-level evidence to individuals. A cornerstone of metabolic care is nutrition, for which there is a multifold of published guidelines that agree on many issues but disagree on others. Using a series of nine questions, we provide a review of the latest data in this field and a background to promote efforts to address the need for international consistency in recommendations related to the metabolic care of the critically ill patient. Our purpose is not to replace existing guidelines, but to comment on differences and add perspective.

Objectives: In the treatment of acute myocardial infarction (MI), the time delay to achieve reperfusion of the infarction-related artery has been linked to survival rates. Primary or direct angioplasty has been found to be an excellent means of achieving reperfusion in acute ST-elevation MI compared to thrombolytic therapy in randomized trials. However, no mortality benefit of primary angioplasty over thrombolysis was observed in several registries, in which delays in performing primary angioplasty were longer. Our objectives were to evaluate the door-to-balloon time (DBT) in our institution and investigate its relationship with clinical and prognostic variables.

Ludwig's angina is a rare infectious condition originating in the oropharyngeal region, most commonly from the teeth. The principal symptoms consist of cervical pain, dyspnea, dysphagia, symmetrical neck swelling and fever. Serious complications include respiratory collapses, mediastinitis, pleural empyema, pericarditis and pericardial tamponade, and may result in the death of the patient. The most useful investigations in patients with suspected Ludwig's angina are clinical assessment, a cervico-thoracic CT-scan to determine the extent of the lesions, microbiological examination and panoramic radiography to detect possible dental focuses of infection. Treatment consists of ensuring adequate ventilation by securing the upper airways, broad spectrum antibiotic therapy, eradication of the source of infection, and often early surgical decompression may be necessary. Rapid diagnosis and appropriate treatment can reduce the mortality rate to 10%.

Blood lactate concentrations are often used to assess global tissue perfusion in critically ill patients; however, there are scarce data on lactate concentrations after subarachnoid hemorrhage (SAH). We aimed to assess the prognostic role of serial blood lactate measurements on hospital mortality and neurological outcomes at 3 months after SAH. We reviewed all SAH patients admitted to the intensive care unit from 2007 to 2019 and recorded the highest daily arterial lactate concentration for the first 6 days. Patients with no lactate concentration were excluded. Hyperlactatemia was defined as a blood lactate concentration >2.0 mmol/L. A total of 456 patients were included: 158 (35%) patients died in hospital and 209 (46%) had an unfavorable outcome (UO) at 3 months. The median highest lactate concentration was 2.7 (1.8-3.9) mmol/L. Non-survivors and patients with UO had significantly higher lactate concentrations compared to other patients. Hyperlactatemia increased the chance of dying (OR 4.19 (95% CI 2.38-7.39)) and of having UO in 3 months (OR 4.16 (95% CI 2.52-6.88)) after adjusting for confounding factors. Therefore, initial blood lactate concentrations have prognostic implications in patients with SAH; their role in conjunction with other prognostic indicators should be evaluated in prospective studies.

Preiser, J. C.; Vlasselaer, D.@; Reper, P.#; Zhang, H.; Metz, G.; Vanderkelen, A.#; Vincent, J. L. Author Information

Many insights into the etiology and outcomes of respiratory failure have been gleaned from studies using administrative data (1-3).However, the validity of identifying patients receiving invasive mechanical ventilation (IMV) in such datasets is not well established.One widely cited study in support of claims-based IMV definitions was limited to three centers within one Canadian provincial system and included only 46 ventilated patients (4).Another single-center study addressed only the positive predictive value of administrative definitions (5).We sought to assess a more complete array of operating characteristics for several administrative definitions of IMV and to characterize the patients best identified by these definitions among a larger and more diverse sample. MethodsWe evaluated two populations: (1) 500 randomly selected patients admitted in 2013 to 9 intensive care units (ICUs) within three hospitals affiliated with the University of Pennsylvania Health System (UPHS), and (2) all patients admitted from 2008 through 2013 to 21 ICUs in 21 hospitals in the Kaiser Permanente Northern California (KPNC) integrated healthcare delivery system.Organizationally independent medical, surgical, general, and subspecialty ICUs were selected from the UPHS hospitals, including one quaternary care center, one tertiary care center, and one community hospital with academic affiliation in urban Philadelphia.KPNC hospitals included a mix of community and academically affiliated ICUs, with local and regional organizational structures and diverse patient case mixes.For UPHS patients, we obtained data on use and duration of IMV by hand review of medical charts and hand calculated the Simplified Acute Physiology Score 3 (SAPS3) retrospectively.For KPNC patients, we obtained data on use and duration of IMV on the basis of validated electronic medical record algorithms (6).Electronic SAPS3 scores were calculated retrospectively (7).For all patients, we obtained International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for IMV (96.7x) and endotracheal intubation (96.0x); diagnosis codes for acute respiratory failure (518.51,518.53, 518.81, and 518.84); and Medicare Severity Diagnosis-Related Groups (MS-DRG) codes including intubation, IMV, or tracheostomy (207, 208, 870, 927, 933, 003, and 004) from discharge records.We estimated the operating characteristics for each category of codes individually and in combinations.We compared age, sex, ICU length of stay, duration of IMV, SAPS3, medical or surgical status, and in-hospital mortality among patients correctly identified as mechanically ventilated (true positives) versus those incorrectly identified as not ventilated (false negatives) using chi-square, Wilcoxon rank-sum, and t tests as appropriate.All statistical analyses were performed using Stata 14.1 (StataCorp, College Station, TX). Results