Hemodilution Then Hemoconcentration after Resuscitation of Patients with Severe Sepsis or Septic Shock.

BACKGROUND: The impact of fluid ri suscitation on hematologic parameters and function has been well studied in hemorrhagic shock. Similar research has not been conducted in resuscitation of septic shock. HYPOTHESIS: In the absence of accompanying hemorrhage, resuscitation of patients with sepsis should be marked by hemodilution, followed by hemoconcentration during recovery. METHODS: Records of patients with primary diagnoses of severe sepsis or septic shock treated in a community hospital intensive care unit (ICU) between 2009 and 2012 were extracted from an electronic d tabase for analysis. Demographic, physiologic, an laboratory values were recorded at daily intervals. RESULTS: 132 patients with an average age of 70. (SD 15.1) years and Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 15. (6.0) were studied. Patients spent an average of 10. (9.9) days in the ICU and 18.9 (12.0) days in hospita 19 (14.4%) did not survive hospitalization. Mean admission hematocrit was 34.8 (6.5%), and lo"m est hematocrit, adjusted for (average 0.2 U PRBC) transfusions, 25.3 (5.1)% (P < .001), occurred after an average of four days of treatment, and 7.2 (5.4 L of cumulative positive fluid balance. By day 10 adjusted hematocritincreased to 26.9(8.1) (P =.006' 'Ihere was a significant (P < .001) albeit loose correlation (R = .35) of cumulative positive fluid balance associated with lowest hematocrit. CONCLUSION: Fluid resuscitation of patients with severe sepsis or septic shock is marked by initial reductions of hematocrit followed by increases during recovery, as fluid is mobilized.

Morning Chronotype Is Associated with Improved Adherence to Continuous Positive Airway Pressure among Individuals with Obstructive Sleep Apnea.

Rationale: Poor adherence limits the effectiveness of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). A better understanding of CPAP adherence is needed to develop novel strategies to improve it. Objectives: To determine if the chronotype (morning, evening, or intermediate) of patients with OSA is associated with differences in CPAP adherence. If such an association exists, determine the mechanisms underlying this association. Methods: We performed a secondary analysis of the APPLES (Apnea Positive Pressure Long-term Efficacy Study) clinical trial. We assessed chronotype using the Morningness-Eveningness Questionnaire (MEQ) among participants randomized to the CPAP arm with daily adherence data (n = 469). Evening (MEQ ⩽ 41), intermediate (41 < MEQ < 59), and morning type (MEQ ⩾ 59) categories were the exposures. We modeled daily CPAP use (hours per night) over a 6-month period, using a linear mixed model, adjusted for covariates (e.g., age, sex, marital status). To assess mechanisms of the association, we performed mediation analyses using sleep duration, weekend catch-up sleep, depression, and other factors. Results: Most participants were obese men with severe OSA (body mass index of 32.3 ± 7.3 kg/m2, 65% male, and apnea-hypopnea index 39.8 ± 24.6/h). Participants were 44% morning, 47% intermediate, and 8% evening chronotype. Participants with the morning chronotype reported the shortest sleep duration on weekends (7.3 vs. 7.6 and 7.9 h/night) compared with the intermediate and evening types. Participants with the morning chronotype exhibited a 40-min/night higher CPAP use (P = 0.001) than persons with the intermediate chronotype. This relationship was mildly attenuated (32.8 min/night; P = 0.011) after adjustment for covariates. None of the selected factors (e.g., sleep duration, weekend catch-up sleep) exhibited a significant mediation effect. Conclusions: Morning chronotype is associated with a clinically meaningful increase in CPAP adherence compared with other chronotypes. Mechanisms of this association require further study. Chronotype may be a novel predictor of CPAP adherence. Clinical trial registered with www.clinicaltrials.gov (NCT00051363).

Sleep Deficiency in Obstructive Sleep Apnea.

Sleep deficiency in patients with obstructive sleep apnea includes abnormal quality, timing, and duration of sleep, and the presence of other comorbid conditions. These include insomnia, circadian misalignment disorders, and periodic limb movements of sleep. The co-occurrence of these conditions with obstructive sleep apnea likely plays a role in the pathogenesis, clinical presentation, and management of obstructive sleep apnea. Considering these conditions and their treatment in evaluating sleep deficiency in obstructive sleep apnea may help to improve patient outcomes. However, future research is needed to understand the intersection between obstructive sleep apnea and these disorders.