Introduction
Several studies have shown a correlation between body mass index (BMI) and both the development of critical illness and adverse outcomes in critically ill patients. The goal of our study was to examine this relationship prospectively with particular attention to the influence of concomitant diabetes mellitus (DM).
Methods
We analyzed data from 15,408 participants in the Atherosclerosis Risk in Communities (ARIC) study for this analysis. BMI and the presence of DM were defined at baseline. We defined 'acute organ failure' as those subjects who met a standard definition with diagnostic codes abstracted from hospitalization records. Outcomes assessed included the following: risk of the development of acute organ failure within three years of the baseline examination; in-hospital death while ill with acute organ failure; and death at three years among all subjects and among those with acute organ failure.
Results
At baseline, participants with a BMI of at least 30 were more likely than those in lower BMI categories to have DM (22.4% versus 7.9%, p < 0.01). Overall, BMI was not a significant predictor of developing acute organ failure. The risk for developing acute organ failure was increased among subjects with DM in comparison with those without DM (2.4% versus 0.7%, p < 0.01). Among subjects with organ failure, both in-hospital mortality (46.5% versus 12.2%, p < 0.01) and 3-year mortality (51.2% versus 21.1%, p < 0.01) was higher in subjects with DM.
Conclusion
Our findings suggest that obesity by itself is not a significant predictor of either acute organ failure or death during or after acute organ failure in this cohort. However, the presence of DM, which is related to obesity, is a strong predictor of both acute organ failure and death after acute organ failure.
Sepsis is one of the most common conditions encountered in the intensive care unit and is the 10th leading cause of death overall in the United States. Both long-term survival and health-related quality of life are reduced in survivors of sepsis, yet there is little knowledge of the effect of sepsis-specific interventions on either long-term survival or health-related quality of life. The present article discusses the importance of studying health-related quality of life as it relates to sepsis management strategies, particularly in the context of pharmacologic therapy with recombinant human activated protein C.
The growing basic and clinical investigations into the extraskeletal effects of vitamin D have revealed roles in the functioning of the immune system, generating interesting questions about this nutrient's connections to sepsis. This article briefly reviews the current science of the function of vitamin D in the immune system as well as the emerging clinical literature regarding its associations with respiratory infections, sepsis, and critical illness. Finally, we offer views on the potential future directions for research in the field by outlining potential relevant scenarios and outcomes.
Medical databases serve a critical function in healthcare, including the areas of patient care, administration, research and education. The quality and breadth of information collected into existing databases varies tremendously, between databases, between institutions and between national boundaries. The field of critical care medicine could be advanced substantially by the development of comprehensive and accurate databases.
Introduction
Diabetes mellitus (DM) is one of the most common chronic co-morbid medical conditions in the USA and is frequently present in patients with sepsis. Previous studies reported that people with DM and severe sepsis are less likely to develop acute lung injury (ALI). We sought to determine whether organ dysfunction differed between people with and without DM and sepsis.
Methods
Using the National Hospital Discharge Survey US, sepsis cases from 1979 to 2003 were integrated with DM prevalence from the Centers for Disease Control and Prevention (CDC) Diabetes Surveillance System.
Results
During the study period 930 million acute-care hospitalisations and 14.3 million people with DM were identified. Sepsis occurred in 12.5 million hospitalisations and DM was present in 17% of patients with sepsis. In the population, acute respiratory failure was the most common organ dysfunction (13%) followed by acute renal failure (6%). People with DM were less likely to develop acute respiratory failure (9% vs. 14%, p < 0.05) and more likely to develop acute renal failure (13% vs. 7%, p < 0.05). Of people with DM and sepsis, 27% had a respiratory source of infection compared with 34% in people with no DM (p < 0.05). Among patients with a pulmonary source of sepsis, 16% of those with DM and 23% of those with no DM developed acute respiratory failure (p < 0.05); in non-pulmonary sepsis acute respiratory failure occurred in 6% of people with DM and 10% in those with no DM (p < 0.05).
Conclusions
In sepsis, people with diabetes are less likely to develop acute respiratory failure, irrespective of source of infection. Future studies should determine the relationship of these findings to reduced risk of ALI in people with DM and causative mechanisms.
by
Jean-Louis Vincent;
Andrew Rhodes;
Azriel Perel;
Greg Martin;
Giorgio Della Rocca;
Benoit Vallet;
Michael R Pinsky;
Christoph K Hofer;
Jean-Louis Teboul;
Willem-Pieter de Boode;
Sabino Scolletta;
Antoine Vieillard-Baron;
Daniel De Backer;
Keith R Walley;
Marco Maggiorini;
Mervyn Singer
Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. With increased concerns about the use of invasive techniques, notably the pulmonary artery catheter, to measure cardiac output, recent years have seen an influx of new, less-invasive means of measuring hemodynamic variables, leaving the clinician somewhat bewildered as to which technique, if any, is best and which he/she should use. In this consensus paper, we try to provide some clarification, offering an objective review of the available monitoring systems, including their specific advantages and limitations, and highlighting some key principles underlying hemodynamic monitoring in critically ill patients.
