Toward Increased Understanding of the Steroid Controversy in Septic Shock No abstract available

Promoting Family Engagement in the ICU: Experience From a National Collaborative of 63 ICUs Objectives: As part of an improvement program targeting ICU, a national collaborative was launched to help hospitals implement patient- and family-centered care engagement initiatives. Design: Ten-month quality improvement collaborative. Setting: Guided by a national patient and family advisory group, participating teams implemented an individual project including open visitation; integrating families on rounds; establishing a patient and family advisory committee; using patient and family diaries, among others. Subjects: Sixty-three adult and PICU teams from both academic and community hospitals in 34 states participated. Interventions: Monthly team calls, quarterly webinars, newsletters, an online eCommunity, and team reporting assignments were used to facilitate project implementation. Measurements and Main Results: The Family Satisfaction with Care in the ICU 24 was used to assess family satisfaction. Clinician perceptions were assessed with the Institute for Patient- and Family-Centered Care Self-Assessment Inventory. Thematic analysis was used to explore narrative data captured from team reports of project barriers, facilitators, and the experience of participating in the collaborative. A total of 2,530 family member and 3,999 clinician surveys were completed. Postimplementation, family members reported statistically significant increases in overall family satisfaction, satisfaction with decision-making, and satisfaction with quality of care (Family Satisfaction with Care in the ICU mean score change range 0.83–1.24; p ≤ 0.027). Clinicians reported that opportunities for families to participate as members of the care team increased. Major barriers included lack of buy-in and ability to promote change in the clinical setting, managing the workload of implementation, and funding to support initiatives. Conclusions: A national collaborative format was useful to assist ICU teams to implement patient- and family-engagement initiatives. Enlisting stakeholder support, engaging unit-based champions, and highlighting benefits of family engagement can help ICU teams to promote family member involvement and engagement. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Kleinpell disclosed that this article reports on the work of a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (6262-SCCM), and disclosed that she served as Society of Critical Care Medicine (SCCM) President-Elect and President during the time of the project. Drs. Kleinpell and Ms. Harmon received support for article research from PCORI. Dr. Zimmerman’s institution received funding from the National Institutes of Health and Immunexpress (research funding), and he received funding from Elsevier Publishing (royalties for co-editing Pediatric Critical Care) and SCCM (travel reimbursement to attend board meetings). Ms. Harmon’s institution received funding from PCORI. Mr. Hanson received funding from Eugene Washington PCORI Engagement Award for the “Improving Care for Critically Ill Patients and Families Through Research Dissemination and Implementation” SCCM Collaborative. Dr. Hwang received funding from SCCM. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Ruth Kleinpell, PhD, RN, Vanderbilt University School of Nursing, 461 21st Avenue South 407 GH, Nashville, TN 37240. E-mail: ruth.kleinpell@vanderbilt.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes Objectives: To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management. Design: Retrospective study. Setting: ICUs in a single tertiary care hospital. Patients: Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring. Interventions: None. Measurements and Main Results: Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1–2) versus poor (Cerebral Performance Category 3–5) at hospital discharge. White non-Hispanic (“White”) patients were more likely to have good outcomes than white Hispanic/nonwhite (“Non-white”) patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients. Conclusions: Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity. This work was performed at Brigham and Women’s Hospital. Dr. Jacobs contributed to acquisition of data, analysis of the data, and drafting the article. Mr. Beers and Ms. Park contributed to acquisition of data. Drs. Scirica and Hsu contributed to acquisition of data and revising the article for intellectual content. Dr. Henderson contributed to revising the article for intellectual content. Dr. Bevers contributed to analysis of the data and revising the article for intellectual content. Dr. Dworetzky contributed to analysis of the data and writing of the article. Dr. Lee contributed to