Host-Response Subphenotypes Offer Prognostic Enrichment in Patients With or at Risk for Acute Respiratory Distress Syndrome Objectives: Classification of patients with acute respiratory distress syndrome into hyper- and hypoinflammatory subphenotypes using plasma biomarkers may facilitate more effective targeted therapy. We examined whether established subphenotypes are present not only in patients with acute respiratory distress syndrome but also in patients at risk for acute respiratory distress syndrome (ARFA) and then assessed the prognostic information of baseline subphenotyping on the evolution of host-response biomarkers and clinical outcomes. Design: Prospective, observational cohort study. Setting: Medical ICU at a tertiary academic medical center. Patients: Mechanically ventilated patients with acute respiratory distress syndrome or ARFA. Interventions: None. Measurements and Main Results: We performed longitudinal measurements of 10 plasma biomarkers of host injury and inflammation. We applied unsupervised latent class analysis methods utilizing baseline clinical and biomarker variables and demonstrated that two-class models (hyper- vs hypoinflammatory subphenotypes) offered improved fit compared with one-class models in both patients with acute respiratory distress syndrome and ARFA. Baseline assignment to the hyperinflammatory subphenotype (39/104 [38%] acute respiratory distress syndrome and 30/108 [28%] ARFA patients) was associated with higher severity of illness by Sequential Organ Failure Assessment scores and incidence of acute kidney injury in patients with acute respiratory distress syndrome, as well as higher 30-day mortality and longer duration of mechanical ventilation in ARFA patients (p < 0.0001). Hyperinflammatory patients exhibited persistent elevation of biomarkers of innate immunity for up to 2 weeks postintubation. Conclusions: Our results suggest that two distinct subphenotypes are present not only in patients with established acute respiratory distress syndrome but also in patients at risk for its development. Hyperinflammatory classification at baseline is associated with higher severity of illness, worse clinical outcomes, and trajectories of persistently elevated biomarkers of host injury and inflammation during acute critical illness compared with hypoinflammatory patients. Our findings provide strong rationale for examining treatment effect modifications by subphenotypes in randomized clinical trials to inform precision therapeutic approaches in critical care. Drs. Kitsios, Morris, and McVerry involved in conception and design. Dr.Kitsios, Ms. Yang, and Drs. Manatakis, Evankovich, Bain, Dunlap, Shah, and Barbash, Ms. Rapport, Drs. Zhang and Nouraie, Ms. DeSensi, and Drs. Weathington, Benos, Lee, Morris, and McVerry involved in acquisition, analysis, or interpretation of data. Drs. Kitsios, Evankovich, Bain, Dunlap, Shah, and Barbash, Ms. Rapport, and Drs. Weathington, Lee, Morris, and McVerry involved in clinical cohort phenotyping. Drs. Kitsios, Yang, Manatakis, Evankovich, Bain, Dunlap, Shah, and Barbash, Ms. Rapport, Drs. Zhang and Nouraie, Ms. DeSensi, and Drs. Weathington, Chen, Ray, Mallampalli, Benos, Lee, Morris, and McVerry involved in drafting of work and/or revising for important intellectual content. Dr. Kitsios, Ms. Yang, and Drs. Manatakis, Evankovich, Bain, Dunlap, Shah, and Barbash, Ms. Rapport, Drs. Zhang and Nouraie, Ms. DeSensi, and Drs. Weathington, Chen, Ray, Mallampalli, Benos, Lee, Morris, and McVerry involved in final approval of version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 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). Supported, in part, by grants from National Institutes of Health (NIH) (K23 HL139987 [to Dr. Kitsios]; U01 HL098962 [to Dr. Morris]; P01 HL114453 [to Drs. Ray, Mallampalli, and McVerry]; R01 HL097376 [to Drs. Mallampalli and McVerry]; R01 HL116472 [to Dr. Chen]; K24 HL123342 [to Dr. Morris]; U01 HL137159 [to Drs. Manatakis and Benos]; R01 LM012087 [to Drs. Manatakis and Benos]; R01 HL142084 [to Dr. Lee]; R01 HL136143 [to Dr. Lee]; F32 HL137258 [to Dr. Evankovich]; F32 HL142172 [to Dr. Bain]; K08 HS025455 [to Dr. Barbash]; K23 GM122069 [to Dr. Shah]; R35 HL139860 [to Dr. Chen]; and R01 HL133184 [to Dr. Chen]). Dr. Kitsios receives research funding from Karius. Drs. Kitsios, Nouraie, Evankovich, Bain, Shah, Barbash, Zhang, Weathington, Chen, Ray, Mallampalli, Benos, Lee, Morris, and McVerry received support for article research from the NIH. Drs. Chen and Mallampalli are consultants for Koutif Pharmaceuticals, and they received funding from Koutif Pharmaceuticals (consulting). Dr. Morris’s institution received funding from Gilead. Dr. McVerry received funding from Vapotherm (consulting) and Bayer Pharmaceuticals (research support). The remaining authors have disclosed that they do not have any potential conflicts of interest. All de-identified datasets as well as the statistical code in R used for analyses for this study are provided in https://github.com/MicrobiomeALIR. For information regarding this article, E-mail: kitsiosg@upmc.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

