These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

A B S T R A C T The effects of insulin on the renal handling of sodium, potassium, calcium, and phosphate were studied in man while maintaining the blood glucose concentration at the fasting level by negative feedback servocontrol of a variable glucose infusion. In studies on six water-loaded normal subjects in a steady state of water diuresis, insulin was administered i.v. to raise the plasma insulin concentration to between 98 and 193 PU/ml and infused at a constant rate of 2 mU/kg body weight per min over a total period of 120 min. The blood glucose concentration was not significantly altered, and there was no change in the filtered load of glucose; glomerular filtration rate (CIN) and renal plasma flow (CPAH) were unchanged. Urinary sodium excretion (UNaV) decreased from 401±46 (SEM) to 213+18 iteq/min during insulin administration, the change becoming significant (P < 0.02) within the 30-60-min collection period. Free water clearance (CH2o) increased from 10.6±0.6 to 13±0.5 ml/min (P <0.025); osmolar clearance decreased and urine flow was unchanged. There was no change in plasma aldosterone concentration, which was low throughout the studies, and a slight reduction was observed in plasma glucagon concentration. Urinary potassium (UKV) and phosphate (Ui.V) excretion were also both decreased during insulin administration; UKV decreased from 66±9 to 21±1 Meq/min (P < 0.005), and UrV decreased from 504±93 to 230 ±43 Ag/min (P <0.01). The change in UKV was associated with a significant reduction in plasma potassium concentration. There was also a statistically significant but small reduction in plasma phosphate concentration which was not considered sufficient alone to account for the large reduction in UPV. Urinary calcium excretion (UCaV) increased from 126±24 to 200±17 ug/min (P < 0.01).These studies demonstrate a reduction in UNaV associated with insulin administration that occurs in the absence of changes in the filtered load of glucose, glomerular filtration rate, renal blood flow, and plasma aldosterone concentration. The effect of insulin on CH2o suggests that insulin's effect on sodium excretion is due to enhancement of sodium reabsorption in the diluting segment of the distal nephron.

Background Severe sepsis is associated with persistent high-levels of morbidity among older survivors. But the impact of severe sepsis on population health—particularly population levels of disability—is unknown. Objectives Ascertain the absolute number of patients surviving at least 3 years after severe sepsis in Medicare, and estimate their burden of cognitive dysfunction and disability. Design Retrospective cohort analysis of Medicare data. Setting All short-stay inpatient hospitals in the United States, 1996–2008. Participants Patients aged 65 and older. Measurements Severe sepsis was detected using a standard administrative definition. Case-fatality, prevalence and incidence rates were calculated. Results There were 637,867 Medicare patients alive at the end of 2008 who survived severe sepsis 3 or more years earlier. An estimated 476,862 (95% CI: 455,026, 498,698) had functional disability, with 106,311 (95% CI: 79,692, 133,930) survivors having moderate-to-severe cognitive impairment. The annual number of new 3-year survivors following severe sepsis rose 119% during 1998–2008. The increase in survivorship resulted from more new diagnoses of severe sepsis rather than a change in case fatality rates; severe sepsis rates rose from 13.0 per 1,000 Medicare beneficiary-years to 25.8 (p<0.001), whereas 3-year case fatality rates changed much less, from 73.5%to 71.3% (p<0.001) for the same cohort. Increasing rates of organ dysfunction among hospitalized patients drove the increase in severe sepsis incidence, with an additional small contribution from population aging. Conclusions Sepsis survivorship, which carries with it substantial long-term morbidity, is a common and rapidly growing public health problem for older Americans. There has been little change in long-term case fatality, despite changes in practice. Clinicians should anticipate more frequent sequelae of severe sepsis in their patient populations.

Background During in-hospital cardiac arrests, it is uncertain how long resuscitation should continue prior to termination of efforts. We hypothesized that the duration of resuscitation varies across hospitals, and that patients at hospitals with longer attempts have higher survival rates. Methods Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 hospitals within a large national registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts among its non-survivors as a measure of the hospital’s overall tendency for longer attempts. We then determined the association between a hospital’s tendency for longer attempts and risk-adjusted survival using multilevel regression models. Findings The overall proportion of patients achieving immediate survival with return of spontaneous circulation (ROSC) was 48·5% while 15·4% survived to discharge. For patients achieving ROSC, the median resuscitation time was 12 minutes (IQR: 6–21) while it was 20 minutes (IQR: 14–30) for those not achieving ROSC (i.e., non-survivors). Compared with patients at hospitals with the shortest attempts (median duration, 16 minutes), patients at hospitals with the longest attempts (median duration, 25 minutes) had a higher likelihood of ROSC (adjusted risk-ratio 1·12, [95% CI: 1·06–1·18]; p <0·001) and survival to discharge (adjusted risk-ratio 1·12, [95% CI: 1·02–1·23]; p=0·021). These findings were more prominent in cardiac arrests due to asystole and pulseless electrical activity (p for interaction<0.01 for both ROSC and survival to discharge). Interpretation The duration of resuscitation attempts varies across hospitals. Patients at hospitals with longer attempts have a higher likelihood of ROSC and survival to discharge, particularly when the arrest is due to asystole and pulseless electrical activity. Funding The American Heart Association, the Robert Wood Johnson Foundation Clinical Scholars Program, the National Institutes of Health.