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Search Results: 1 - 10 of 216995 matches for " Charles L Sprung "
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The International Sepsis Forum's controversies in sepsis: corticosteroids should be used to treat septic shock
Sergey Goodman, Charles L Sprung
Critical Care , 2002, DOI: 10.1186/cc1537
Abstract: In the early 1980s we were big proponents of using corticosteroids in septic shock, whereas in the late 1980s, following publication of the findings of the Veterans Administration Systemic Sepsis Cooperative Study Group on corticosteroids in sepsis [1] and those of the study of steroids in sepsis conducted by Bone and colleagues [2], we thought corticosteroids were a bad idea. In fact, subsequently, two meta-analyses [3,4] concluded that steroids were not beneficial in sepsis and septic shock. Based on recent data, there is enough evidence to suggest that we probably should be using corticosteroids in our septic shock patients. Although we support the use of steroids for treating septic shock, we clearly need a large trial in this area. In fact, we are starting a prospective, randomized, double-blind trial in Europe that will enroll large numbers of patients with septic shock (the CORTICUS study).In 1984, our group showed [5] that there was a short period of time with a difference in mortality between a steroid-treated group and a control group, and that there was a significant reversal in shock between the groups at 24 hours. We stated at that time that perhaps we should be giving steroids for a longer period of time rather than just two doses. This approach was likely to reverse shock in more patients and perhaps improve survival.There has clearly been a change in thinking of how steroids should be used, in treating both septic shock and the acute respiratory distress syndrome. Older studies used large doses for short periods of time, and were given early in the treatment – typically one or two doses of methylprednisolone (30 mg/kg). This was often done before any organisms were identified, and hence using corticosteroids might be associated with an increased incidence of complications related to superinfections. However, more recent studies recommend smaller doses of steroids, used for longer periods and given even later in the course of the disease.During septic
Early administration of corticosteroids and mortality
Charles L Sprung, Baruch M Batzofin
Critical Care , 2012, DOI: 10.1186/cc11196
Abstract: Kyeongman Jeon, Hye Yun Park and Sookyoung WooWe thank Drs Sprung and Batzofin for their thoughtful comments regarding our recent article [1]. We understand their concern that more severely ill patients might received delayed initiation of low-dose corticosteroid therapy compared to patients who received early therapy. However, the baseline severity of illness or number of organ failures was not different between early vs. late treatment groups. The 28-day mortality rates increased significantly with increased quintiles of time to initiation of low-dose corticosteroid therapy as described in the original article (P = 0.0107) [1]. Simplified Acute Physiology Score 3 (SAPS 3) and Sequential Organ Failure Assessment (SOFA) score by quintiles were significantly different when tested with Kruskal-Wallis test (P = 0.0492). However, because this test does not identify where the differences occur or how many differences actually occur [2]. We examined the trends of severity of illness across the quintile of time to initiation of low-dose corticosteroid therapy with Jonckheere-Terpstra test [2]. As a result, severity of illness assessed by SAPS 3 and SOFA scores was not different across the quintiles of time to initiation of low-dose corticosteroid therapy (P = 0.9953 and P = 0.8437, respectively) (Figure 1). Therefore, the finding of increased mortality in patients receiving delayed initiation of low-dose corticosteroid therapy was not related to their increased severity of illness.SAPS: Simplified Acute Physiology Score; SOFA: Sequential Organ Failure Assessment.The authors declare that they have no competing interests.
Withdrawing and withholding life-sustaining therapies are not the same
Phillip D Levin, Charles L Sprung
Critical Care , 2005, DOI: 10.1186/cc3487
Abstract: During rounds in the critical care unit a discussion arises regarding continued antibiotic therapy in a patient who has not responded. Should antibiotics be added, should the current therapy be maintained, or should the antibiotics be stopped? No one would dispute that these options are different. Replacing the word 'antibiotics' with 'inotropes', 'ventilation', or 'life support' does not alter this reality. Stopping life-support measures (withdrawal of therapy) is not the same as refraining from starting them (withholding) or maintaining current therapy. The former is an active measure, whereas the latter two are passive. Often patients' families clearly understand this difference; they ask, 'Are you just going to let him [the patient] go doctor, or are you going to pull the plug?'An appreciation of the differences between withdrawing and withholding life-support therapies can also be found in the medical literature from physician questionnaires and empirical observations of end-of-life practice. The experience of withholding as compared to withdrawing therapy has been examined in two large questionnaire-based surveys, one from North America and the other from Europe. In the North American study [1] 26% of physicians reported being more disturbed at the prospect of withdrawing therapy than they were about withholding. Similarly, the European survey [2] showed that more physicians were willing to withhold treatment in a patient vignette than were willing to withdraw. In an additional study [3], when directly questioned on the equivalence of withdrawing and withholding treatments, only 34% of 1446 physicians and nurses saw these two options as equivalent. These surveys indicate that, regardless of theoretical equivalence, physicians do not see withholding and withdrawing as the same.Practically, a recent large European study [4] highlighted the differences in effect of withholding and withdrawing therapy. The circumstances surrounding the deaths of 4248 ICU patients
