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1.  Perceptions of an open visitation policy by intensive care unit workers 
Background
An intensive care unit (ICU) admission is a stressful event for the patient and the patient’s family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU. Some studies recognize that the open visitation policy (OVP) is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction. However, some issues have been presented as barriers for the adoption of that strategy. This study was designed to evaluate perceptions of physicians, nurses, and respiratory therapists (RTs) of an OVP and to quantify visiting times in a Brazilian private intensive care unit (ICU).
Methods
This observational and descriptive study was performed in the medical-surgical (22 beds) and neurologic ICU (8 beds) of Sírio-Libanês Hospital (HSL), São Paulo, Brazil. All physicians, nurses, and RTs from ICU were invited to participate in the study. A questionnaire was applied to all ICU workers who accepted to participate in the study. The questionnaire consisted of 22 questions about the visiting policy. During five consecutive days, we evaluated the time that the visitors stayed in the patient room, as well as the type of visitor.
Results
A total of 106 ICU workers participated in this study (42 physicians, 39 nurses, and 25 RTs). Only three of the questions exposed a negative perception of the visiting policy: 53.3% of the participants do not think that the OVP consistently increases family satisfaction with patient’s care; 59.4% of ICU workers think that the OVP impairs the organization of the patient’s care; 72.7% of participants believe that their work suffers more interruptions because of the OVP. The median visiting time per day was 11.5 hours.
Conclusions
According to physicians, nurses, and respiratory therapists, the greatest impact of OVP is the benefit to the patients rather than to the family or to the staff. Furthermore, they feel that they need communication training to better interact with family members who are present in the ICU 24 hours per day.
doi:10.1186/2110-5820-3-34
PMCID: PMC3854481  PMID: 24135292
Intensive care unit; Family; Visitation policy; Family centered care; Patient centered care
2.  Mechanisms and etiologies of thrombocytopenia in the intensive care unit: impact of extensive investigations 
Background
Thrombocytopenia is common in the intensive care unit. Potential mechanisms and etiologies behind this phenomenon are multiple and often entangled. We assessed the effect of a systematic approach, using routinely available tests, on the proportion of patients in whom the mechanism (primary objective) and etiology (secondary objective) of thrombocytopenia in a mixed intensive care unit (ICU) could be identified.
Methods
Before-and-after study of all patients with thrombocytopenia was used. ‘Before’ group had no intervention. New standard operating procedures for thrombocytopenia management were introduced. In the ‘After’ group, bone marrow aspiration; determination of fibrinogen dosage, prothrombin time, factor V, D-dimers; assay of fibrin monomers, ferritin, triglycerides, lactic acid dehydrogenase, aspartate transaminase, alanine aminotransferase, vitamin B12, folates, reticulocytes, haptoglobin, and bilirubin were performed.
Results
In the Before group (n = 20), the mechanism (central, peripheral, or mixed) was identified in 10 % versus 83% in After group (n = 23) (p < 0.001) (48% peripheral, 35% mixed). Before intervention, ≥1 etiology was identified in 15% versus 95.7% in the After group (p < 0.001).
Conclusions
Systematic and extensive investigation using routine tests highlights the mechanisms and etiology of thrombocytopenia in most cases.
doi:10.1186/s13613-014-0024-x
PMCID: PMC4273722  PMID: 25593741
Thrombocytopenia; Intensive care unit; Bone marrow aspiration
3.  Should we measure intra-abdominal pressures in every intensive care patient? 
Annals of Intensive Care  2012;2(Suppl 1):S9.
Intra-abdominal pressure (IAP) is seldom measured by default in intensive care patients. This review summarises the current evidence on the prevalence and risk factors of intra-abdominal hypertension (IAH) to assist the decision-making for IAP monitoring.
IAH occurs in 20% to 40% of intensive care patients. High body mass index (BMI), abdominal surgery, liver dysfunction/ascites, hypotension/vasoactive therapy, respiratory failure and excessive fluid balance are risk factors of IAH in the general ICU population. IAP monitoring is strongly supported in mechanically ventilated patients with severe burns, severe trauma, severe acute pancreatitis, liver failure or ruptured aortic aneurysms. The risk of developing IAH is minimal in mechanically ventilated patients with positive end-expiratory pressure < 10 cmH2O, PaO2/FiO2 > 300, and BMI < 30 and without pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding or laparotomy and the use of vasopressors/inotropes on admission. In these patients, omitting IAP measurements might be considered.
In conclusions, clear guidelines to select the patients in whom IAP measurements should be performed cannot be given at present. In addition to IAP measurements in at-risk patients, a clinical assessment of the signs of IAH should be a part of every ICU patient's bedside evaluation, leading to prompt IAP monitoring in case of the slightest suspicion of IAH development.
doi:10.1186/2110-5820-2-S1-S9
PMCID: PMC3390289  PMID: 22873425
intra-abdominal pressure; intra-abdominal hypertension; abdominal compartment syndrome; patient monitoring; intensive care; epidemiology.
4.  End of life in the intensive care unit: should French law be adapted? 
Background
Longstanding concerns regarding end of life in the ICU led in France to the publication of guidelines, updated in 2009, that take into account the insights provided by a recent law (Leonetti’s law) regarding patients’ rights. After the French President asked a specific expert to review end of life issues, the French Intensive Care Society (SRLF) surveyed their members (doctors and paramedics) about various aspects of end of life in the ICU.
Methods
SRLF members were invited to respond to a questionnaire, sent by Email, designed to assess their knowledge of Leonetti’s law and to determine how many caregivers would agree with the authorization of lethal drug administration in selected end of life situations.
