Nearly 20% of critically ill patients required out of operating room reintubation. Reintubation was associated with higher mortality, stay, and cost. Moreover, a difficult airway at reintubation was associated with higher mortality.

ObjectiveThis report aimed to describe the outcomes of the patients with severe H1N1 associated acute respiratory distress syndrome who were treated with extracorporeal membrane oxygenation therapy.MethodsThis retrospective review analyzed a single-center cohort of adult patients with H1N1-related acute respiratory distress syndrome who were managed with veno-venous extracorporeal membrane oxygenation during the winter of 2013/2014.ResultsA total of 10 patients received veno-venous extracorporeal membrane oxygenation for H1N1 influenza between January 2013 and March 2014. Seven patients were transferred to our center for extracorporeal membrane oxygenation consideration (all within 72 hours of initiating mechanical ventilation). The median patient age was forty years, and 30% were female. The median arterial oxygen partial pressure to fraction of inspired oxygen ratio was 62.5, and the median RESP score was 6. Three patients received inhaled nitric oxide, and four patients were proned as rescue therapy before extracorporeal membrane oxygenation was initiated. The median duration of mechanical ventilation was twenty-two days (range, 14 - 32). The median length of stay in the intensive care unit was twenty-seven days (range, 14 - 39). The median hospital length of stay was 29.1 days (range, 16.0 - 46.9). Minor bleeding complications occurred in 6 of 10 patients. Eight of the ten patients survived to hospital discharge.ConclusionThe survivors were relatively young and discharged with good functional status (i.e., enhancing quality-adjusted life-years-saved). Our experience shows that even a relatively new extracorporeal membrane oxygenation program can play an important role in that capacity and provide excellent outcomes for the sickest patients.

Objective: We have employed our electronic medical record (EMR) in an effort to identify patients at the onset of severe sepsis through an automated analysis that identifies simultaneous occurrence of systemic inflammatory response syndrome (SIRS) and organ dysfunction. The purpose of this study was to determine the positive predictive value of this alert for severe sepsis and other important outcomes in hospitalized adults. Design: Prospective cohort. Setting: Banner Good Samaritan Medical Center, Phoenix AZ Patients: Forty adult inpatients who triggered alert logic within our EMR indicating simultaneous occurrence of SIRS and organ dysfunction. Interventions: Interview of bedside nurse and chart review within six hours of alert firing to determine the clinical event that triggered each alert. Results: Eleven of 40 patients (28%) had a major clinical event (immediately lifethreatening illness) associated with the alert firing. Severe sepsis or septic shock accounted for four of these-yielding a positive predictive value of 0.10 (95%CI: 0.04-0.23) of the alert for detection of severe sepsis. The positive predictive value of the alert for detection of major clinical events was 0.28 (95%CI: 0.16-0.43), and for detecting either a major or minor clinical event was 0.45 (95%CI: 0.31-0.60). Twenty-two of 40 patients (55%) experienced a false alert. Conclusions: Our first-generation SIRS/organ dysfunction alert has a low positive predictive value for severe sepsis, and generates many false alerts, but shows promise for the detection of acute clinical events that require immediate attention. We are currently investigating refinements of our automated alert system which we believe have potential to enhance patient safety.

18 hours after sepsis, when compared to baseline values before the CLP procedure (29.9 ± 1.1% and 57.3 ± 1.6%, respectively; P<0.05). In contrast, treatment with AICAR significantly improved both fractional shortening (26.6 ± 3.4%) and ejection fraction (52.4 ± 5.9%) when compared to vehicle treatment (P<0.05). At Western blotting analysis, the beneficial effects of AICAR were associated with increased AMPK phosphorylation, as well as increase of nuclear expression of peroxisome proliferator-activated receptor-ϒ co-activator α (PGC-1α), a major regulator of mitochondrial function and biogenesis. Conclusions: Our data indicate that AICAR confers cardioprotective effects during experimental sepsis through activation of AMPK-dependent metabolic repair mechanisms. These findings can potentially lead to a new therapeutic strategy for prevention of cardiac dysfunction in sepsis.Learning Objectives: Red cell distribution width (RDW), a quantitative measure of the variability in size of erythrocytes, has been associated with an increased hospital mortality in critically ill patients. The reason for this association remains unclear, especially on rheology. We hypothezised that an increased RDW might contribute to microcirculatory alterations in sepsis. Methods:Analysis of prospectively collected database. Microcirculatory measurements were obtained either during severe sepsis (n = 27), or septic shock (n = 95). When multiple measurements were obtained, only the first was considered. Patients' demographics, comorbidities, the Acute Physiologic and Chronic Health Evaluation (APACHE) II score on admission and the Sequential Organ Failure Assessment (SOFA) score on the day of microcirculatory assessment were collected. The microcirculation of the sublingual area was evaluated using the Sidestream Dark-Field (SDF) videomicroscopy. RDW (normal ranges: 10.9-13.4%) was obtained retrospectively from routine blood analysis on the day of microcirculation evaluation. A sub-group analysis was performed after exclusion of patients with diabetes, heart failure, autoimmune disease, recent blood transfusion, cancer and haematological diseases, which can all influence RDW independently from critically illness. Data are presented as median [IQRs] Results: 122 patients were included. Median RDW on the day of microcirculation evaluation was 13.8 [12.8-15.5] and was within normal ranges in 48 (39%) patients. We found no correlation between RDW and microcirculatory parameters (functional capillary density, FCD -r = -0.12; proportion of small perfused vessels, PPV -r=0.17; mean flow index, MFI -r=-0.17). Also, no differences in FCD, PPV and MFI were found between patients with normal and altered RDW. Similar results were also found when the sub-group analysis was performed. We found not correlation of RDW with APACHE and SOFA scores. RDW values were not different between survivors and non-survivors. Conclusions: RDW was not associated with microcirculatory alterations or survival in septic patients.

No abstract