High-Frequency Oscillatory Ventilation and Ventilator-Induced Lung Injury: Size Does Matter Objectives: The theoretical basis for minimizing tidal volume during high-frequency oscillatory ventilation may not be appropriate when lung tissue stretch occurs heterogeneously and/or rapidly. The objective of this study was to assess the extent to which increased ventilation heterogeneity may contribute to ventilator-induced lung injury during high-frequency oscillatory ventilation in adults compared with neonates on the basis of lung size, using a computational model of human lungs. Design: Computational modeling study. Setting: Research laboratory. Subjects: High-fidelity, 3D computational models of human lungs, scaled to various sizes representative of neonates, children, and adults, with varying injury severity. All models were generated from one thoracic CT image of a healthy adult male. Interventions: Oscillatory ventilation was simulated in each lung model at frequencies ranging from 0.2 to 40 Hz. Sinusoidal flow oscillations were delivered at the airway opening of each model and distributed through the lungs according to regional parenchymal mechanics. Measurements and Main Results: Acinar flow heterogeneity was assessed by the coefficient of variation in flow magnitudes across all acini in each model. High-frequency oscillatory ventilation simulations demonstrated increasing heterogeneity of regional parenchymal flow with increasing lung size, with decreasing ratio of deadspace to total acinar volume, and with increasing frequency above lung corner frequency and resonant frequency. Potential for resonant amplification was greatest in injured adult-sized lungs with higher regional quality factors indicating the presence of underdamped lung regions. Conclusions: The potential for ventilator-induced lung injury during high-frequency oscillatory ventilation is enhanced at frequencies above lung corner frequency or resonant frequency despite reduced tidal volumes, especially in adults, due to regional amplification of heterogeneous flow. Measurements of corner frequency and resonant frequency should be considered during high-frequency oscillatory ventilation management. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the U.S. Department of Defense or National Institutes of Health. Drs. Herrmann and Tawhai performed experiments. Drs. Herrmann and Kaczka prepared figures and drafted article. Drs. Herrmann, Tawhai, and Kaczka conceived and designed research; analyzed data. All authors interpreted results of experiments; edited and revised article; and approved the final version of the article. 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). Supported, in part, by grant from the Office of the Assistant Secretary of Defense for Health Affairs through the Peer Reviewed Medical Research Program under Award number W81XWH-16-1-0434, the University of Iowa Hospitals and Clinics Department of Anesthesia, the National Heart, Lung, and Blood Institute Grants R01-HL-112986 and R01-HL-126838, and the University of Auckland Medical Technologies Centre of Research Excellence. Drs. Herrmann and Kaczka are cofounders and shareholders of OscillaVent, Inc. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: david-kaczka@uiowa.