Results
Questionnaires returned by 616 (23%) of 2,700 members were analyzed. Most members (82.5%) reported that they had a good knowledge of Leonetti’s law, which most (88%) said they have often applied. One third of respondents had received ‘assisted death’ requests from patients and more than 50% from patients’ relatives. One quarter of respondents had experienced the wish to give lethal drugs to end of life patients. Assuming that palliative care in the ICU is well-managed, 25.7% of the respondents would approve a law authorizing euthanasia, while 26.5% would not. Answers were influenced by the fear of a possible risk of abuse. Doctors and nurses answered differently.
Conclusion
ICU caregivers appear to be well acquainted with Leonetti’s law. Nevertheless, in selected clinical situations with suitable palliative care, one quarter of respondents were in favor of a law authorizing administration of lethal drugs to patients.
doi:10.1186/2110-5820-4-6
PMCID: PMC4015966  PMID: 24568144
Euthanasia; Palliative care; End of life; Intensive care unit
5.  Mild hypoglycemia is strongly associated with increased intensive care unit length of stay 
Background
Hypoglycemia is associated with increased mortality in critically ill patients. The impact of hypoglycemia on resource utilization has not been investigated. The objective of this investigation was to evaluate the association of hypoglycemia, defined as a blood glucose concentration (BG) < 70 mg/dL, and intensive care unit (ICU) length of stay (LOS) in three different cohorts of critically ill patients.
Methods
This is a retrospective investigation of prospectively collected data, including patients from two large observational cohorts: 3,263 patients admitted to Stamford Hospital (ST) and 2,063 patients admitted to three institutions in The Netherlands (NL) as well as 914 patients from the GLUCONTROL trial (GL), a multicenter prospective randomized controlled trial of intensive insulin therapy.
Results
Patients with hypoglycemia were more likely to be diabetic, had higher APACHE II scores, and higher mortality than did patients without hypoglycemia. Patients with hypoglycemia had longer ICU LOS (median [interquartile range]) in ST (3.0 [1.4-7.1] vs. 1.2 [0.8-2.3] days, P < 0.0001), NL (5.2 [2.6-10.3] vs. 2.0 [1.3-3.2] days, P < 0.0001), and GL (9 [5-17] vs. 5 [3-9] days, P < 0.0001). For the entire cohort of 6,240 patients ICU LOS was 1.8 (1.0-3.3) days for those without hypoglycemia and 3.0 (1.5-6.7) days for those with a single episode of hypoglycemia (P < 0.0001). This was a consistent finding even when patients were stratified by severity of illness or survivor status. There was a strong positive correlation between the number of episodes of hypoglycemia and ICU LOS among all three cohorts.
Conclusions
This multicenter international investigation demonstrated that hypoglycemia was consistently associated with significantly higher ICU LOS in heterogeneous cohorts of critically ill patients, independently of severity of illness and survivor status. More effective methods to prevent hypoglycemia in these patients may positively impact their cost of care.
doi:10.1186/2110-5820-1-49
PMCID: PMC3273438  PMID: 22115519
hypoglycemia; intensive care unit; length of stay; resource utilization; APACHE II; mortality; intensive insulin therapy
6.  Short- and long-term outcomes of HIV-infected patients admitted to the intensive care unit: impact of antiretroviral therapy and immunovirological status 
Background
The purpose of this study was to assess the short- and long-term outcomes of HIV-infected patients admitted to intensive care units (ICU) according to immunovirological status at admission and highly active antiretroviral therapy (HAART) use in ICU.
Methods
Retrospective study of 98 HIV-infected patients hospitalized between 1997 and 2008 in two medical ICU in Montpellier, France. The primary outcome was mortality in ICU. The secondary end point was probability of survival in the year following ICU admission.
Results
Eighty-two (83.6%) admissions in ICU were related to HIV infection and 45% of patients had received HAART before admission. Sixty-two patients (63.3%) were discharged from ICU, and 34 (34.7%) were alive at 1 year. Plasma HIV RNA viral load (VL) and CD4+ cell count separately were not associated with outcome. Independent predictors of ICU mortality were the use of vasopressive agents (odds ratio (OR), 3.779; 95% confidence interval (CI), 1.11–12.861; p = 0.0334) and SAPS II score (OR, 1.04; 95% CI, 1.003-1.077; p = 0.0319), whereas introducing or continuing HAART in ICU was protective (OR, 0.278; 95% CI, 0.082-0.939; p = 0.0393). Factors independently associated with 1-year mortality were immunovirological status with high VL (>3 log10/ml) and low CD4 (<200/mm3; hazard ratio (HR), 5.19; 95% CI, 1.328-20.279; p = 0.0179) or low VL (<3 log10/ml) and low CD4 (HR, 4.714; 95% CI, 1.178-18.867; p = 0.0284) vs. high CD4 and low VL, coinfection with C hepatitis virus (HR, 3.268; 95% CI, 1.29-8.278; p = 0.0125), the use of vasopressive agents (HR, 3.68; 95% CI, 1.394-9.716; p = 0.0085), and SAPS II score (HR, 1.09; 95% CI, 1.057-1.124; p <0.0001). Introducing HAART in a patient with no HAART at admission was associated with a better long-term outcome (HR, 0.166; 95% CI, 0.043-0.642; p = 0.0093).
Conclusions
In a population of HIV-infected patients admitted to ICU, short- and long-term outcomes are related to acute illness severity and immunovirological status at admission. Complementary studies are necessary to identify HIV-infected patients who benefit from HAART use in ICU according to immunovirological status and the reasons of ICU admission.
doi:10.1186/2110-5820-2-25
PMCID: PMC3465211  PMID: 22762133
Intensive care units; Human immunodeficiency virus; Acquired immunodeficiency syndrome; Antiretroviral therapy; Prognostic factors; Critical care; Mortality
7.  Adverse event reporting in adult intensive care units and the impact of a multifaceted intervention on drug-related adverse events 
Background
Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs.
