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1.  Risk factors for acute organ failure in intensive care unit patients who receive respiratory support in the absence of non-respiratory organ failure: an international prospective cohort study 
Critical Care  2012;16(2):R61.
Many supposed low-risk intensive care unit (ICU) admissions develop acute organ failure (AOF). Identifying patients at high risk of developing AOF and targeting them with preventative strategies may be effective. Our study question was: in a population of ICU patients receiving positive pressure respiratory support (invasive or non-invasive) in the absence of non-respiratory AOF, what is the 14-day incidence of, risk factors for and time to acute organ failure?
In an international prospective cohort study, patients receiving positive pressure respiratory support (invasive or non-invasive) in the absence of non-respiratory AOF were enrolled and followed for 14 days. The primary outcome measure was the incidence of any AOF (defined as SOFA 3 to 4) during follow-up.
A total of 123 of 766 screened patients (16.1%) were enrolled. Data are reported for 121 patients. In total, 45 out of 121 patients (37.2%) developed AOF. Mortality rates were higher in those with AOF: 17.8% versus 4.0% OR 5.11, P = 0.019) for ICU mortality; and 28.9% versus 11.8% (OR 2.80, P = 0.019) for hospital mortality. Median ICU length of stay was also longer in those with AOF (11 versus 3.0 days; P < 0.0001). Hypoxemic respiratory failure (P = 0.001) and cardiovascular dysfunction (that is, SOFA 1 to 2; P = 0.03) were associated with AOF. The median time to first AOF was two days.
Patients receiving positive (invasive or non-invasive) pressure respiratory support in the absence of non-respiratory AOF are commonly admitted to ICU; AOF is frequent in these patients. Organ failure developed within a short period after admission. Hypoxemic respiratory failure and cardiovascular dysfunction were strongly associated with AOF.
PMCID: PMC3681390  PMID: 22512834
2.  Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis 
Critical Care  2011;15(1):R46.
Pleural effusions are frequently drained in mechanically ventilated patients but the benefits and risks of this procedure are not well established.
We performed a literature search of multiple databases (MEDLINE, EMBASE, HEALTHSTAR, CINAHL) up to April 2010 to identify studies reporting clinical or physiological outcomes of mechanically ventilated critically ill patients who underwent drainage of pleural effusions. Studies were adjudicated for inclusion independently and in duplicate. Data on duration of ventilation and other clinical outcomes, oxygenation and lung mechanics, and adverse events were abstracted in duplicate independently.
Nineteen observational studies (N = 1,124) met selection criteria. The mean PaO2:FiO2 ratio improved by 18% (95% confidence interval (CI) 5% to 33%, I2 = 53.7%, five studies including 118 patients) after effusion drainage. Reported complication rates were low for pneumothorax (20 events in 14 studies including 965 patients; pooled mean 3.4%, 95% CI 1.7 to 6.5%, I2 = 52.5%) and hemothorax (4 events in 10 studies including 721 patients; pooled mean 1.6%, 95% CI 0.8 to 3.3%, I2 = 0%). The use of ultrasound guidance (either real-time or for site marking) was not associated with a statistically significant reduction in the risk of pneumothorax (OR = 0.32; 95% CI 0.08 to 1.19). Studies did not report duration of ventilation, length of stay in the intensive care unit or hospital, or mortality.
Drainage of pleural effusions in mechanically ventilated patients appears to improve oxygenation and is safe. We found no data to either support or refute claims of beneficial effects on clinically important outcomes such as duration of ventilation or length of stay.
PMCID: PMC3221976  PMID: 21288334
3.  Inhaled nitric oxide for acute respiratory distress syndrome 
BMJ : British Medical Journal  2007;334(7597):757-758.
Theoretical promise of benefit does not translate to improvements in morbidity and mortality
PMCID: PMC1852024  PMID: 17431232
4.  Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study 
Critical Care  2007;11(5):R96.
Little is known about the development of acute lung injury outside the intensive care unit. We set out to document the following: the association between predefined clinical conditions and the development of acute lung injury by using the American–European consensus definition; the frequency of lung injury development outside the intensive care unit; and the temporal relationship between antecedent clinical risk conditions, intensive care admission, and diagnosis of lung injury.