design of the study, acquisition of data, analysis of the data, and drafting the article. Dr. Jacobs is partially supported (80%) by the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS) R25NS065743, principal investigator (PI), 2017–2019 (ongoing), she performs contract work (electroencephalogram [EEG] reading) for Carle Foundation Hospital, and she disclosed that she is an inventor on two (unlicensed) patents relating to work she performed during graduate school (United States Patent US 7,935,530 B2. November 28, 2007; United States Patent US 9,630,950. April 25, 2017); she has not received any compensation related to these patents. Drs. Jacobs and Lee received support for article research from the NIH. Ms. Park disclosed work for hire. Dr. Scirica received research grants via Brigham and Women’s Hospital from AstraZeneca, Eisai, Novartis, and Merck, and he has received consulting fees from AbbVie, Allergan, AstraZeneca, Boehringer Ingelheim, Covance, Eisai, Elsevier Practice Update Cardiology, GlaxoSmithKline, Lexicon, Medtronic, Merck, NovoNordisk, Sanofi, and equity in Health [at] Scale, outside the submitted work. Dr. Bevers receives research support from the American Academy of Neurology and David Heitman Neurovascular Research Fund (unrelated to the current work), outside the scope of the submitted work; he reports grants and personal fees from Biogen and EBSCO Health, outside the scope of the submitted work; and he reports personal fees for editorial work from Dynamed, LCC, outside the scope of the submitted work. Dr. Dworetzky reads EEGs in her clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace, is a consultant for SleepMed (EEG interpretation) and for Best Doctors (clinical consults) & Oxford University Press (royalties). Dr. Lee reads EEGs in his clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace and Advance Medical; he was supported by the NIH (NINDS R03NS091864 02, PI, 2015–2018). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jlee38@bwh.harvard.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Outcomes in Critically Ill Patients With Traumatic Brain Injury: Ethnicity, Documentation, and Insurance Status Objectives: Disparities in traumatic brain injury outcomes for ethnic minorities and the uninsured have previously been demonstrated; however, outcomes in undocumented immigrants have not been examined. We wanted to determine whether ethnicity, insurance, and documentation status served as risk factors for disparities in traumatic brain injury outcomes between undocumented immigrants and documented residents. Design: Retrospective study. Setting: Patients diagnosed with traumatic brain injury admitted to the surgical/trauma ICU at a level 1 trauma center serving a large immigrant population in New York City from 2009 to 2016. Patients: Four-hundred seventy-one traumatic brain injury patients requiring surgical/trauma ICU admission. Interventions: None. Measurements and Main Results: Undocumented immigrants constituted 29% of the population, were younger (39 vs 57 yr old, respectively; p < 0.0001), Hispanic (83%; p < 0.0001), and uninsured (87%; p < 0.0001). Falls resulted in the majority of traumatic brain injuries in the total population, however, undocumented immigrants were almost twice as likely to be assaulted (p = 0.0032). There was no difference in presence of midline shifts, Injury Severity Score, Glasgow Coma Score, hypotension, hypoxia, and pupillary reactions between undocumented immigrants and documented residents. Undocumented immigrants presented with significantly more effaced basilar cisterns (p = 0.0008). There was no difference in hospital care between undocumented immigrants and documented residents as determined by emergency department to surgical/trauma ICU transfer times (p = 0.967). Undocumented immigrants were more likely to be discharged home (53% vs 33%, respectively; p = 0.0009) and less likely to be sent to rehabilitation (25% vs 32%, respectively; p = 0.0009). After adjusting length of stay and mortality for covariates, undocumented immigrants had shorter length of stay (p < 0.05) and there was no difference in hospital mortality between undocumented immigrants and documented residents. Conclusions: Undocumented immigrants with traumatic brain injuries were more likely to be younger, have shorter length of stay, and experience similar mortality rates to documented residents. Social economic status may play a role in events prior to hospitalization and likely does in disposition outcomes. All work was performed at Elmhurst Hospital Center. The authors have disclosed that they do not have any potential conflicts of interest. Presented, in part, preliminary data at the Society of Critical Care Medicine 47th Critical Care Congress, San Antonio, TX, February 26, 2018. For information regarding this article, E-mail: coritsg@nychhc.