Methods
This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology.
Results
A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention.
Conclusions
AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.
doi:10.1186/2110-5820-2-47
PMCID: PMC3526522  PMID: 23174137
Adverse events; Medical errors; Patient safety; Quality improvement; Intensive care; Reliability
8.  Outbreak of multidrug-resistant Klebsiella pneumoniae carrying qnrB1 and blaCTX-M15 in a French intensive care unit 
Background
The prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae is increasing globally and is a major clinical concern. Between June 2008 and September 2009, 4% of patients in an intensive care unit (ICU) were found to be colonized or infected by strains of Klebsiella pneumoniae multiresistant to ceftazidime, ciprofloxacin, and tobramycin; an investigation was initiated and isolates were characterized by molecular typing and resistance patterns.
Methods
Antibiotic susceptibilities were determined by Vitek2®, Etest®, and agar dilution. Gene encoding beta-lactamases and plasmid-mediated quinolone resistance PMQR determinants (qnr, aac(6′)-Ib) were characterized by PCR, sequencing, and transfer assays. DiversiLab® fingerprints were used to study the relatedness of isolates.
Results
Fourteen isolates co-expressing blaCTX-M15, qnrB1, and aac(6′)-Ib-cr were identified. Genotypic analysis of these isolates identified 12 clonally related strains recovered from 10 patients. The increased prevalence of blaCTX-M15-qnrB1-aac(6′)-Ib-cr-producing K. pneumoniae coincided with the presence in the ICU of a patient originally from Nigeria. This patient was infected by a strain not clonally related to the others but harbouring qnrB1 and aac(6′)-Ib-cr genes, a finding not hitherto observed in France. We suspected transmission of resistance plasmids followed by rapid dissemination of the multiresistant K. pneumoniae clone by cross-transmission.
Conclusion
This study highlights the importance of microbiological screening for multidrug-resistant strains in ICUs, particularly among patients from regions in which multidrug-resistant bacteria are known to exist.
doi:10.1186/2110-5820-3-18
PMCID: PMC3707830  PMID: 23815782
Outbreak; Klebsiella pneumoniae; Extended-spectrum beta-lactamase; Intensive care unit; Screening; Quinolone resistance
9.  Sedation in French intensive care units: a survey of clinical practice 
Background
Sedation is used frequently for patients in intensive care units who require mechanical ventilation, but oversedation is one of the main side effects. Different strategies have been proposed to prevent oversedation. The extent to which these strategies have been adopted by intensivists is unknown.
Methods
We developed a six-section questionnaire that covered the drugs used, modalities of drug administration, use of sedation scales and procedural pain scales, use of written local procedures, and targeted objectives of consciousness. In November 2011, the questionnaire was sent to 1,078 intensivists identified from the French ICU Society (SRLF) database.
Results
The questionnaire was returned by 195 intensivists (response rate 18.1%), representing 135 of the 282 ICUs (47.8%) listed in the French ICU society (SRLF) database. The analysis showed that midazolam and sufentanil are the most frequently used hypnotics and opioids, respectively, administered in continuous intravenous (IV) infusions. IV boluses of hypnotics without subsequent continuous IV infusion are used occasionally (in <25% of patients) by 65% of intensivists. Anxiolytic benzodiazepines (e.g., clorazepam, alprazolam), hydroxyzine, and typical neuroleptics, via either an enteral or IV route, are used occasionally by two thirds of respondents. The existence of a written, local sedation management procedure in the ICU is reported by 55% of respondents, 54% of whom declare that they use it routinely. Written local sedation procedures mainly rely on titration of continuous IV hypnotics (90% of the sedation procedures); less frequently, sedation procedures describe alternative approaches to prevent oversedation, including daily interruption of continuous IV hypnotic infusion, hypnotic boluses with no subsequent continuous IV infusion, or the use of nonhypnotic drugs. Among the responding intensivists, 98% consider eye opening, either spontaneously or after light physical stimulation, a reasonable target consciousness level in patients with no severe respiratory failure or intracranial hypertension.
Conclusions
Despite a low individual response rate, the respondents to our survey represent almost half of the ICUs in the French SRLF database. The presence of a written local sedation procedure, a cornerstone of preventing oversedation, is reported by only half of respondents; when present, it is used in for a limited number of patients. Sedation procedures mainly rely on titration of continuous IV hypnotics, but other strategies to limit oversedation also are included in sedation procedures. French intensivists no longer consider severely altered consciousness a sedation objective for most patients.
doi:10.1186/2110-5820-3-24
PMCID: PMC3751696  PMID: 23937955
Sedation; Midazolam; Propofol; Opioids; Intensive care unit; Mechanical ventilation; Practice survey; Oversedation
10.  Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey 
Background
ICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.
Methods
Web-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.
Results
Of the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.
Conclusion
The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.
doi:10.1186/2110-5820-4-10
PMCID: PMC4113284  PMID: 24708581
Chest radiography; Imaging; Intensive care
11.  Earlobe arterialized capillary blood gas analysis in the intensive care unit: a pilot study 
Background
Earlobe arterialized capillary blood gas analysis can be used to estimate arterial gas content and may be suitable for diagnosis and management of critically ill patients. However, its utility and applicability in the ICU setting remains unexplored.
Methods
A prospective observational validation study was designed to evaluate this technique in a cohort of mechanically ventilated adult critically ill patients admitted to a polyvalent ICU. Precision and agreement between capillary gas measures and arterial references was examined. Acute Respiratory Distress Syndrome (ARDS) diagnosis capabilities with the proposed technique were also evaluated. Finally, factors associated with sampling failure were explored.