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Acute Respiratory Distress Syndrome Following Pediatric Trauma: Application of Pediatric Acute Lung Injury Consensus Conference Criteria Objectives: To assess the incidence, severity, and outcomes of pediatric acute respiratory distress syndrome following trauma using Pediatric Acute Lung Injury Consensus Conference criteria. Design: Retrospective cohort study. Setting: Level 1 pediatric trauma center. Patients: Trauma patients less than or equal to 17 years admitted to the ICU from 2009 to 2017. Interventions: None. Measurements and Main Results: We queried electronic health records to identify patients meeting pediatric acute respiratory distress syndrome oxygenation criteria for greater than or equal to 6 hours and determined whether patients met complete pediatric acute respiratory distress syndrome criteria via chart review. We estimated associations between pediatric acute respiratory distress syndrome and outcome using generalized linear Poisson regression adjusted for age, injury mechanism, Injury Severity Score, and serious brain and chest injuries. Of 2,470 critically injured children, 103 (4.2%) met pediatric acute respiratory distress syndrome criteria. Mortality was 34.0% among pediatric acute respiratory distress syndrome patients versus 1.7% among patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 3.7; 95% CI, 2.0–6.9). Mortality was 50.0% for severe pediatric acute respiratory distress syndrome at onset, 33.3% for moderate, and 30.5% for mild. Cause of death was neurologic in 60.0% and multiple organ failure in 34.3% of pediatric acute respiratory distress syndrome nonsurvivors versus neurologic in 85.4% of nonsurvivors without pediatric acute respiratory distress syndrome (p = 0.001). Among survivors, 77.1% of pediatric acute respiratory distress syndrome patients had functional disability at discharge versus 30.7% of patients without pediatric acute respiratory distress syndrome patients (p < 0.001), and only 17.5% of pediatric acute respiratory distress syndrome patients discharged home without ongoing care versus 86.4% of patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 1.5; 1.1–2.1). Conclusions: Incidence and mortality associated with pediatric acute respiratory distress syndrome following traumatic injury are substantially higher than previously recognized, and pediatric acute respiratory distress syndrome development is associated with high risk of poor outcome even after adjustment for underlying injury type and severity. This work performed at Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA. 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). Supported, in part, by National Institute of Child Health and Human Development grant 5 T32 HD057822-08. Drs. Killien’s and Rivara’s institutions received funding from the National Institutes of Health (NIH). Drs. Killien, Vavilala, and Rivara received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: elizabeth.killien@seattlechildrens.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Agmatine Protects Against the Progression of Sepsis Through the Imidazoline I2 Receptor-Ribosomal S6 Kinase 2-Nuclear Factor-κB Signaling Pathway Objectives: The knowledge that agmatine is found in the human body has existed for several years; however, its role in sepsis has not yet been studied. In the present study, we investigate the role of agmatine in the progression and treatment of sepsis. Design: Clinical/laboratory investigations. Setting: Medical centers/University-based research laboratory. Subjects: Elective ICU patients with severe sepsis and healthy volunteers; C57BL/6 mice weighing 18–22 g. Interventions: Serum agmatine level and its associations with inflammatory markers were assessed in patients with sepsis. Agmatine was administered intraperitoneally to mice before a lipopolysaccharide challenge. Human peripheral blood mononuclear cells and murine macrophages were pretreated with agmatine followed by lipopolysaccharide stimulation. Measurements and Main Results: Serum agmatine levels were significantly decreased in patients with sepsis and lipopolysaccharide-induced mice, and correlated with Acute Physiology and Chronic Health Evaluation II score, procalcitonin, tumor necrosis factor-α, and interleukin-6 levels. In a therapeutic experiment, exogenous agmatine attenuated the cytokine production of peripheral blood mononuclear cells from patients with sepsis and healthy controls. Agmatine also exerted a significant beneficial effect in the inflammatory response and organ damage and reduced the death rate in lipopolysaccharide-induced mice. Imidazoline I2 receptor agonist 2-benzofuran-2-yl blocked the pharmacological action of agmatine; whereas, other imidazoline receptor ligands did not. Furthermore, agmatine significantly impaired the inflammatory response by inactivating nuclear factor-κB, but not protein 38 mitogen-activated protein kinase, c-Jun N-terminal kinase, extracellular signal-regulated kinase, and inducible nitric oxide synthase signaling in macrophages. Activation of imidazoline I2 receptor or knockdown of