In the previous issue of Critical Care, Blanco and colleagues contributed to a growing body of literature on the international epidemiology of severe sepsis. Taken together, these studies confirm that the sepsis incidence is high, that the development of organ dysfunction is a major determinant of mortality and that the occurrence of organ dysfunction is influenced by chronic comorbid medical conditions. It is clear that early detection of organ dysfunction and serial sequential organ dysfunction scoring provides us with the best chance to optimize clinical care. Identifying factors that contribute to the development of organ dysfunction in sepsis will lead to the development of new treatment modalities that will reduce mortality. Future studies must therefore focus on the impact of new treatment modalities for preventing progression to multiple organ dysfunction syndrome and consequent mortality in sepsis.
Albumin is a frequently prescribed drug in hospitalized patients, and its effect on clinical outcomes has been scrutinized in recent years. Data from meta-analyses has suggested harm related to albumin therapy in critically ill patients, and new observational data are consistent with these results. However, appropriately powered randomized, controlled trials have shown albumin to be safe in broad groups of critically ill patients. This article will discuss the reasons for differences between observational and controlled trial data, and the implications for future albumin use and clinical research.
Introduction: Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality, which is very high in this population. Uncertainty also exists about the associated risk of ICU-acquired weakness.Methods: We conducted a systematic review and meta-analysis. We searched the Cochrane (Central) database, MEDLINE, EMBASE, ACP Journal Club, and clinical trial registries for randomized trials investigating survival effects of neuromuscular blocking agents in adults with ARDS. Two independent reviewers abstracted data and assessed methodologic quality. Primary study investigators provided additional unpublished data.Results: Three trials (431 patients; 20 centers; all from the same research group in France) met inclusion criteria for this review. All trials assessed 48-hour infusions of cisatracurium besylate. Short-term infusion of cisatracurium besylate was associated with lower hospital mortality (RR, 0.72; 95% CI, 0.58 to 0.91; P = 0.005; I2 = 0). This finding was robust on sensitivity analyses. Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P = 0.02; I2 = 0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P = 0.93; I2 = 49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P = 0.57; I2 = 0). Primary studies lacked protracted measurements of weakness.Conclusions: Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.
Introduction: Patients with sepsis suffer high morbidity and mortality. We sought to conduct a systematic review of the literature to evaluate the association between hemodynamic goals of therapy and patient outcomes. Methods: We conducted a comprehensive search of the literature to systematically review hemodynamic goals used in clinical trials in patients with sepsis. We searched the literature using the Pubmed (1965-June 2006), Embase (1974-June 2006), CINAHL (1982-June 2006), pre-CINAHL, and Cochrane Library (2006, issue 3) electronic databases on 1 August 2006 for the following terms: sepsis, septic shock, severe sepsis, human clinical trials. We also hand-searched references and our personal files. Studies were selected if they met all of the following criteria: randomized, controlled trial study design; enrollment of adult patients with sepsis; presence of a hemodynamic goal for patient management; > 24-hour follow-up; and survival included as an outcome. Studies were independently selected and reviewed by two investigators. Results: A total of 6,006 citations were retrieved, and 13 eligible articles were reviewed. Mean arterial pressure was a treatment goal in nine studies, and systolic blood pressure was a treatment goal in three studies. A goal for pulmonary artery occlusion pressure, central venous pressure, and cardiac index was given in four, three, and five studies, respectively. The range of hemodynamic goals used in the trials were: mean arterial pressure 60-100 mmHg, central venous pressure 6-13 mmHg, pulmonary artery occlusion pressure 13-17 mmHg, and cardiac index 3-6 l/min/m2. All trials that used a systolic blood pressure goal used 90 mmHg as the aim. Conclusion: For those trials that specify hemodynamic goals, the wide range of treatment targets suggest a lack of agreement on blood pressure and filling pressure goals for management of patients with sepsis. There was also inconsistency between trials in which measures were targeted. Further research is necessary to determine whether this lack of consistency in hemodynamic goals may contribute to heterogeneity in treatment effects for clinical trials of novel sepsis therapies.