Results
Fifty-five patients were included into this study. Precision of capillary samples was high (Coefficient of Variation PO2 = 9.8%, PCO2 = 7.7%, pH = 0.3%). PO2 measures showed insufficient agreement levels (Concordance Correlation Coefficient = 0.45; bias = 12 mmHg; percentage of error = 19.3%), whereas better agreement was observed for PCO2 and pH (Concordance Correlation Coefficient = 0.94 and 0.93 respectively; depreciable bias; percentage of error 11.4% and 0.5% respectively). The sensitivity and specificity for diagnosing ARDS were 100% and 92.3% using capillary gasometric measures. Sampling was unsuccessful in 43.6% of cases due to insufficient blood flow. Age > 65 years was independently associated with failure (odds ratio = 1.6), however hemodynamic failure and norepinephrine treatment were also influencing factors.
Conclusions
Earlobe capillary blood gas analysis is precise and can be useful for detecting extreme gasometrical values. Diagnosis of ARDS can be done accurately using capillary measurements. Although this technique may be insufficient for precise management of patients in the ICU, it has the potential for important benefits in the acute phase of various critical conditions and in other critical care arenas, such as in emergency medicine, advanced medical transport and pre-hospital critical care.
doi:10.1186/2110-5820-4-11
PMCID: PMC4003517  PMID: 24731793
Acute respiratory failure; Arterialized; Capillary blood; Emergency medicine; Intensive care medicine; Mechanical ventilation
12.  An observational study on rhabdomyolysis in the intensive care unit. Exploring its risk factors and main complication: acute kidney injury 
Background
Because neither the incidence and risk factors for rhabdomyolysis in the ICU nor the dynamics of its main complication, i.e., rhabdomyolysis-induced acute kidney injury (AKI) are well known, we retrospectively studied a large population of adult ICU patients (n = 1,769).
Methods
CK and sMb (serum myoglobin) and uMb (urinary myoglobin) were studied as markers of rhabdomyolysis and AKI (RIFLE criteria). Hemodialysis and mortality were used as outcome variables.
Results
Prolonged surgery, trauma, and vascular occlusions are associated with increasing CK values. CK correlates with sMb (p < 0.001) and peaks significantly later than sMb or uMb.
The logistic regression showed a positive correlation between CK and the development of AKI, with an OR of 2.21. Univariate logistic regression suggests that elevations of sMb and uMb are associated with the development of AKI, with odds ratios of 7.87 and 1.61 respectively. The ROC curve showed that for all three markers a significant correlation with AKI, for sMb with the greatest area under the curve. The best cutoff values for prediction of AKI were CK > 773 U/l; sMb > 368 μg/l and uMb > 38 μg/l respectively.
Conclusions
Because it also has extrarenal elimination kinetics, our data suggest that measuring myoglobin in patients at risk for rhabdomyolysis in the ICU may be useful.
doi:10.1186/2110-5820-3-8
PMCID: PMC3614462  PMID: 23497406
Rhabdomyolysis; Intensive care unit–ICU; Creatine kinase; Creatine phosphokinase; Myoglobin; Serum myoglobin; Urinary myoglobin; Acute kidney injury
13.  Development of trigger-based semi-automated surveillance of ventilator-associated pneumonia and central line-associated bloodstream infections in a Dutch intensive care 
Annals of Intensive Care  2014;4(1):40.
Background
Availability of a patient data management system (PDMS) has created the opportunity to develop trigger-based electronic surveillance systems (ESSs). The aim was to evaluate a semi-automated trigger-based ESS for the detection of ventilator-associated pneumonia (VAP) and central line-associated blood stream infections (CLABSIs) in the intensive care.
Methods
Prospective comparison of surveillance was based on a semi-automated ESS with and without trigger. Components of the VAP/CLABSI definition served as triggers. These included the use of VAP/CLABSI-related antibiotics, the presence of mechanical ventilation or an intravenous central line, and the presence of specific clinical symptoms. Triggers were automatically fired by the PDMS. Chest X-rays and microbiology culture results were checked only on patient days with a positive trigger signal from the ESS. In traditional screening, no triggers were used; therefore, chest X-rays and culture results had to be screened for all patient days of all included patients. Patients with pneumonia at admission were excluded.
Results
A total of 553 patients were screened for VAP and CLABSI. The incidence of VAP was 3.3/1,000 ventilation days (13 VAP/3,927 mechanical ventilation days), and the incidence of CLABSI was 1.7/1,000 central line days (24 CLABSI/13.887 central line days). For VAP, the trigger-based screening had a sensitivity of 92.3%, a specificity of 100%, and a negative predictive value of 99.8% compared to traditional screening of all patients. For CLABSI, sensitivity was 91.3%, specificity 100%, and negative predictive value 99.6%.
Conclusions
Pre-selection of patients to be checked for signs and symptoms of VAP and CLABSI by a computer-generated automated trigger system was time saving but slightly less accurate than conventional surveillance. However, this after-the-fact surveillance was mainly designed as a quality indicator over time rather than for precise determination of infection rates. Therefore, surveillance of VAP and CLABSI with a trigger-based ESS is feasible and effective.
doi:10.1186/s13613-014-0040-x
PMCID: PMC4303743  PMID: 25646148
Hospital-acquired infection (HAI); Quality improvement; Electronic surveillance system; Decision support capabilities; Infection prevention (IP); Patient data management system
14.  Development of trigger-based semi-automated surveillance of ventilator-associated pneumonia and central line-associated bloodstream infections in a Dutch intensive care 
Background
Availability of a patient data management system (PDMS) has created the opportunity to develop trigger-based electronic surveillance systems (ESSs). The aim was to evaluate a semi-automated trigger-based ESS for the detection of ventilator-associated pneumonia (VAP) and central line-associated blood stream infections (CLABSIs) in the intensive care.