ribosomal S6 kinase 2 counteracted the effects of agmatine on phosphorylation and degradation of inhibitor of nuclear factor-κBα. Conclusions: Endogenous agmatine metabolism correlated with the progression of sepsis. Supplemental exogenous agmatine could ameliorate the lipopolysaccharide-induced systemic inflammatory responses and multiple organ injuries through the imidazoline I2 receptor-ribosomal S6 kinase 2-nuclear factor-κB pathway. Agmatine could be used as both a clinical biomarker and a promising pharmaconutrient in patients with severe sepsis. Drs. Li, Zhu, and Tian contributed equally. This work was performed at Army Medical Center (Daping Hospital), Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China. Drs. Li, Xu, and Liang involved in conception and design. Drs. Li, Zhu, Tian, X. Ma, Fan, Luo, Yu, Sun, Yang, Tang, and W. Ma involved in experiments. Dr. Li involved in analysis and interpretation. Drs. Li, Xu, and Liang involved in drafting the article. 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). Supported, in part, by grant from the National Nature Science Foundation of China (numbers 81671906, 81871612, and 81902018), the Fund of Basic Science and Frontier Technology Research of Chongqing (number cstc2017jcyjAX0159), Hubei Provincial Natural Science Foundation of China (number 2019CFB109), the Fund of State Key Laboratory of Trauma, Burn and Combined Injury (number SKLKF201601), and the Fund for Transformation of Scientific and Technological Achievements from Third military medical university (number 2016XZH11). Drs. Li, Zhu, Tian, X. Ma, Fan, Yu, Yang, Tang, W. Ma, and Yan received support for article research from National Nature Science Foundation of China (NSFC). Dr. Liang received support for article research from the NSFC (numbers 81671906 and 81871612), the Fund of Basic Science and Frontier Technology Research of Chongqing (number cstc2017jcyjAX0159), the Fund of State Key Laboratory of Trauma, Burn and Combined Injury (number SKLKF201601), and the Fund for Transformation of Scientific and Technological Achievements from Third military medical university (number 2016XZH11). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: (Xiang Xu, PhD); 13638356728@163.com (Huaping Liang, PhD). Drs. Xu and Liang are corresponding author. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Microcirculation Evolution in Patients on Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Objectives: Despite the increasing use of venoarterial extracorporeal membrane oxygenation to treat severe cardiogenic shock patients, microcirculation data in this context are scarce. We evaluated the venoarterial extracorporeal membrane oxygenation impact on macrocirculatory hemodynamics and microcirculation in patients with refractory cardiogenic shock and compared the evolutions of those parameters between patients successfully weaned-off extracorporeal membrane oxygenation and those who died on extracorporeal membrane oxygenation. Design: Prospective study. Setting: Academic medical ICU. Patients: Consecutive patients with refractory cardiogenic shock (cardiac arrest excluded) who required venoarterial extracorporeal membrane oxygenation and for whom sublingual microcirculation measurements before cannulation were possible. Interventions: All patients were followed until death or venoarterial extracorporeal membrane oxygenation removal. Microcirculatory and macrocirculatory evaluations were made before, and 2, 4, 12, 24, and 48 hours after extracorporeal membrane oxygenation initiation, respectively. Patients weaned-off extracorporeal membrane oxygenation were also evaluated 6 hours before and after venoarterial extracorporeal membrane oxygenation removal. Measurements and Main Results: Fourteen patients (median age, 58 yr [interquartile range, 56–62 yr]; Sequential Organ Failure Assessment score, 14 [12–18]) were included. Acute myocardial infarction (50%) was the main cause of cardiogenic shock. Six patients (33%) were successfully weaned-off extracorporeal membrane oxygenation. Profound microcirculation parameter changes found before venoarterial extracorporeal membrane oxygenation implantation regressed within 12 hours after extracorporeal membrane oxygenation onset. Pre-extracorporeal membrane oxygenation macrocirculation, echocardiography, arterial blood gases, and microcirculation parameters did not differ between patients who died on extracorporeal membrane oxygenation and those successfully weaned. However, perfused small-vessel