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  • 1. Cholley, BP
    et al.
    Mayo, PH
    Poelaert, J
    Vieillard-Baron, A
    Vignon, P
    Alhamid, S
    Balik, M
    Beaulieu, Y
    Breitkreutz, R
    Canivet, J-L
    Doelken, P
    Flaatten, H
    Frankel, H
    Haney M, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hilton, A
    Maury, E
    McDermid, RC
    McLean, AS
    Mendes, C
    Pinsky, MR
    Price, S
    Schmidlin, D
    Slama, M
    Talmor, D
    Teles, JM
    Via, G
    Voga, G
    Wouters, P
    Yamamoto, T
    International expert statement on training standards for critical care ultrasonography2011In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 37, no 7, p. 1077-1083Article in journal (Refereed)
    Abstract [en]

    Training in ultrasound techniques for intensive care medicine physicians should aim at achieving competencies in three main areas: (1) general critical care ultrasound (GCCUS), (2) "basic" critical care echocardiography (CCE), and (3) advanced CCE. A group of 29 experts representing the European Society of Intensive Care Medicine (ESICM) and 11 other critical care societies worldwide worked on a potential framework for organizing training adapted to each area of competence. This framework is mainly aimed at defining minimal requirements but is by no means rigid or restrictive: each training organization can be adapted according to resources available. There was 100% agreement among the participants that general critical care ultrasound and "basic" critical care echocardiography should be mandatory in the curriculum of intensive care unit (ICU) physicians. It is the role of each critical care society to support the implementation of training in GCCUS and basic CCE in its own country.

  • 2.
    Claesson, Jonas
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences.
    Lehtipalo, Stefan
    Winsö, Ola
    Do lung recruitment maneuvers decrease gastric mucosal perfusion?2003In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 29, no 8, p. 1314-1321Article in journal (Refereed)
  • 3. Guidet, Bertrand
    et al.
    de Lange, Dylan W
    Boumendil, Ariane
    Leaver, Susannah
    Watson, Ximena
    Boulanger, Carol
    Szczeklik, Wojciech
    Artigas, Antonio
    Morandi, Alessandro
    Andersen, Finn
    Zafeiridis, Tilemachos
    Jung, Christian
    Moreno, Rui
    Walther, Sten
    Oeyen, Sandra
    Schefold, Joerg C
    Cecconi, Maurizio
    Marsh, Brian
    Joannidis, Michael
    Nalapko, Yuriy
    Elhadi, Muhammed
    Fjølner, Jesper
    Flaatten, Hans
    The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs: the VIP2 study2020In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 46, no 1, p. 57-69Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Premorbid conditions affect prognosis of acutely-ill aged patients. Several lines of evidence suggest geriatric syndromes need to be assessed but little is known on their relative effect on the 30-day survival after ICU admission. The primary aim of this study was to describe the prevalence of frailty, cognition decline and activity of daily life in addition to the presence of comorbidity and polypharmacy and to assess their influence on 30-day survival.

    METHODS: Prospective cohort study with 242 ICUs from 22 countries. Patients 80 years or above acutely admitted over a six months period to an ICU between May 2018 and May 2019 were included. In addition to common patients' characteristics and disease severity, we collected information on specific geriatric syndromes as potential predictive factors for 30-day survival, frailty (Clinical Frailty scale) with a CFS > 4 defining frail patients, cognitive impairment (informant questionnaire on cognitive decline in the elderly (IQCODE) with IQCODE ≥ 3.5 defining cognitive decline, and disability (measured the activity of daily life with the Katz index) with ADL ≤ 4 defining disability. A Principal Component Analysis to identify co-linearity between geriatric syndromes was performed and from this a multivariable model was built with all geriatric information or only one: CFS, IQCODE or ADL. Akaike's information criterion across imputations was used to evaluate the goodness of fit of our models.

    RESULTS: We included 3920 patients with a median age of 84 years (IQR: 81-87), 53.3% males). 80% received at least one organ support. The median ICU length of stay was 3.88 days (IQR: 1.83-8). The ICU and 30-day survival were 72.5% and 61.2% respectively. The geriatric conditions were median (IQR): CFS: 4 (3-6); IQCODE: 3.19 (3-3.69); ADL: 6 (4-6); Comorbidity and Polypharmacy score (CPS): 10 (7-14). CFS, ADL and IQCODE were closely correlated. The multivariable analysis identified predictors of 1-month mortality (HR; 95% CI): Age (per 1 year increase): 1.02 (1.-1.03, p = 0.01), ICU admission diagnosis, sequential organ failure assessment score (SOFA) (per point): 1.15 (1.14-1.17, p < 0.0001) and CFS (per point): 1.1 (1.05-1.15, p < 0.001). CFS remained an independent factor after inclusion of life-sustaining treatment limitation in the model.

    CONCLUSION: We confirm that frailty assessment using the CFS is able to predict short-term mortality in elderly patients admitted to ICU. Other geriatric syndromes do not add improvement to the prediction model. Since CFS is easy to measure, it should be routinely collected for all elderly ICU patients in particular in connection to advance care plans, and should be used in decision making.

  • 4. Guidet, Bertrand
    et al.
    Flaatten, Hans
    Boumendil, Ariane
    Morandi, Alessandro
    Andersen, Finn H.
    Artigas, Antonio
    Bertolini, Guido
    Cecconi, Maurizio
    Christensen, Steffen
    Faraldi, Loredana
    Fjølner, Jesper
    Jung, Christian
    Marsh, Brian
    Moreno, Rui
    Oeyen, Sandra
    Öhman, Christina Agwald
    Pinto, Bernardo Bollen
    Soliman, Ivo W.
    Szczeklik, Wojciech
    Valentin, Andreas
    Watson, Ximena
    Zafeiridis, Tilemachos
    De Lange, Dylan W.
    Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit2018In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 44, no 7, p. 1027-1038Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.

    METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.

    RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.

    CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.

    TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807).

  • 5. Huijben, Jilske A
    et al.
    Wiegers, Eveline J A
    Lingsma, Hester F
    Citerio, Giuseppe
    Maas, Andrew I R
    Menon, David K
    Ercole, Ari
    Nelson, David
    van der Jagt, Mathieu
    Steyerberg, Ewout W
    Helbok, Raimund
    Lecky, Fiona
    Peul, Wilco
    Birg, Tatiana
    Zoerle, Tommaso
    Carbonara, Marco
    Stocchetti, Nino
    Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis.2020In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 46, no 5, p. 995-1004Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers.

    METHODS: This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers.

    RESULTS: A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01).

    CONCLUSIONS: Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.

  • 6.
    Milton, A
    et al.
    Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
    Schandl, A
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Soliman, I W
    Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
    Meijers, K
    Department of Anaesthesiology and Intensive Care, Sodersjukhuset, Stockholm, Sweden.
    van den Boogaard, M
    Department of Intensive Care Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
    Larsson, I M
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Brorsson, Camilla
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Östberg, U
    Department of Anaesthesiology and Intensive Care, Östersund Hospital, Östersund, Sweden.
    Oxenbøll-Collet, M
    Department of Intensive Care, Rigshospitalet Copenhagen, Copenhagen, Denmark.
    Savilampi, J
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Paskins, S
    Department of Intensive Care, Odense University Hospital, Odense, Denmark.
    Bottai, M
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Sackey, P V
    Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
    Development of an ICU discharge instrument predicting psychological morbidity: a multinational study2018In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 44, no 12, p. 2038-2047Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To develop an instrument for use at ICU discharge for prediction of psychological problems in ICU survivors.

    METHODS: Multinational, prospective cohort study in ten general ICUs in secondary and tertiary care hospitals in Sweden, Denmark and the Netherlands. Adult patients with an ICU stay ≥ 12 h were eligible for inclusion. Patients in need of neurointensive care, with documented cognitive impairment, unable to communicate in the local language, without a home address or with more than one limitation of therapy were excluded. Primary outcome was psychological morbidity 3 months after ICU discharge, defined as Hospital Anxiety and Depression Scale (HADS) subscale score ≥ 11 or Post-traumatic Stress Symptoms Checklist-14 (PTSS-14) part B score > 45.

    RESULTS: A total of 572 patients were included and 78% of patients alive at follow-up responded to questionnaires. Twenty percent were classified as having psychological problems post-ICU. Of 18 potential risk factors, four were included in the final prediction model after multivariable logistic regression analysis: symptoms of depression [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.10-1.50], traumatic memories (OR 1.44, 95% CI 1.13-1.82), lack of social support (OR 3.28, 95% CI 1.47-7.32) and age (age-dependent OR, peak risk at age 49-65 years). The area under the receiver operating characteristics curve (AUC) for the instrument was 0.76 (95% CI 0.70-0.81).

    CONCLUSIONS: We developed an instrument to predict individual patients' risk for psychological problems 3 months post-ICU, http://www.imm.ki.se/biostatistics/calculators/psychmorb/ . The instrument can be used for triage of patients for psychological ICU follow-up.

    TRIAL REGISTRATION: The study was registered at clinicaltrials.gov, NCT02679157.

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  • 7. Robba, Chiara
    et al.
    Galimberti, Stefania
    Graziano, Francesca
    Wiegers, Eveline J. A.
    Lingsma, Hester F.
    Iaquaniello, Carolina
    Stocchetti, Nino
    Menon, David
    Citerio, Giuseppe
    Brorsson, Camilla (Contributor)
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study2020In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients' characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients' outcomes.

    METHODS: We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score.

    RESULTS: Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01-1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22-2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01-1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05-1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27-2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9-50.2%) and timing (early 0-17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07-2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003).

    CONCLUSIONS: Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.

  • 8.
    Wahlström, Marie Rodling
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Olivecrona, Magnus
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
    Koskinen, Lars-Owe D
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
    Rydenhag, Bertil
    Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Naredi, Silvana
    Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Severe traumatic brain injury in pediatric patients: treatment and outcome using an intracranial pressure targeted therapy–the Lund concept2005In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 31, no 6, p. 832-839Article in journal (Refereed)
    Abstract [en]

    Objective: This study evaluated the outcome of treatment according to the Lund concept in children with severe traumatic brain injury and investigated whether the preset goals of the protocol were achieved.

    Design and setting: A two-center retrospective study in neurointensive care units at university hospitals.

    Patients: Forty-one children with severe traumatic brain injury from blunt trauma and arriving at hospital within 24 h after injury. Median age was 8.8 years (range 3 months–14.2 years), Glasgow Coma Scale 7 (3–8), and Injury Severity Score 25 (16–75). All children had pathological findings on initial computed tomography. All developed intracranial hypertension, and survivors required intensive care longer than 72 h.

    Interventions: Treatment according to the principles of the Lund concept.

    Measurements and results: Neurosurgery was required in 46% of the children. Survival rate was 93% and favorable outcome (Glasgow Outcome Score 4 or 5) was 80% at long-term follow-up (median 12 months postinjury, range 2.5–26). The preset physiological and biochemical goals were achieved in over 90% of observations.

    Conclusions: Treating pediatric patients with severe traumatic brain injury, according to the Lund concept, results in a favorable outcome when the protocol is followed.

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