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To estimate performance characteristics and impact on care processes of a machine learning, early sepsis recognition tool embedded in the electronic medical record. Design Retrospective review of electronic medical records and outcomes to determine sepsis prevalence among patients about whom a warning was received in real time and timing of that warning compared with clinician recognition of potential sepsis as determined by actions documented in the electronic medical record. Setting Acute care, nonteaching hospital. Patients Patients in the emergency department, observation unit, and adult inpatient care units who had sepsis diagnosed either by clinical codes or by Center for Medicare and Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) criteria for severe sepsis and patients who had machine learning-generated advisories about a high risk of sepsis. Interventions Noninterventional study. Measurements and Main Results Using two different definitions of sepsis as "true" sepsis, we measured the sensitivity and early warning clinical utility. Using coded sepsis to define true positives, we measured the positive predictive value of the early warnings. Sensitivity was 28.6% and 43.6% for coded sepsis and severe sepsis, respectively. The positive predictive value of an alert was 37.9% for coded sepsis. Clinical utility (true positive and earlier advisory than clinical recognition) was 2.2% and 1.6% for the two different definitions of sepsis. Use of the tool did not improve sepsis mortality rates. Conclusions Performance characteristics were different than previously described in this retrospective assessment of real-time warnings. Real-world testing of retrospectively validated models is essential. The early warning clinical utility may vary depending on a hospital's state of sepsis readiness and embrace of sepsis order bundles. Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.To identify medications administered to pediatric patients on extracorporeal membrane oxygenation and to review the available pharmacokinetics and pharmacodynamics literature for the most commonly administered medications. Design Retrospective single-center study. Setting ICUs at Children's Hospital of Philadelphia. this website Patients Pediatric patients supported by extracorporeal membrane oxygenation between October 1, 2014, and September 30, 2018. Interventions None. Measurements and Main Results Drug exposure was described according to age group ( 12 yr) and ICU (cardiac, neonatal, pediatric). The association of drug exposure with patient's characteristics was examined using one-way analysis of variance for categorical variables and linear regression for continuous variables. All pharmacokinetics and pharmacodynamics literature for the 50 most commonly administered medications on extracorporeal membrane oxygenation was reviewed, with inclusion of studies that reported dosing regimens in conjunction with pharmacokine of the Society of Critical Care Medicine.Care-related infections affect up to 11% of ICU patients. Running therapeutic albumin is sometimes associated to less infection whether a specific method of its infusion is of any interest to modulate innate defense is unknown. Our objectives were 1) to test whether the method for albumin infusion is important to prevent care-related infections and 2) to analyze in vitro the antioxidative role of albumin on host defense proteins during shock (using vasostatin-I as an example). Design In a prospective, randomized, open-label trial, shock patients were allocated to receive either continuously 4% albumin or intermittently 20% albumin, as long as they were infused with norepinephrine. A translational study including in vivo and in vitro analyses of albumin-vasostatin-I interactions is reported. Setting A tertiary ICU caring for 1,000 patients per year. Patients Fifty shock patients with serum albumin less than 20 g/L. Interventions In vivo colonization and nosocomial infections were recorded and time-dependent changes in serum albumin, chromogranin A, and vasostatin-I concentrations as well. In vitro, we studied biochemical albumin-vasostatin-I relationship using biochemical methods. Measurements and Main Results Over 18 days, we recorded a decrease in colonization (four vs 12 episodes; p = 0.035) and nosocomial infection frequency (two vs 13 episodes; p = 0.002) in patients infused continuously 4% albumin versus controls. In vitro, albumin interacts with the disulfide loop vasostatin-I (residues 17-40) and continuous 4% albumin infusion restores its oxidative status required for antimicrobial activity. Conclusions Continuous 4% albumin is effective in reducing care-related infections in shock patients by increasing the availability of antimicrobial vasostatin-I. This might guide future care of shock patients. Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.We performed a meta-analysis to assess whether the newly introduced quick Sequential Organ Failure Assessment score could predict sepsis outcomes and compared its performance to systematic inflammatory response syndrome, the previously widely used screening criteria for sepsis. Data Sources We searched multiple electronic databases including MEDLINE, the Cochrane Library, Embase, Web of Science, and Google Scholar (up to March 1, 2019) that evaluated quick Sequential Organ Failure Assessment score, systemic inflammatory response syndrome, or both (International Prospective Register of Systematic Reviews [PROSPERO] CRD42018103327). Study Selection Studies were included if the outcome was mortality, organ dysfunction, admission to ICU, ventilatory support, or prolonged ICU stay and if prediction performance was reported as either area under the curve, odds ratio, sensitivity, or specificity. Data Extraction The criterion validity of the quick Sequential Organ Failure Assessment score and systemic inflammatory rns (emergency department vs ICU), study design (retrospective vs prospective), and countries (developed vs resource-limited). Quick Sequential Organ Failure Assessment score was more specific (specificity, 74.58%; 95% CI, 73.55-75.61%) than systemic inflammatory response syndrome (specificity, 35.24%; 95% CI, 22.80-47.69%) but less sensitive (56.39%; 95% CI, 50.52-62.27%) than systemic inflammatory response syndrome (78.84%; 95% CI, 74.48-83.19%). Conclusions Overall, quick Sequential Organ Failure Assessment score outperforms systemic inflammatory response syndrome in predicting sepsis outcome, but quick Sequential Organ Failure Assessment score has relative strengths/weaknesses (more specific but less sensitive) compared with systemic inflammatory response syndrome. Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
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