density, small-vessel density, and percent perfused vessels were consistently higher and then stabilized 48 hours postcannulation for patients successfully weaned-off extracorporeal membrane oxygenation. Conclusions: Microcirculation is severely impaired in patients with refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation. Inability to rapidly restore microcirculation during the first 24 hours, despite normal global/macrocirculatory hemodynamics, was associated with death on extracorporeal membrane oxygenation. Further studies are now warranted to better determine the relevant microcirculation determinants during venoarterial extracorporeal membrane oxygenation support, before future routine use of this promising tool in clinical practice. Drs. Chommeloux, Montero, Franchineau, Nieszkowska, and Schmidt helped with conception and design; Drs. Chommeloux, Montero, Franchineau, Combes, and Schmidt helped with analysis and interpretation; and all authors helped with drafting the article for important intellectual content. 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. Montero received funding from European Society of Cardiology. Dr. Luyt received funding from lecturing for Merck Sharp & Dohme, Thermofischer Brahms, Biomerieux, and from consulting for Bayer and Carmat. Dr. Combes received lecture fees from Getinge and Baxter. Dr. Schmidt received lectures fees from Getinge, Dräger, and Xenios. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Matthieu Schmidt, MD, PhD, Service de Ledecine Intensive Reanimation, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié–Salpêtrière, 47, bd de l’Hôpital, 75651 Paris Cedex 13, France. E-mail: matthieu.schmidt@aphp.fr Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation Objectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes. Design: Prospective cohort study. Setting: Tertiary referral critical care center. Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation. Interventions: Laryngoscopy following endotracheal intubation. Measurements and Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48–2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0–6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0–0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0–1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury. Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness. This work was performed at the Vanderbilt University Medical Center. Drs. Shinn, Kimura, and Campbell, Ms. Lowery, and Dr. Gelbard had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Shinn, Du, and Gelbard were involved with statistical analysis. All authors provided revisions and approved the final article. Trial Registration: Clinical Trials ID# NCT03250975. 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 websites (http://journals.lww.com/ccmjournal). Supported, in part, by a Vanderbilt Institute for Clinical and Translational Research grant to purchase video laryngoscopy recording capabilities. Dr. Shinn received funding from Vanderbilt Institute for Clinical and Translational Research grant (to purchase video laryngoscopy recording capabilities). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: alexander.gelbard@vumc.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Interleukin-17D Aggravates Sepsis by Inhibiting Macrophage Phagocytosis Objectives: Interleukin-17D has been shown to participate in the control of viral infections and cancer. Here we hypothesized that interleukin-17D may play a potential role in sepsis. Design: Prospective randomized animal investigation and in vitro human blood studies. Setting: Research laboratory from a university hospital. Subjects: Female C57BL/6J mice, sepsis patients by Sepsis-3 definitions, ICU patient controls, and healthy individuals. Interventions: Serum concentrations of interleukin-17D were measured and analyzed in human sepsis patients, patient controls, and healthy individuals. The contribution of interleukin-17D to sepsis-related survival, bacterial burden, and organ injury was assessed in a murine model of cecal ligation and puncture–induced polymicrobial sepsis by the use of anti–interleukin-17D antibody and recombinant interleukin-17D protein. The effects of interleukin-17D on bacterial phagocytosis by macrophages were also investigated using in vitro cell models. Measurements and Main Results: On the day of ICU admission (day 0), septic patients had significantly higher serum concentrations of interleukin-17D than patient controls and healthy individuals. Serum