Insulin-treated diabetes is not associated with increased mortality in critically ill patients
Jean-Louis Vincent, Jean-Charles Preiser, Charles L Sprung, Rui Moreno, Yasser Sakr
Critical Care , 2010, DOI: 10.1186/cc8866
Abstract: The SOAP study was a cohort, multicenter, observational study which included data from all adult patients admitted to one of 198 participating ICUs from 24 European countries during the study period. For this substudy, patients were classified according to whether or not they had a known diagnosis of insulin-treated diabetes mellitus. Outcome measures included the degree of organ dysfunction/failure as assessed by the sequential organ failure assessment (SOFA) score, the occurrence of sepsis syndromes and organ failure in the ICU, hospital and ICU length of stay, and all cause hospital and ICU mortality.Of the 3147 patients included in the SOAP study, 226 (7.2%) had previously diagnosed insulin-treated diabetes mellitus. On admission, patients with insulin-treated diabetes were older, sicker, as reflected by higher simplified acute physiology system II (SAPS II) and SOFA scores, and more likely to be receiving hemodialysis than the other patients. During the ICU stay, more patients with insulin-treated diabetes required renal replacement therapy (hemodialysis or hemofiltration) than other patients. There were no significant differences in ICU or hospital lengths of stay or in ICU or hospital mortality between patients with or without insulin-treated diabetes. Using a Cox proportional hazards regression analysis with hospital mortality censored at 28-days as the dependent factor, insulin-treated diabetes was not an independent predictor of mortality.Even though patients with a history of insulin-treated diabetes are more severely ill and more likely to have renal failure, insulin-treated diabetes is not associated with increased mortality in ICU patients.Diabetes mellitus is an increasingly common condition, and is estimated to affect approximately 246 million adults worldwide [1]. Although diabetes is occasionally the reason for admission to an intensive care unit (ICU), it is more commonly present as a comorbid condition. Although hyperglycemia can induce a number
Characteristics and outcomes of cancer patients in European ICUs
Fabio Taccone, Antonio A Artigas, Charles L Sprung, Rui Moreno, Yasser Sakr, Jean-Louis Vincent
Critical Care , 2009, DOI: 10.1186/cc7713
Abstract: This was a substudy of the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, a cohort, multicentre, observational study that included data from all adult patients admitted to one of 198 participating ICUs from 24 European countries during the study period. Patients were followed up until death, hospital discharge or for 60 days.Of the 3147 patients enrolled in the SOAP study, 473 (15%) had a malignancy, 404 (85%) had solid tumours and 69 (15%) had haematological cancer. Patients with solid cancers had the same severity of illness as the non-cancer population, but were older, more likely to be a surgical admission and had a higher frequency of sepsis. Patients with haematological cancer were more severely ill and more commonly had sepsis, acute lung injury/acute respiratory distress syndrome, and renal failure than patients with other malignancies; these patients also had the highest hospital mortality rate (58%). The outcome of all cancer patients was comparable with that in the non-cancer population, with a 27% hospital mortality rate. However, in the subset of patients with more than three failing organs, more than 75% of patients with cancer died compared with about 50% of patients without cancer (p = 0.01).In this large European study, patients with cancer were more often admitted to the ICU for sepsis and respiratory complications than other ICU patients. Overall, the outcome of patients with solid cancer was similar to that of ICU patients without cancer, whereas patients with haematological cancer had a worse outcome.Remarkable advances have been made in the early diagnosis and aggressive management of patients with malignancies, resulting in dramatic improvements in overall survival rates [1,2]. As a result, increasing numbers of patients are admitted to the intensive care unit (ICU), either for cancer-related complications or for treatment-associated side effects [3]. Several studies have reported very high mortality rates for cancer patients after a
Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study
Phillip D Levin, Mila Golovanevski, Allon E Moses, Charles L Sprung, Shmuel Benenson
Critical Care , 2011, DOI: 10.1186/cc10446
Abstract: Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms.Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001).Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.The Centers for Disease Control estimate that annually in the US approximately 1.7 million patients suffer from hospital-acquired infections with 99,000 deaths [1] and a cost of up to $33.8 billion [2]. About 20% of ICU patients will develop nosocomial infections, often caused by resistant bacteria [3,4], and many more become colonized by resistant bacteria [4,5].Bacter
Glucocorticoids in sepsis: dissecting facts from fiction
Charles L Sprung, Djillali Annane, Mervyn Singer, Rui Moreno, Didier Keh, the CORTICUS Study Group
Critical Care , 2011, DOI: 10.1186/cc10428
Abstract: The authors declare that they have no competing interests.
