Critical Care Medicine

Epinephrine is widely used as an integral part of advanced cardiac life support (ACLS) despite a paucity of clinical data supporting its use with cardiopulmonary resuscitation. Recent studies have demonstrated a potential association with epinephrine and poor outcomes.

To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest, a prospective, randomized controlled trial was conducted. Consecutive adult patients (n = 418 ACLS with intravenous drug administration and n = 433 ACLS without intravenous drugs) with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system were included.

Short-term survival was significantly longer in patients who received intravenous drugs and ACLS compared with ACLS alone (P = 0.004). However, the rates of survival to hospital discharge (10.5% vs.  9.2%; P = 0.61), survival with favorable neurologic outcome (9.8% vs.  8.1%; P = 0.45), and survival at 1 yr (10% vs.  8%; P = 0.53) were similar between the two groups. No difference in the quality of cardiopulmonary resuscitation was observed. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the ACLS plus intravenous drug administration group versus  the ACLS-alone group.

These results indicate an apparent lack of long-term benefit of epinephrine and other intravenous medications in the management of out-of-hospital cardiac arrest. The results should be interpreted with caution because the study overestimated survival rates in the nondrug group. Nevertheless, these data suggest that factors other than intravenous drug administration contribute to long-term outcome after out-of-hospital cardiac arrest.

Prolonged mechanical ventilation after cardiac surgery is associated with in-hospital mortality rates as high as 40% and is also a serious economic burden on the healthcare system. Furthermore, it is difficult to predict which patients will require prolonged mechanical ventilation. This prospective observational study consecutively enrolled patients mechanically ventilated 3 days after surgery, and preoperative, intraoperative, and postoperative data were recorded.

Among 2,620 patients who underwent cardiac surgery on day 3, 163 patients were still receiving ventilatory assistance. By day 10, 50 (31%) patients had been successfully weaned, 78 (48%) were still receiving mechanical ventilation and 35 (21%) died. Factors associated with successful weaning on day 3 included urine output more than or equal to 500 ml/24 h, Glasgow Coma Score of 15, arterial bicarbonates more than or equal to 20 mm, platelet count more than or equal to 100 g/l, patients without inotropic support with epinephrine/norepinephrine, and absence of lung injury. Data from this study were used to develop a scoring system. This scoring may help identify patients who can be rapidly weaned from ventilator support and reduce the need for interventions in patients likely to be extubated.

These data may be helpful in preventing invasive procedures, such as tracheostomy, in patients with high probability of successful weaning after cardiac surgery. Prospective validation of the scoring system proposed in other intensive care units (ICUs) dedicated to cardiac surgery is necessary to assess the external validity of the proposed score.

Infection is a major cause of morbidity and mortality in ICUs worldwide, and cases of infection-related deaths are increasing. Relatively little information is available about the global epidemiology of such infections.

To examine the extent and patterns of ICU infections worldwide, the Extended Prevalence of Infection in Intensive Care II study, a 1-day, prospective, point prevalence study with follow-up was conducted including 14,414 patients.

Fifty-one percent of patients were infected on the study day, and the majority of these infections were respiratory (64%). Patients who had longer ICU stays before the study day had higher rates of infection, especially infections from resistant staphylococci, Acinetobacter , Pseudomonas  species, and Candida  species:

Central and South America had the highest infection rate (60%), and Africa had the lowest rate (46%). Gram-negative infections were more common in all regions, except North America (49.9 vs.  55.1, for Gram-negative vs.  Gram-positive). Countries with lower healthcare expenditures reported higher infection rates.

This large international epidemiologic study from 1,265 ICUs in 75 countries is a comprehensive, current picture of infections in ICUs. Infection remains a major concern with direct effect on mortality and morbidity. Major international differences were detected in the prevalence and types of infections, as well as mortality rates, suggesting differences in approaches to improve infection prophylaxis, and management should be identified and perhaps adopted.

In 2009, a pandemic influenza A (H1N1) virus emerged and spread globally, infecting patients in 191 countries and territories by September. Risk factors for severity and additional clinical characteristics are still being described. In this article, the authors describe the clinical characteristics of patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.

Data were collected from 272 patients in 24 states (25% of all cases reported to the Centers for Disease Control and Prevention during this time period) who were hospitalized for at least 24 h for influenza-like illness and who tested positive for the 2009 H1N1 virus. Forty-five percent of the patients were children younger than 18 yr, and 5% were 65 yr of age or older. Seventy-three percent of the patients had at least one underlying medical condition (e.g. , asthma; diabetes; heart, lung, neurologic diseases, and pregnancy), including 60% of children, 83% of adults, and 100% of patients 65 yr or older of age. Of the 249 patients who underwent chest radiography at admission, 40% had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness.

Overall, 25% of patients were admitted to an ICU and 7% died. The majority of deaths were in patients with underlying medical conditions (68%). All patients who died had received antiviral therapy; however, none of the patients had received therapy within 48 h after the onset of symptoms.

This article is the first epidemiologic report on influenza H1N1 in 2009 in hospitalized patients in the United States. Comorbidities in hospitalized patients are reviewed, such as age less than 65 yr, pregnancy, and immunosuppression. In addition, other factors such as morbid obesity seem to influence severity of illness caused by H1N1. Antiviral therapy provided benefit to some patients when received within 48 h of symptom onset.