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1.
Intensive care med ; 43(12)Dec. 2017. tab
Article in English | BIGG - GRADE guidelines | ID: biblio-947327

ABSTRACT

OBJECTIVE: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS: A multispecialty task force of 16 international experts in Critical Care Medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. DESIGN/METHODS: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. RESULTS: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 µg/dl) after cosyntropin (250 µg) administration and a random plasma cortisol of <10 µg/dl may be used by clinicians. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). CONCLUSIONS: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.


Subject(s)
Humans , Respiratory Distress Syndrome, Newborn/drug therapy , Shock, Septic/drug therapy , Methylprednisolone/therapeutic use , Adrenal Cortex Hormones/administration & dosage , Sepsis/drug therapy , Hydrocortisone/administration & dosage , Methylprednisolone/administration & dosage , Critical Illness , Adrenal Insufficiency/drug therapy , Systemic Inflammatory Response Syndrome/drug therapy
2.
Am J Respir Crit Care Med ; 160(5 Pt 1): 1585-91, 1999 Nov.
Article in English | MEDLINE | ID: mdl-10556125

ABSTRACT

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.


Subject(s)
Pneumonia, Bacterial/complications , Positive-Pressure Respiration , Respiratory Insufficiency/therapy , Acute Disease , Adult , Aged , Aged, 80 and over , Community-Acquired Infections/therapy , Female , Humans , Intubation, Intratracheal , Length of Stay , Lung Diseases, Obstructive/complications , Male , Middle Aged , Pneumonia, Bacterial/mortality , Prospective Studies , Respiration, Artificial , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , Survival Rate
3.
Clin Infect Dis ; 27(3): 463-70, 1998 Sep.
Article in English | MEDLINE | ID: mdl-9770141

ABSTRACT

A prospective observational cohort study of nosocomial sinusitis was carried out in two medical intensive care units. Sinusitis was diagnosed by computed tomographic scanning and the culture of sinus fluid obtained by puncture of a maxillary sinus. Clinical and epidemiological data were collected at the time of admission to the unit and daily thereafter. Specimens from the nares, oropharynx, trachea, and stomach were cultured on admission and daily thereafter. The cumulative incidence of nosocomial sinusitis was 7.7%, and the incidence rates were 12 cases per 1,000 patient-days and 19.8 cases per 1,000 nasoenteric tube-days. Risk factors for nosocomial sinusitis, as determined by multiple logistic regression analysis, included nasal colonization with enteric gram-negative bacilli (odds ratio [OR], 6.4; 95% confidence interval [95% CI], 2.2-18.8; P = .007), feeding via nasoenteric tube (OR, 14.1; 95% CI, 1.7-117.6; P = .015), sedation (OR, 15.9; 95% CI, 1.9-133.5; P = .011), and a Glasgow coma score of < or = 7 (OR, 9.1; 95% CI, 3.0-27.3; P = .0001).


Subject(s)
Cross Infection/epidemiology , Intensive Care Units , Sinusitis/epidemiology , Cohort Studies , Cross Infection/diagnostic imaging , Cross Infection/microbiology , Humans , Incidence , Male , Middle Aged , Paranasal Sinuses/diagnostic imaging , Paranasal Sinuses/microbiology , Prospective Studies , Radiography , Risk Factors , Sinusitis/diagnostic imaging , Sinusitis/microbiology
4.
Ann Pharmacother ; 27(2): 185-7, 1993 Feb.
Article in English | MEDLINE | ID: mdl-8439696

ABSTRACT

OBJECTIVE: To determine if nurses could correctly use a metered-dose inhaler plus spacer (MDI-spacer) device after a brief description and demonstration of proper use by a clinical pharmacist. DESIGN: Pretest, educational intervention, posttest. SETTING: University hospital. PARTICIPANTS: Twenty-three nurses. INTERVENTIONS: Nurses were asked to use the MDI-spacer (Aerochamber) and were scored using a nine-point checklist (pretest). Educational intervention by the clinical pharmacist consisted of a five-minute discussion and correct demonstration of the device. Nurses were then asked to use the device again (posttest). MAIN OUTCOME MEASURES: Pre- and posttest scores. RESULTS: Total scores were improved after the educational intervention (66 percent pretest vs. 88 percent posttest, p = 0.0001). In an item analysis, four of the nine steps had improved significantly. CONCLUSIONS: A brief discussion and demonstration of correct use of MDI-spacers is effective in improving nurses' skill in using the device.


Subject(s)
Nebulizers and Vaporizers , Nursing Staff, Hospital/standards , Task Performance and Analysis , Clinical Competence , Hospitals, University , Humans , Inservice Training , Nursing Staff, Hospital/education , Tennessee
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