interleukin-17D levels remained significantly elevated in septic patients from ICU admission to day 3 and correlated with Sequential (Sepsis-related) Organ Failure Assessment scores and documented bacteremia on day 0. Furthermore, nonsurvivors of septic patients displayed significantly higher interleukin-17D levels compared with survivors of septic patients on days 0 and 1 of ICU admission. In animal models of sepsis, treatment with anti–interleukin-17D antibody protected mice from cecal ligation and puncture–induced severe sepsis, which was associated with improved bacterial clearance and organ injury. Conversely, administration of recombinant interleukin-17D protein aggravated cecal ligation and puncture–induced nonsevere sepsis. Furthermore, we found that interleukin-17D impaired bacterial phagocytosis by macrophages. Phagocytosis inhibition by interleukin-17D involved its ability to down-regulate the activation of nuclear factor-κB signaling pathway in macrophages upon bacterial infection. Conclusions: This study indicates a previously undescribed role of interleukin-17D in sepsis and identifies a new target for antisepsis treatment. Drs. Yan and Tu contributed equally to this work. 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). Supported, in part, by the National Natural Science Foundation of China (grant numbers: 81722001 and 81572038) and Chongqing Science and Technology Commission Grant for Distinguished Young Scholars of Chongqing (grant number: cstc2014jcyjjq10002). The funding agencies had no role in study design, collection and analyses of data, decision to publish, or preparation of the article. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: caoju723@163.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Bioactive Adrenomedullin, Organ Support Therapies, and Survival in the Critically Ill: Results from the French and European Outcome Registry in ICU Study Objectives: Adrenomedullin has vascular properties and elevated plasma adrenomedullin levels were detected in sepsis. We assessed, in septic and nonseptic ICU patients, the relation between circulating adrenomedullin, the need for organ support and mortality, using an assay of bioactive adrenomedullin. Design: Prospective multicenter observational cohort study. Setting: Data from the French and euRopean Outcome reGistry in ICUs study. Patients: Consecutive patients admitted to intensive care with a requirement for invasive mechanical ventilation and/or vasoactive drug support for more than 24 hours following ICU admission and discharged from ICU were included. Interventions: Clinical and biological parameters were collected at baseline, including bioactive-adrenomedullin. Status of ICU survivors was assess until 1 year after discharge. The main outcome was the need for organ support, including renal replacement therapy and/or for inotrope(s) and/or vasopressor(s). Secondary endpoints were the ICU length of stay and the 28-day all-cause mortality. Measurements and Main Results: Median plasma bioactive adrenomedullin (n = 2,003) was 66.6 pg/mL (34.6–136.4 pg/mL) and the median Simplified Acute Physiology Score II score 49 (36–63). Renal replacement therapy was needed in 23% and inotropes(s) and/or vasopressor(s) in 77% of studied patients. ICU length of stay was 13 days (7–21 d) and mortality at 28 days was 22 %. Elevated bioactive adrenomedullin independently predicted 1) the need for organ support (odds ratio, 4.02; 95% CI, 3.08–5.25) in ICU patients whether admitted for septic or nonseptic causes and 2) the need for renal replacement therapy (odds ratio, 4.89; 3.83–6.28), and for inotrope(s) and/or vasopressor(s) (odds ratio, 3.64; 2.84–4.69), even in patients who were not on those supports at baseline. Elevated bioactive adrenomedullin was also associated with a prolonged length of stay (odds ratio, 1.85; 1.49–2.29) and, after adjustment for Simplified Acute Physiology Score II, with mortality (odds ratio, 2.31; 1.83–2.92). Conclusions: Early measurement of bioactive adrenomedullin is a strong predictor of the need of organ support and of short-term mortality in critically ill patients. This work was performed at Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France. Drs. Lemasle and Blet contributed equally to this work. 