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Hyperosmolar Therapy in Pediatric Severe Traumatic Brain Injury—A Systematic Review Objectives: Traumatic brain injury is a leading cause of hospital visits for children. Hyperosmolar therapy is often used to treat severe traumatic brain injury. Hypertonic saline is used predominantly, yet there remains disagreement about whether hypertonic saline or mannitol is more effective. Data Sources: Literature search was conducted using Pubmed, Cochrane, and Embase. Systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study Selection: Retrospective and prospective studies assessing use of hyperosmolar therapy in pediatric patients with severe traumatic brain injury were included. Data Extraction: Two independent authors performed article review. Two-thousand two-hundred thirty unique articles were initially evaluated, 11 were included in the final analysis, with a total of 358 patients. Study quality was assessed using Modified Newcastle-Ottawa Scale and Jadad score. Data Synthesis: Of the 11 studies, all evaluated hypertonic saline and four evaluated both hypertonic saline and mannitol. Nine reported that hypertonic saline lowered intracranial pressure and two reported that mannitol lowered intracranial pressure. The studies varied significantly in dose, concentration, and administrations schedule for both hypertonic saline and mannitol. Five studies were prospective, but only one directly compared mannitol to hypertonic saline. The prospective comparison study found no difference in physiologic outcomes. Clinical outcomes were reported using different measures across studies. For hypertonic saline-treated patients, mechanical ventilation was required for 6.9–9 days, decompressive craniectomy was required for 6.25–29.3% of patients, ICU length of stay was 8.0–10.6 days, in-hospital mortality was 10–48%, and 6-month mortality was 7–17%. In mannitol-treated patients, ICU length of stay was 9.5 days, in-hospital mortality was 56%, and 6-month mortality was 19%. Conclusions: Both hypertonic saline and mannitol appear to lower intracranial pressure and improve clinical outcomes in pediatric severe traumatic brain injury, but the evidence is extremely fractured both in the method of treatment and in the evaluation of outcomes. Given the paucity of high-quality data, it is difficult to definitively conclude which agent is better or what treatment protocol to follow. Ms. Stopa and Ms. Dolmans contributed equally and shared first authorship. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: sizzy@partners.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Pro: Selective Digestive Decontamination Is Neither Safe Nor Efficacious for Critically Ill Patients No abstract available

Deconstructing Poststroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage Objectives: Poststroke delirium may be underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurologic deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in patients with intracerebral hemorrhage. Design: Prospective observational cohort study. Setting: Neurocritical Care and Stroke Units at a university ­hospital. Patients: Consecutive patients with intracerebral hemorrhage from February 2018 to May 2018. Interventions: None. Measurements and Main Results: An attending neurointensivist performed 257 total daily assessments for delirium on 60 patients (mean age 68.0 [SD 18.4], 62% male, median intracerebral hemorrhage score 1.5 [interquartile range 1–2], delirium prevalence 57% [n = 34]). Each assessment included the Confusion Assessment Method for the ICU, Intensive Care Delirium Screening Checklist, a focused bedside cognitive examination, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria, then compared performance of the Confusion Assessment Method for the ICU and Intensive Care Delirium Screening Checklist against reference-standard expert diagnosis. Symptom fluctuation (61% of all assessments), psychomotor changes (46%), sleep-wake disturbances (46%), and impaired arousal (37%) had the highest prevalence and were never rated “unable to assess,” while inattention (36%), disorientation (27%), and disorganized thinking (18%) were also common but were often rated "unable to assess" (32%, 43%, and 44% of assessments, respectively), most frequently due to aphasia (32% of patients). Including nonverbal assessments of attention decreased the frequency of "unable to assess" ratings to 11%. Since the Intensive Care Delirium Screening Checklist may be positive without the presence of symptoms that require verbal assessment, it was more accurate (sensitivity = 77%, specificity = 97%, area under the receiver operating characteristic curve, 0.87) than the Confusion Assessment Method