Comparison Between Continuous and Intermittent Administration of Hydrocortisone During Septic Shock: A Randomized Controlled Clinical Trial.

OBJECTIVES: The best modality of administration of hydrocortisone during septic shock has been poorly evaluated and the guidelines remain unclear in this respect. This study aimed to compare bolus of hydrocortisone to a continuous infusion during septic shock. DESIGN: Randomized controlled, open-label trial. SETTING: Medical ICU of a university hospital. PATIENTS: Adult patients with septic shock requiring more than 2 mg/h (approximately 33.3 µg/mn) of norepinephrine after adequate fluid administration were eligible.Patients already receiving corticosteroids or who have a contraindication to corticosteroids, patients who died within 24 h and those with a decision of not to resuscitate were excluded. INTERVENTIONS: Patients were randomized either to receive hydrocortisone 200 mg/d by continuous infusion or by boluses of 50 mg every 6 h throughout the prescription of vasopressors with a maximum of 7 days. RESULTS: Twenty-nine patients were included in each group. Shock reversal was significantly higher in the HC bolus group (66% vs. 35%, P = 0.008). The median time to shock reversal was 5 days (95% CI, 4.31-5.69) in the HC bolus group compared to 6 days (95% CI, 4.80-7.19) in the HC continuous infusion group (log Rank = 0.048). The number of hours spent with blood glucose ≥ 180 mg/dL was higher in the HC continuous infusion group with a median of 64 h [IQR (2-100)] versus 48 h [IQR (14-107)] in the HC bolus group, (P = 0.60), and daily insulin requirements were similar between the two groups (P = 0.63). The occurrence of other side effects, mortality, and ICU LOS were similar between the study groups. CONCLUSION: Hydrocortisone administered by intermittent bolus was associated with higher shock reversal at day 7 compared with a continuous infusion.

Delirium in the Intensive Care Unit: Incidence, Risk Factors, and Impact on Outcome.

BACKGROUND: The incidence and risk factors for delirium vary among studies. OBJECTIVE: We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study. PATIENTS: All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU. RESULTS: A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6-20] vs. 2 days[0-7]) respectively and length of stay in ICU (21.5 days [10.5-32.5] vs. 8 days [5-13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39-12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31-8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47-8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05-7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08-13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality. CONCLUSION: Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.

Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance.

OBJECTIVES: We tested whether the poor ability of pulse pressure variation to predict fluid responsiveness in cases of acute respiratory distress syndrome was related to low lung compliance. We also tested whether the changes in cardiac index induced by passive leg-raising and by an end-expiratory occlusion test were better than pulse pressure variation at predicting fluid responsiveness in acute respiratory distress syndrome patients. DESIGN: Prospective study. SETTING: Medical intensive care unit. PATIENTS: We included 54 patients with circulatory shock (63 ± 13 yrs; Simplified Acute Physiology Score II, 63 ± 24). Twenty-seven patients had acute respiratory distress syndrome (compliance of the respiratory system, 22 ± 3 mL/cm H2O). In nonacute respiratory distress syndrome patients, the compliance of the respiratory system was 45 ± 9 mL/cm H2O. MEASUREMENTS AND MAIN RESULTS: We measured the response of cardiac index (transpulmonary thermodilution) to fluid administration (500 mL saline). Before fluid administration, we recorded pulse pressure variation and the changes in pulse contour analysis-derived cardiac index induced by passive leg-raising and end-expiratory occlusion. Fluid increased cardiac index ≥ 15% (44% ± 39%) in 30 "responders." Pulse pressure variation was significantly correlated with compliance of the respiratory system (r = .58), but not with tidal volume. The higher the compliance of the respiratory system, the better the prediction of fluid responsiveness by pulse pressure variation. A compliance of the respiratory system of 30 mL/cm H2O was the best cut-off for discriminating patients regarding the ability of pulse pressure variation to predict fluid responsiveness. If compliance of the respiratory system was >30 mL/cm H2O, then the area under the receiver-operating characteristics curve for predicting fluid responsiveness was not different for pulse pressure variation and the passive leg-raising and end-expiratory occlusion tests (0.98 ± 0.03, 0.91 ± 0.06, and 0.97 ± 0.03, respectively). By contrast, if compliance of the respiratory system was ≤ 30 mL/cm H2O, then the area under the receiver-operating characteristics curve was significantly lower for pulse pressure variation than for the passive leg-raising and end-expiratory occlusion tests (0.69 ± 0.10, 0.94 ± 0.05, and 0.93 ± 0.05, respectively). CONCLUSIONS: The ability of pulse pressure variation to predict fluid responsiveness was inversely related to compliance of the respiratory system. If compliance of the respiratory system was ≤ 30 mL/cm H2O, then pulse pressure variation became less accurate for predicting fluid responsiveness. However, the passive leg-raising and end-expiratory occlusion tests remained valuable in such cases.