Methods
Prospective comparison of surveillance was based on a semi-automated ESS with and without trigger. Components of the VAP/CLABSI definition served as triggers. These included the use of VAP/CLABSI-related antibiotics, the presence of mechanical ventilation or an intravenous central line, and the presence of specific clinical symptoms. Triggers were automatically fired by the PDMS. Chest X-rays and microbiology culture results were checked only on patient days with a positive trigger signal from the ESS. In traditional screening, no triggers were used; therefore, chest X-rays and culture results had to be screened for all patient days of all included patients. Patients with pneumonia at admission were excluded.
Results
A total of 553 patients were screened for VAP and CLABSI. The incidence of VAP was 3.3/1,000 ventilation days (13 VAP/3,927 mechanical ventilation days), and the incidence of CLABSI was 1.7/1,000 central line days (24 CLABSI/13.887 central line days). For VAP, the trigger-based screening had a sensitivity of 92.3%, a specificity of 100%, and a negative predictive value of 99.8% compared to traditional screening of all patients. For CLABSI, sensitivity was 91.3%, specificity 100%, and negative predictive value 99.6%.
Conclusions
Pre-selection of patients to be checked for signs and symptoms of VAP and CLABSI by a computer-generated automated trigger system was time saving but slightly less accurate than conventional surveillance. However, this after-the-fact surveillance was mainly designed as a quality indicator over time rather than for precise determination of infection rates. Therefore, surveillance of VAP and CLABSI with a trigger-based ESS is feasible and effective.
doi:10.1186/s13613-014-0040-x
PMCID: PMC4303743  PMID: 25646148
Hospital-acquired infection (HAI); Quality improvement; Electronic surveillance system; Decision support capabilities; Infection prevention (IP); Patient data management system
15.  Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study 
Background
This study was design to investigate the prognostic value for death at day-28 of lactate course and lactate clearance during the first 24 hours in Intensive Care Unit (ICU), after initial resuscitation.
Methods
Prospective, observational study in one surgical ICU in a university hospital. Ninety-four patients hospitalized in the ICU for severe sepsis or septic shock were included. In this septic cohort, we measured blood lactate concentration at ICU admission (H0) and at H6, H12, and H24. Lactate clearance was calculated as followed: [(lactateinitial - lactatedelayed)/ lactateinitial] x 100%].
Results
The mean time between severe sepsis diagnosis and H0 (ICU admission) was 8.0 ± 4.5 hours. Forty-two (45%) patients died at day 28. Lactate clearance was higher in survivors than in nonsurvivors patients for H0-H6 period (13 ± 38% and −13 ± 7% respectively, p = 0.021) and for the H0-H24 period (42 ± 33% and −17 ± 76% respectively, p < 0.001). The best predictor of death at day 28 was lactate clearance for the H0-H24 period (AUC = 0.791; 95% CI 0.6-0.85). Logistic regression found that H0-H24 lactate clearance was independently correlated to a survival status with a p = 0.047 [odds ratio = 0.35 (95% CI 0.01-0.76)].
Conclusions
During the first 24 hr in the ICU, lactate clearance was the best parameter associated with 28-day mortality rate in septic patients. Protocol of lactate clearance-directed therapy should be considered in septic patients, even after the golden hours.
doi:10.1186/2110-5820-3-3
PMCID: PMC3614435  PMID: 23398782
Sepsis; Lactate; Lactate clearance; Prognostic factor; Goal-directed therapy
16.  Delirium in postoperative nonventilated intensive care patients: risk factors and outcomes 
Background
Delirium features can vary greatly depending on the postoperative population studied; however, most studies focus only on high-risk patients. Describing the impact of delirium and risk factors in mixed populations can help in the development of preventive actions.
Methods
The occurrence of delirium was evaluated prospectively in 465 consecutive nonventilated postoperative patients admitted to a surgical intensive care unit (SICU) using the confusion assessment method (CAM). Patients with and without delirium were compared. A multiple logistic regression was performed to identify the main risk factors for delirium in the first 24 h of admission to the SICU and the main predictors of outcomes.
Results
Delirium was diagnosed in 43 (9.2%) individuals and was more frequent on the second and third days of admission. The presence of delirium resulted in longer lengths of SICU and hospital stays [6 days (3–13) vs. 2 days (1–3), p < 0.001 and 26 days (12–39) vs. 6 days (3–13), p <0.001, respectively], as well as higher hospital and SICU mortality rates [16.3% vs. 4.0%, p = 0.004 and 6.5% vs. 1.7%, p = 0.042, respectively]. The risk factors for delirium were age (odds ratio (OR), 1.04 [1.02-1.07]), Acute Physiologic Score (APS; OR, 1.11 [1.04-1.2]), emergency surgery (OR, 8.05 [3.58-18.06]), the use of benzodiazepines (OR, 2.28 [1.04-5.00]), and trauma (OR, 6.16 [4.1-6.5]).
Conclusions
Delirium negatively impacts postoperative nonventilated patients. Risk factors can be used to detect high-risk patients in a mixed population of SICU patients.
doi:10.1186/2110-5820-2-51
PMCID: PMC3544687  PMID: 23272945
Delirium; Postoperative; Surgery; Confusion assessment method
17.  Eligibility of patients withheld or withdrawn from life-sustaining treatment to organ donation after circulatory arrest death: epidemiological feasibility study in a French Intensive Care Unit 
Background
Transplantation brings sustainably improved quality of life to patients with end-stage organ failure. Persisting shortfall in available organs prompted French authorities and practitioners to focus on organ retrieval in patients withdrawn from life-sustaining treatment and awaiting cardiac arrest (Maastricht classification category III). The purpose of this study was to assess the theoretical eligibility of non-heart-beating donors dying in the intensive care unit (ICU) after a decision to withhold or withdraw life-sustaining treatment (WoWt).