for the ICU (sensitivity = 41%, specificity = 88%, area under the receiver operating characteristic curve, 0.64). Conclusions: Delirium is common after intracerebral hemorrhage, but severe neurologic deficits may confound its assessment and lead to underdiagnosis. The Intensive Care Delirium Screening Checklist’s inclusion of nonverbal features may make it more accurate than the Confusion Assessment Method for the ICU in patients with neurologic deficits, but novel tools designed for such patients may be warranted. Dr. Reznik is supported by the Rhode Island Foundation and departmental funds from Brown University’s Center for Biomedical Informatics. Dr. Margolis is partially supported by grant funding from the American Academy of Clinical Neuropsychology Foundation and a research career development award from the Department of Neurology at Lifespan Health System and The Miriam Hospital. Dr. Wendell received funding from Biogen (investigator meeting for Phase 3 Study to Evaluate the Efficacy and Safety of Intravenous BIIB093 [Glibenclamide] for Severe Cerebral Edema Following Large Hemispheric Infarction [CHARM]). Dr. Barrett received funding from National Institutes of Health (NIH), Wallerstein Foundation for Geriatric Improvement, DART Neuroscience, Bright Cloud International Corp; she received funding from WebMD/emedicine.com (textbook chapter honoraria) and Kessler Foundation (employee); and she received support for article research from the NIH. Dr. Boukrina’s institution received funding from NIH grant 1R21HD095488-01. Drs. Barrett and Boukrina are supported by the American Heart Association (Scientist Development Grant 17SDG33660442) and the Kessler Foundation. Dr. Asaad is supported by NIH grants R01-MH115035 and P20-GM103645. Dr. Jones is primarily supported by NIH grants R01-AG044518, R01-AG051170, and R01-AG029672, VA grant 650D48063, and departmental funds from the Departments of Psychiatry and Neurology at the Alpert Medical School at Brown University. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Michael E. Reznik, MD, Division of Neurocritical Care, Department of Neurology, Rhode Island Hospital, 593 Eddy Street, APC 712, Providence, RI 02903. E-mail: Michael_Reznik@brown.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity Objective: Although bleeding frequently occurs in critical illness, no published definition to date describes the severity of bleeding accurately in critically ill children. We sought to develop diagnostic criteria for bleeding severity in critically ill children. Design: Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity. Setting: PICU. Patients: Children at risk of bleeding in PICUs. Interventions: None. Measurements and Main Results: Twenty-four physicians worldwide (10 on a steering committee and 14 on an expert committee) from disciplines related to bleeding participated in development of a definition for clinically relevant bleeding. A provisional definition was created from 35 descriptors of bleeding. Using a modified online Delphi process and conference calls, the final definition resulted after seven rounds of voting. The Bleeding Assessment Scale in Critically Ill Children definition categorizes bleeding into severe, moderate, and minimal, using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding. The criteria do not include treatments such as red cell transfusion or surgical interventions performed in response to the bleed. The definition was prospectively applied to 40 critically ill children with 46 distinct bleeding episodes. The kappa statistic between the two observers was 0.74 (95% CI, 0.57–0.91) representing substantial inter-rater reliability. Conclusions: The Bleeding Assessment Scale in Critically Ill Children definition of clinically relevant bleeding severity is the first physician-driven definition applicable for bleeding in critically ill children derived via international expert consensus. The Bleeding Assessment Scale in Critically Ill Children definition includes clear criteria for bleeding severity in critically ill children. We anticipate that it will facilitate clinical communication among pediatric intensivists pertaining to bleeding and serve in the design of future epidemiologic studies if it is validated with patient outcomes. Supported, in part, by Clinical and Translational Science Award award No. UL1TR000058 from the National Center for Advancing Translational Sciences (for access to Research Electronic Data Capture). Drs. Nellis and Josephson received support for article research from the National Institutes of Health. Dr. Zantek disclosed that she is an Executive Board member of the North American Specialized Coagulation Laboratory Association, and that her spouse is an employee of Boston Scientific and owns stock in Boston Scientific and ENDO International PLC. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: man9026@med.cornell.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Validation of Early Warning Scores at Two Long-Term Acute Care Hospitals Objectives: Early warning scores were developed to identify high-risk patients on the hospital wards. Research on early warning scores has focused on patients in short-term acute care hospitals, but there are other settings, such as long-term acute care hospitals, where these tools could be useful. However, the accuracy of early warning scores in long-term acute care hospitals is unknown. Design: Observational cohort study. Setting: Two long-term acute care hospitals in Illinois from January 2002 to September 2017. Patients: Admitted adult long-term acute care hospital patients. Interventions: None. Measurements and Main Results: Demographic characteristics, vital signs, laboratory values, nursing flowsheet data, and outcomes data were collected from the electronic health record. The accuracy of individual variables, the Modified Early Warning Score, the National Early Warning Score version 2, and our previously developed electronic Cardiac Arrest Risk Triage score were compared for predicting the need for acute hospital transfer or death using the area under the receiver operating characteristic curve. A total of 12,497 patient admissions were included, with 3,550 experiencing the composite outcome. The median age was 65 (interquartile range, 54–74), 46% were female, and the median length of stay in the long-term acute care hospital was 27 days (interquartile range, 17–40 d), with an 8% in-hospital mortality. Laboratory values were the best predictors, with blood urea nitrogen being the most accurate (area under the receiver operating characteristic curve, 0.63) followed by albumin, bilirubin, and WBC count (area under the receiver operating characteristic curve, 0.61). Systolic blood pressure was the most accurate vital sign (area under the receiver operating characteristic curve, 0.60). Electronic Cardiac Arrest Risk Triage (area under the receiver operating characteristic curve, 0.72) was significantly more accurate than National Early Warning Score version 2 (area under the receiver operating characteristic curve, 0.66) and Modified Early Warning Score (area under the receiver operating characteristic curve, 0.65; p < 0.01 for all pairwise comparisons). Conclusions: In this retrospective cohort study, we found that the electronic Cardiac Arrest Risk Triage score was significantly more accurate than Modified Early Warning Score and National Early Warning Score version 2 for predicting acute hospital transfer and mortality. Because laboratory values were more predictive than vital signs and the average length of stay in an long-term acute care hospital is much longer than short-term acute hospitals, developing a score specific to the long-term acute care hospital population would likely further improve accuracy, thus allowing earlier identification of high-risk patients for potentially life-saving interventions. Dr. Churpek’s institution received funding from National Heart, Lung, and Blood Institute (K08HL121080) and National Institute for General Medicine Sciences (R01 GM123193), and he received support for article research from the National Institutes of Health. Drs. Churpek and Edelson received funding from research support from EarlySense (Tel Aviv, Israel), and they disclosed that they have a patent pending for risk stratification algorithms for hospitalized patients (ARCD. P0535US.P2). Dr. Prister disclosed that after the study was conducted, RML chose to pursue implementation of the electronic Cardiac Arrest Risk Triage system at their long-term acute care hospitals. Dr. Edelson c/f (received funding from in Quant HC [ownership interest]) which is developing products for risk stratification of hospitalized patients, and she received research support and honoraria from Philips Healthcare (Andover, MA) as well as research support from the American Heart Association (Dallas, TX) and Laerdal Medical (Stavanger, Norway). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: matthew.churpek@uchospitals.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report Objectives: We report a case of a man with tamponade decompression syndrome following pericardial drainage. Data Sources: ICU - Montreal Heart Institute. Study Selection: Case report. Data Extraction: Clinical and surgical records. Data Synthesis None. Conclusions: Our case adds further concerns in supporting a patient with tamponade decompression syndrome, including mechanical circulatory support, due to the reversible nature of this condition. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jpricartebratti@gmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.