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. Geven and his institution have received funding from Adrenomed AG. Dr. Monnet received support for article research from Assistance publique hôpitaux de Paris. Drs. Struck and Hartmann received funding from sphingotec GmbH (employees). Dr. Hartmann disclosed off-label product use of biomarker assay for adrenomedullin. Dr. Bergmann disclosed he is a member of the Adrenomed Board (but he receives no financial compensation). Dr. Mebazaa’s institution received funding from Adrenomed (paid to ship the samples), and he received funding from the Steering Committee of Adrenoss-2 (member). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: etienne.gayat@aphp.fr Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians Objectives: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses’ and physicians’ rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses. Design: Prospective observational study. Setting: A total of 68 adult ICUs in 13 European countries and the United States. Subjects: ICU physicians and nurses. Interventions: None. Measurements and Main Results: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses’ involvement at end-of-life, average without nurses’ involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions. Conclusions: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies. This work was carried out 68 adult ICUs in 13 European countries and the United States. Please see the Acknowledgments section at the end of the article for details. 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. Benoit received funding from the Research Foundation Flanders (1800513N and 1800518N) and from ESICM/European Critical Care Research Network clinical research award. Dr. Piers received funding from Fund Marie-Thérèse De Lava, King Baudouin Foundation, Belgium. Dr. Hartog received funding from the German Federal Ministry of Education and Research via the Center for Sepsis Control and Care (FKZ 01EO1002) and a grant from the Innovation Funds of the German Federal Joint Committee (FKZ 91VSF17010). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: hanne.irene.jensen@rsyd.dk Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Bioelectrical Impedance Measurements for Assessment of Kidney Function in Critically Ill Patients Objectives: To evaluate the use of multifrequency bioelectrical impedance analysis to predict creatinine/urea clearance based on 24 hours urine collection. A practical formula was developed, and its performance was compared with that of established formulas such as Cockcroft-Gault, Modification of Diet in Renal Disease, and Jelliffe’s. Design: An open-label prospective observational cohort study. Setting: A 12-bed ICU at a nonuniversity major teaching hospital (Gelre ziekenhuizen Apeldoorn/Zutphen, The Netherlands). Patients: Adult critical care patients with an expected ICU length of stay at admission of at least 48 hours. Interventions: Each patient’s body composition was assessed using a validated Quadscan 4000 analyzer (Bodystat, Isle of Man, British Isles). Twenty-four hours urine was collected, and laboratory variables in serum including creatinine, urea, and albumin were obtained at the beginning and end of the collection period. Measurements and Main Results: A total of 151 patients, stratified to an acute and nonacute ICU-group, were enrolled in the study over a 2-year period. A formula to predict creatinine/urea clearance based on 24 hours urine collection was developed using stepwise linear regression using a training data set of 75 patients. This formula was subsequently tested and compared with other relevant predictive equations using a validation data set of 76 patients. Serum creatinine values ranged from 40 to 446 µmol/L. With the predictive model based on estimated body cell mass and a “prediction marker” more than 71% of the observed variance in creatinine/urea clearance based on 24 hours urine collection could be explained. Predictive performance was superior to the other eight evaluated models (R2 = 0.39–0.55) and demonstrated to be constant over the whole range of creatinine/urea clearance based on 24 hours urine collection values. Conclusions: Multifrequency bioelectrical impedance analysis measurements can be used to predict creatinine/urea clearance based on 24 hours urine collection with superior performance than currently established prediction models. This rapid, noninvasive method enables correction for influences of a patient’s actual body composition and may prove valuable in daily clinical practice. 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). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: l.van.gendt@gelre.nl Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.