We conducted a 4-month prospective observational study in three Spanish teaching hospitals, enrolling consecutive patients who developed clinical conditions previously linked to lung injury, both inside and outside the intensive care unit. Patients were followed prospectively for outcomes, including the diagnosis of acute lung injury or acute respiratory distress syndrome.
A total 815 patients were identified with at least one clinical insult; the most common were sepsis, pneumonia, and pancreatitis. Pulmonary risk conditions were observed in 30% of cases. Fifty-three patients (6.5%) developed acute lung injury; 33 of these (4.0%) met criteria for acute respiratory distress syndrome. Lung injury occurred most commonly in the setting of sepsis (46/53; 86.7%), but shock (21/59; 36%) and pneumonia (20/211; 9.5%) portended the highest proportional risk; this risk was higher in patients with increasing numbers of clinical risk conditions (2.2%, 14%, and 21% (P < 0.001) in patients with one, two, and three conditions, respectively). Median days (interquartile range) from risk condition to diagnosis of lung injury was shorter with pulmonary (0 (0 to 2)) versus extrapulmonary (3 (1 to 5)) (P = 0.029) risk conditions. Admission to the intensive care unit was provided to 9/20 (45%) patients with acute lung injury and to 29/33 (88%) of those with acute respiratory distress syndrome. Lung injury patients had higher mortality than others (acute lung injury 25.0%; acute respiratory distress syndrome 45.5%; others 10.3%; P < 0.001).
The time course from clinical insult to diagnosis of lung injury was rapid, but may be longer for extrapulmonary cases. Some patients with lung injury receive care and die outside the intensive care unit; this observation needs further study.
PMCID: PMC2556739  PMID: 17784960
5.  Year in review 2006: Critical Care – respirology 
Critical Care  2007;11(4):224.
The present article summarises and places in context original research articles from the respirology section published in Critical Care in 2006. Twenty papers were identified and were grouped by topic into those addressing acute lung injury and ventilator-induced lung injury, those examining high-frequency oscillation, those studying pulmonary physiology and mechanics, those assessing tracheostomy, and those exploring other topics.
PMCID: PMC2206500  PMID: 17764586
6.  Outcomes of interfacility critical care adult patient transport: a systematic review 
Critical Care  2005;10(1):R6.
We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.
We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined.
Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.
Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.
PMCID: PMC1550794  PMID: 16356212
7.  Is it time to increase the frequency of use of high-frequency oscillatory ventilation? 
Critical Care  2005;9(4):339-340.
In this issue of Critical Care, Bollen and colleagues present the results of a multicentre randomised controlled trial, comparing high-frequency oscillatory ventilation with conventional ventilation as the primary ventilation mode for adults with acute respiratory distress syndrome. The study was stopped early after recruiting only 61 patients because of declining enrolment, and although no differences were detected in any primary or secondary endpoint, this trial only had sufficient power to detect extreme differences in outcomes between groups. This editorial attempts to put these results in context with previous work and highlights challenges to be addressed in future studies.
PMCID: PMC1269471  PMID: 16137379
8.  Pro/con clinical debate: Tracheostomy is ideal for withdrawal of mechanical ventilation in severe neurological impairment 
Critical Care  2004;8(5):327-330.
Most clinical trials on the topic of extubation have involved patients outside the neurological intensive care unit. As a result, in this area clinicians are left with little evidence on which to base their decision making. Although tracheostomies are increasingly common procedures, they are not without complications and costs, and hence a decision to perform them should not be taken lightly. In this issue of Critical Care two groups debate the merits of tracheostomy before extubation in a patient with neurological impairment. What becomes very clear is the need for more high quality data for this common clinical problem.
PMCID: PMC1065006  PMID: 15469593
brain injury; intubation; neurosurgical intensive care; tracheostomy; weaning
9.  Thirty years of critical care medicine 
Critical Care  2010;14(3):311.
Critical care medicine is a relatively young but rapidly evolving specialty. On the occasion of the 30th International Symposium on Intensive Care and Emergency Medicine, we put together some thoughts from a few of the leaders in critical care who have been actively involved in this field over the years. Looking back over the last 30 years, we reflect on areas in which, despite large amounts of research and technological and scientific advances, no major therapeutic breakthroughs have been made. We then look at the process of care and realize that, here, huge progress has been made. Lastly, we suggest how critical care medicine will continue to evolve for the better over the next 30 years.
PMCID: PMC2911692  PMID: 20550727

Results 1-9 (9)