Methods
We collected the clinical and biological characteristics of all consecutive patients admitted to our ICU and qualified for a WoWt procedure under the terms of the French Leonetti law governing end-of-life care during a 12-month period. The theoretical organ donor eligibility (for kidney, liver, or lung retrieval) of deceased patients was determined a posteriori 1) according to routine medical criteria for graft selection and 2) according to the WoWt measures implemented and their impact on organ viability.
Results
A total of 596 patients (mean age: 67 ± 16 yr; gender ratio M/F: 1.6; mean SAPS (Simplified Acute Physiology Score) II: 54 ± 24) was admitted to the ICU, of which 84 patients (mean age: 71 ± 14 yr, 14% of admissions, gender ratio M/F: 3.2) underwent WoWt measures. Eight patients left the unit alive. Forty-four patients presented a contraindication ruling out organ retrieval either preexisting admission (n = 20) or emerged during hospitalization (n = 24). Thirty-two patients would have been eligible as kidney (n = 23), liver (n = 22), or lung donors (n = 2). Cardiopulmonary support was withdrawn in only five of these patients, and three died within 120 minutes after withdrawal (the maximum delay compatible with organ viability for donor grafts).
Conclusions
In this pilot study, a significant number of patients deceased under WoWt conditions theoretically would have been eligible for organ retrieval. However, the WoWt measures implemented in our unit seems incompatible with donor organ viability. A French multicenter survey of end-of-life practices in ICU may help to identify potential appropriate organ donors and to interpret nation-specific considerations of the related professional, legal, and ethical frameworks.
doi:10.1186/2110-5820-3-36
PMCID: PMC3826506  PMID: 24199966
Tissue and organ harvesting; Withholding treatment; Life support care; Medical futility; Organ donation
18.  Evaluation of the depth of sedation in an intensive care unit based on the photo motor reflex variations measured by video pupillometry 
Background
Evaluating depth of sedation in the intensive care unit (ICU) is crucial for the management of mechanically ventilated patients but can be challenging in some situations. Because the depth of hypnosis is correlated with the decrease in photomotor reflex (PMR), we suggest using pupillometric video as an automated, noninvasive, simple, and reproducible technique to evaluate the depth of sedation in ICU patients. We compare the effectiveness of this procedure to the bispectral index (BIS).
Methods
Thirty-one patients requiring sedation and ventilation were included in this monocentric, observational study. The posology of hypnotics and morphinics were based on the Richmond Agitation and Sedation Scale (RASS). PMR was measured by the Neurolight® (IDMED) system and BIS value by BIS Vista® (Anandic Medical Systems). RASS, PMR, and BIS were measured three times daily in all patients. Data acquired by pupillometric video included variation in pupillary diameter (ΔPD), latency time (LT), and maximal speed of pupillary constriction (Vmax). These parameters were analyzed after having classified BIS values in three groups (<40 heavy sedation; 40 ≤ BIS ≤ 60 acceptable sedation; >60 light sedation). Exclusion criteria were neurological or ophthalmologic pathologies that could interfere with PMR.
Results
There was a significant difference in Vmax and ΔPD between the BIS < 40 group and 40 ≤ BIS ≤ 60 groups (p < 0.0001 for each) and between the BIS < 40 and BIS > 60 groups (p < 0.0001 for each). There were no significant differences in Vmax and ΔPD between the 40 ≤ BIS ≤ 60 and BIS > 60 groups. There was no correlation between any of the BIS groups and LT.
Conclusions
Vmax and ΔPD seem to be relevant criteria compared with the BIS and the RASS. Pupillometric video monitoring of depth of sedation could be beneficial in ICU patients, especially for those under myorelaxant drugs, where no clinical evaluation of sedation is possible.
doi:10.1186/2110-5820-3-5
PMCID: PMC3605207  PMID: 23433043
Sedation; Photomotor reflex; Video pupillometry; Bispectral index
19.  Pharmacodynamics of cisatracurium in the intensive care unit: an observational study 
Background
Data from previous studies indicate that optimal conditions for intubation are met 120 seconds after administration of 0.15 mg.kg-1 cisatracurium (ED95 × 3) following the induction of anesthesia. The aim of this study was to compare the doses required for complete paralysis after induction of anesthesia in ICU patients with the dose used in patients undergoing elective surgery.
Methods
Seventeen ICU patients undergoing percutaneous tracheostomy and 17 patients undergoing an elective surgical procedure under muscle relaxation were included. In both groups, an initial intravenous bolus of cisatracurium besylate was given at a dose of 0.15 mg.kg-1 followed by repeated boluses of 0.03 mg.kg-1 every four minutes. The objective was to obtain no response to the train-of-four (TOF). The contractile response of the corrugator supercilii muscle was monitored every minute by observing the TOF in response to a peripheral nerve stimulator with a constant current set to 60 mA.
Results
After the initial dose of cisatracurium, none of ICU patients (0/17) versus 15/17 of the elective surgery patients were completely paralyzed (P < 0.0001). There was a delay in the onset of neuromuscular blockade among the ICU patients. The cumulative doses of cisatracurium were significantly higher in the ICU group with 38 ± 14 mg (that is, 10 ± 4.7 ED95) versus 11 ± 2 mg (that is, 3 ± 0.3 ED95) in the elective surgery group (P < 0.0001).
