Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. (Carroll)

Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. Crit Care Med. 2017 Apr;45(4):715-724.

OBJECTIVE: We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION: Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION: Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS: Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS: Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Delirium in Critically Ill Children: An International Point Prevalence Study. (Carroll)

Traube C, Silver G, Reeder RW, et al. Delirium in Critically Ill Children: An International Point Prevalence Study. Crit Care Med. 2017 Apr; 45(4) :584-590.

OBJECTIVES: To determine prevalence of delirium in critically ill children and explore associated risk factors.

DESIGN: Multi-institutional point prevalence study.

SETTING: Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia.

PATIENTS: All children admitted to the pediatric critical care units on designated study days (n = 994).

INTERVENTION: Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected.

MEASUREMENTS AND MAIN RESULTS: Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics.

CONCLUSIONS: Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. (Carroll)

Chan T, et al. Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. Crit Care Med. 2017 Apr; 45(4):670-678.

OBJECTIVES: Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support.

DESIGN: Retrospective analysis of registry data.

SETTING: Prospectively collected multi-institutional registry data.

SUBJECTS: Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality.

CONCLUSIONS: Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.

Early Systolic Dysfunction Following Traumatic Brain Injury: A Cohort Study. (Stulce)

Krishnamoorthy V, Rowhani-Rahbar A, Gibbons EF, et al. Early Systolic Dysfunction Following Traumatic Brain Injury: A Cohort Study. Crit Care Med. 2017 Apr 10. [Epub ahead of print]

OBJECTIVE: Prior studies have suggested that traumatic brain injury may affect cardiac function. Our study aims were to determine the frequency, longitudinal course, and admission risk factors for systolic dysfunction in patients with moderate-severe traumatic brain injury.

DESIGN: Prospective cohort study.

SETTING: Level 1 trauma center.

MEASUREMENTS: Transthoracic echocardiogram within 1 day and over the first week after moderate-severe traumatic brain injury; transthoracic echocardiogram within 1 day after mild traumatic brain injury (comparison group).

MEASUREMENTS AND MAIN RESULTS: Systolic function was assessed by transthoracic echocardiogram, and systolic dysfunction was defined as fractional shortening less than 25%. Multivariable Poisson regression models examined admission risk factors for systolic dysfunction. Systolic function in 32 patients with isolated moderate-severe traumatic brain injury and 32 patients with isolated mild traumatic brain injury (comparison group) was assessed with transthoracic echocardiogram. Seven (22%) moderate-severe traumatic brain injury and 0 (0%) mild traumatic brain injury patients had systolic dysfunction within the first day after injury (p < 0.01). All patients with early systolic dysfunction recovered in 1 week. Younger age (relative risk, 0.87; 95% CI, 0.79-0.94; for 1 yr increase in age) and lower admission Glasgow Coma Scale score (relative risk, 0.34; 95% CI, 0.20-0.58; for one unit increase in Glasgow Coma Scale) were independently associated with the development of systolic dysfunction among moderate-severe traumatic brain injury patients.

CONCLUSIONS: Early systolic dysfunction can occur in previously healthy patients with moderate-severe traumatic brain injury, and it is reversible over the first week of hospitalization. Younger age and lower admission Glasgow Coma Scale score are independently associated with the development of systolic dysfunction after moderate-severe traumatic brain injury.

Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. (Betters)

Compher C, Chittams J, Sammarco T, et al. Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017 Feb; 45(2):156-163.

OBJECTIVES: Controversy exists about the value of greater nutritional intake in critically ill patients, possibly due to varied patient nutritional risk. The objective of this study was to investigate whether clinical outcomes vary by protein or energy intake in patients with risk evaluated by the NUTrition Risk in the Critically Ill score.

DESIGN: Prospective observational cohort.

SETTING: A total of 202 ICUs.

PATIENTS: A total of 2,853 mechanically ventilated patients in ICU greater than or equal to 4 days and a subset of 1,605 patients in ICU greater than or equal to 12 days.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: In low-risk (NUTrition Risk in the Critically Ill, < 5) and high-risk (NUTrition Risk in the Critically Ill, ≥ 5) patients, mortality and time to discharge alive up to day 60 were assessed relative to nutritional intake over the first 12 days using logistic regression and Cox proportional hazard regression, respectively. In high-risk but not low-risk patients, mortality was lower with greater protein (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.98; p = 0.003 and 12-d sample: odds ratio, 0.90; 95% CI, 0.84-0.96; p = 0.003) and energy (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.97; p < 0.001 and 12-d sample: odds ratio, 0.88; 95% CI, 0.83-0.94; p < 0.001) intake. In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, mortality, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant. In high-risk but not low-risk patients, time to discharge alive was shorter with greater protein (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.01 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) and energy intake (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.02 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002). In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, time to discharge alive, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant.

CONCLUSIONS: Greater nutritional intake is associated with lower mortality and faster time to discharge alive in high-risk, longer stay patients but not significantly so in nutritionally low-risk patients.

Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy. (Betters)

Beesley SJ, Wilson EL, Lanspa MJ, et al. Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy. Crit Care Med. 2017 Feb; 45(2) :225-233.

OBJECTIVES: Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock.

DESIGN: Retrospective study of patients admitted for septic shock to study ICUs during 2005-2013.

SETTING: One large academic referral hospital and two community hospitals.

PATIENTS: Adult patients with septic shock requiring vasopressors.

INTERVENTION: None.

MEASUREMENTS: Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score.

RESULTS: We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001).

CONCLUSIONS: Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.