Critical care resource allocation: trying to PREEDICCT outcomes without a crystal ball
Michael D Christian, Robert Fowler, Matthew P Muller, Charles Gomersall, Charles L Sprung, Nathaniel Hupert, David Fisman, Andrew Tillyard, David Zygun, John C Marshal, PREEDICCT Study Group
Critical Care , 2013, DOI: 10.1186/cc11842
Abstract: The International Forum of Acute Care Trialists (InFACT) was formed in 2009 and provided a platform for international critical care research collaboration during the 2009/10 influenza A(H1N1) pandemic [12]. Over the past 2 years, a number of working groups have emerged from InFACT focused upon improving the investigation and care of patients with severe respiratory illness. Arising from these efforts, in June 2012 an inter-national group of clinicians convened the first meeting of the Providing Resources for Effective and Ethical Decisions In Critical Care Triage (PREEDICCT) Study Group. The study group's aim is to develop decision support tools appropriate for triaging critically ill adult patients during epidemics, mass-casualty scenarios or other resource-limited settings. This meeting identified a number of knowledge gaps and research priorities in this area, and suggested a revised framework for the requirements of an adequate triage decision support tool.While purpose-built triage protocols focus on specific events (for example, pandemics), resource allocation decisions are part of everyday practice for critical care physicians worldwide. Several PREEDICCT members work in settings where there are chronically insufficient critical care resources to meet the demand [13]. Critical care physicians also make resource allocation decisions every day in high-income countries, as they decide who might benefit from ICU care, when to accept outside transfers and when insufficient capacity dictates external transfer of patients. Yet intensivists lack objective tools to support these decision-making processes. Further, practices and specific decisions are likely to vary widely by country, by hospital and by individual provider.The first significant shift in direction advocated by our group is to move away from attempting to use a physiologic score alone to predict outcomes. The rationale for basing triage tools on a physiologic score is that all critically ill patients com
Clinical review: The Israeli experience: conventional terrorism and critical care
Gabriella Aschkenasy-Steuer, Micha Shamir, Avraham Rivkind, Rami Mosheiff, Yigal Shushan, Guy Rosenthal, Yoav Mintz, Charles Weissman, Charles L Sprung, Yoram G Weiss
Critical Care , 2005, DOI: 10.1186/cc3762
Abstract: Every hospital should be able to respond to a multiple-casualty terror attack as it can occur anywhere and anytime [1]. Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for the critically injured patients. Despite the violence, all surgical services continued providing all routine services, including our general intensive care unit (GICU). To do so we developed a highly flexible operational system for managing the GICU. The focus of this report will be on the organizational steps needed to provide operational flexibility. In addition, issues related to the diagnosis and management of specific injuries associated with terror events will be discussed.A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. The information we collected included the following: type of attack, number of victims at the location, number of patients treated and admitted to the intensive care unit (ICU), location before admission to the ICU [operating rooms, imaging department or emergency department (ED)], trauma injury severity score (ISS), time for admission to the ED, time to admission to the ICU, length of stay in the ICU and mortality in the ICU.The hospital intensive care facilities include 29 surgical ICU beds (11 general, 6 pediatric, 6 neurosurgical, and 6 cardiothoracic). When these ICUs are full, patients are treated in the 14-bed post-anesthesia care unit (PACU), which is adjacent to the GICU. In addition, nine medical intensive care beds are available. The GICU is part of the Department of Anesthesiology and Critical Care Medicine. All ICU attendi
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study
Jean-Louis Vincent, Yasser Sakr, Konrad Reinhart, Charles L Sprung, Herwig Gerlach, V Marco Ranieri, the 'Sepsis Occurrence in Acutely Ill Patients' investigators
Critical Care , 2005, DOI: 10.1186/cc3895
Abstract: In a cohort, multicenter, observational study, all patients admitted to one of the participating ICUs between 1 May and 15 May 2002 were followed up until death, hospital discharge, or for 60 days. Patients were classified according to whether or not they received albumin at any time during their ICU stay.Of 3,147 admitted patients, 354 (11.2%) received albumin and 2,793 (88.8%) did not. Patients who received albumin were more likely to have cancer or liver cirrhosis, to be surgical admissions, and to have sepsis. They had a longer length of ICU stay and a higher mortality rate, but were also more severely ill, as manifested by higher simplified acute physiology score (SAPS) II and sequential organ failure assessment (SOFA) scores than the other patients. A Cox proportional hazard model indicated that albumin administration was significantly associated with decreased 30-day survival. Moreover, in 339 pairs matched according to a propensity score, ICU and hospital mortality rates were higher in the patients who had received albumin than in those who had not (34.8 versus 20.9% and 41.3 versus 27.7%, respectively, both p < 0.001).Albumin administration was associated with decreased survival in this population of acutely ill patients. Further prospective randomized controlled trials are needed to examine the effects of albumin administration in sub-groups of acutely ill patients.Albumin administration in the critically ill is controversial and hotly debated, despite having been accepted and widely used for more than 50 years. A meta-analysis by the Cochrane group [1] published 5 years ago first put light to this fire, showing an increased mortality in patients treated with albumin in their analysis of 30 randomized controlled trials including 1,419 randomized patients. An accompanying editorial even suggested that, based on these results, "the administration of albumin should be halted" [2]. The Cochrane analysis was criticized by a later meta-analysis [3] because it ex
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