Conclusion
The dosing of cisatracrurium for ICU patients, which is based on the dose recommended for elective anesthesia, is unsuitable because the onset is too slow. This phenomenon is probably caused by changes in the pharmacodynamics and pharmacokinetics. These data suggest that neuromuscular monitoring should be used in the ICU.
doi:10.1186/2110-5820-4-3
PMCID: PMC3996108  PMID: 24521394
Cisatracurium; ICU; Current anesthetic practice; Neuromuscular monitoring
20.  Mechanical ventilation and clinical practice heterogeneity in intensive care units: a multicenter case-vignette study 
Background
Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations.
Methods
We conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated.
Results
Forty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure.
Conclusions
Large clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.
doi:10.1186/2110-5820-4-2
PMCID: PMC3922080  PMID: 24484902
Mechanical ventilation; Clinical practice; Volume-outcome; Protocols
21.  Relative cost and outcomes in the intensive care unit of acute lung injury (ALI) due to pandemic influenza compared with other etiologies: a single-center study 
Background
Critical illness due to 2009 H1N1 influenza has been characterized by respiratory complications, including acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), and associated with high mortality. We studied the severity, outcomes, and hospital charges of patients with ALI/ARDS secondary to pandemic influenza A infection compared with ALI and ARDS from other etiologies.
Methods
A retrospective review was conducted that included patients admitted to the Cleveland Clinic MICU with ALI/ARDS and confirmed influenza A infection, and all patients admitted with ALI/ARDS from any other etiology from September 2009 to March 2010. An itemized list of individual hospital charges was obtained for each patient from the hospital billing office and organized by billing code into a database. Continuous data that were normally distributed are presented as the mean ± SD and were analyzed by the Student’s t test. The chi-square and Fisher exact tests were used to evaluate differences in proportions between patient subgroups. Data that were not normally distributed were compared with the Wilcoxon rank-sum test.
Results
Forty-five patients were studied: 23 in the H1N1 group and 22 in the noninfluenza group. Mean ± SD age was similar (44 ± 13 and 51 ± 17 years, respectively, p = 0.15). H1N1 patients had lower APACHE III scores (66 ± 20 vs. 89 ± 32, p = 0.015) and had higher Pplat and PEEP on days 1, 3, and 14. Hospital and ICU length of stay and duration of mechanical ventilation were comparable. SOFA scores over the first 2 weeks in the ICU indicate more severe organ failure in the noninfluenza group (p = 0.017). Hospital mortality was significantly higher in the noninfluenza group (77 vs. 39%, p = 0.016). The noninfluenza group tended to have higher overall charges, including significantly higher cost of blood products in the ICU.
Conclusions
ALI/ARDS secondary to pandemic influenza infection is associated with more severe respiratory compromise but has lower overall acuity and better survival rates than ALI/ARDS due to other causes. Higher absolute charges in the noninfluenza group are likely due to underlying comorbid medical conditions.
doi:10.1186/2110-5820-2-41
PMCID: PMC3503790  PMID: 22929215
ARDS; ALI; Influenza A; Novel influenza; Mechanical ventilation; Hospital cost
22.  How caregivers view patient comfort and what they do to improve it: a French survey 
Background
Intensive care unit (ICU) patients are exposed to many sources of discomfort. Most of these are related to the patient’s condition, but ICU design or how care is organized also can contribute. The present survey was designed to describe the opinions of ICU caregivers on sources of patient discomfort and to determine how they were dealt with in practice. The architectural and organizational characteristics of ICUs also were analyzed in relation to patient comfort.
Methods
An online, closed-ended questionnaire was developed. ICU caregivers registered at the French society of intensive care were invited to complete this questionnaire.
Results
A total of 915 staff members (55% nurses) from 264 adult and 28 pediatric ICUs completed the questionnaire. Analysis of the answers reveals that: 68% of ICUs had only single-occupancy rooms, and 66% had natural light in each room; ICU patients had access to television in 59% of ICUs; a clock was present in each room in 68% of ICUs. Visiting times were <4 h in 49% of adult ICUs, whereas 64% of respondents considered a 24-h policy to be very useful or essential to patients’ well-being. A nurse-driven analgesia protocol was available in 42% of units. For caregivers, the main sources of patient discomfort were anxiety, feelings of restraint, noise, and sleep disturbances. Paramedics generally considered discomfort related to thirst, lack of privacy, and the lack of space and time references, whereas almost 50% of doctors ignored these sources of discomfort. Half of caregivers indicated they assessed sleep quality. A minority of caregivers declared regular use of noise-reduction strategies. Twenty percent of respondents admitted to having non-work-related conversations during patient care, and only 40% indicated that care often was or always was provided without closing doors. Family participation in care was planned in very few adult ICUs.
Conclusions
Results of this survey showed that ICUs are poorly equipped to ensure patient privacy and rest. Access by loved ones and their participation in care also is limited. The data also highlighted that some sources of discomfort are less often taken into account by caregivers, despite being considered to contribute significantly.
doi:10.1186/2110-5820-3-19
PMCID: PMC3700816  PMID: 23815804
Intensive care unit; Comfort; Survey; Organization; Opinions
23.  Symptoms of depression in ICU physicians 
Background
Work and family are the two domains from which most adults develop satisfaction in life. They also are responsible for stressful experiences. There is a perception in the community that work is increasingly the source of much of our stress and distress. Depressive symptoms may be related to repeated stressful experiences. Intensive care unit (ICU) physicians are exposed to major stressors. However, the existence of depressive symptoms in these doctors has been poorly studied. This study was designed to evaluate the prevalence and associated risk factors of depressive symptoms in junior and senior ICU physicians.
Method
A one-day national survey was conducted in adult intensive care units (ICU) in French public hospitals. Symptoms of depression were assessed using the Centers of Epidemiologic Studies Depression Scale (CES-D).
Results
A total of 189 ICUs participated, and 901 surveys were returned (75.8% response rate). Symptoms of depression were found in 23.8% of the respondents using the CES-D scale. Fifty-eight percent of these intensivists presenting symptoms of depression wished to leave their job compared with only 33% of those who did not exhibit signs of depression as assessed by the CES-D scale (p < 0.0001). Multiple logistic regression showed that organizational factors were associated with the presence of depressive symptoms. Workload (long interval since the last nonworking weekend, absence of relief of service until the next working day after a night shift) and impaired relationships with other intensivists were independently associated with the presence of depressive symptoms. A high level of burnout also was related to the presence of depressive symptoms. In contrast, no demographic factors regarding ICU physicians and no factor related to the severity of illness of patients were retained by the model. The quality of relationships with other physicians (from other departments) was associated with the absence of depressive symptoms (protective effect).
Conclusions
Approximately one of four intensivists presented symptoms of depression. The next step could be to test whether organization modification is associated with less depressive symptoms and less desire to leave the job.
doi:10.1186/2110-5820-2-34
PMCID: PMC3543176  PMID: 22839744
Intensive care unit; Organizational management; Conflict; Burnout; Depression; Physicians
24.  Intra-abdominal pressure measurement using the FoleyManometer does not increase the risk for urinary tract infection in critically ill patients 
Annals of Intensive Care  2012;2(Suppl 1):S10.
Objective
The aim of this study was to determine whether intra-abdominal pressure (IAP) monitoring using the FoleyManometer (Holtech Medical, Charlottenlund, Denmark) increases the risk of urinary tract infection (UTI).
Design
A retrospective database review was conducted.
Setting
The study was conducted in the 12-bed medical intensive care unit of ZNA Stuivenberg Hospital (Antwerp, Belgium), a tertiary hospital.
Patients
There were 5,890 patients admitted to the medical intensive care unit of which 1,097 patients underwent intrabladder pressure (IBP) monitoring as estimate for IAP.
Interventions
Crude and adjusted UTI rates were compared among patients undergoing IAP measurements with three different intrabladder methods: a modified homemade technique, a FoleyManometer with 35 ml reservoir, and a FoleyManometer low volume (FoleyManometerLV) with less than 10 ml priming volume.
Measurements and results
Four consecutive time periods of 24 months were defined and compared with regard to IAP measurement: period 1 (2000-2001), during which IAP monitoring was not used routinely (which serves as a control group), was compared with period 2 (2002-2003), using a modified homemade technique; period 3 (2004-2005), introducing the FoleyManometer; and finally period 4 (2006-2007), in which the FoleyManometerLV was introduced. The incidence of IBP measurements increased from 1.4% in period 1 to 45.4% in period 4 (p < 0.001). At the same time, the Simplified Acute Physiology Score (version 2) (SAPS-II) increased significantly from 24.4 ± 21.5 to 34.9 ± 18.7 (p < 0.001) together with the percentage of ventilated patients from 18.6% to 40.7% (p < 0.001). In total, 1,097 patients had IAP measurements via the bladder. The UTI rates were adjusted for disease severity by multiplying each crude rate with the ratio of control versus study patient SAPS-II probability of mortality. Crude and adjusted UTI rates per 1,000 catheter days (CD) were on average 16.1 and 12.8/1,000 CD, respectively, and were not significantly different between the four time periods.
Conclusions
Intrabladder pressure monitoring as estimate for IAP either via a closed transducer technique or the closed FoleyManometer technique seems safe and does not alter the risk of UTI in critically ill patients.
doi:10.1186/2110-5820-2-S1-S10
PMCID: PMC3390297  PMID: 22873411
intra-abdominal pressure; abdominal compartment syndrome; abdominal hypertension; FoleyManometerLV; intensive care; intravesical pressure; intrabladder pressure; urinary tract infection
25.  Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses 
Background
High inspiratory oxygen concentrations are frequently administered in ventilated patients in the intensive care unit (ICU) but may induce lung injury and systemic toxicity. We compared beliefs and actual clinical practice regarding oxygen therapy in critically ill patients.
Methods
In three large teaching hospitals in the Netherlands, ICU physicians and nurses were invited to complete a questionnaire about oxygen therapy. Furthermore, arterial blood gas (ABG) analysis data and ventilator settings were retrieved to assess actual oxygen practice in the same hospitals 1 year prior to the survey.
Results
In total, 59% of the 215 respondents believed that oxygen-induced lung injury is a concern. The majority of physicians and nurses stated that minimal acceptable oxygen saturation and partial arterial oxygen pressure (PaO2) ranges were 85% to 95% and 7 to 10 kPa (52.5 to 75 mmHg), respectively. Analysis of 107,888 ABG results with concurrent ventilator settings, derived from 5,565 patient admissions, showed a median (interquartile range (IQR)) PaO2 of 11.7 kPa (9.9 to 14.3) [87.8 mmHg], median fractions of inspired oxygen (FiO2) of 0.4 (0.4 to 0.5), and median positive end-expiratory pressure (PEEP) of 5 (5 to 8) cm H2O. Of all PaO2 values, 73% were higher than the upper limit of the commonly self-reported acceptable range, and in 58% of these cases, neither FiO2 nor PEEP levels were lowered until the next ABG sample was taken.
Conclusions
Most ICU clinicians acknowledge the potential adverse effects of prolonged exposure to hyperoxia and report a low tolerance for high oxygen levels. However, in actual clinical practice, a large proportion of their ICU patients was exposed to higher arterial oxygen levels than self-reported target ranges.
doi:10.1186/s13613-014-0023-y
PMCID: PMC4240734  PMID: 25512878
Oxygen; Hyperoxia; Mechanical ventilation; Lung injury; Intensive care medicine; Questionnaire

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