Annals of the American Thoracic Society
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Review
Can intensive care unit delirium be prevented and reduced? Lessons learned and future directions.
Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. ⋯ Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.
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Acute lung injury (ALI) is characterized by inflammation, leukocyte activation, neutrophil recruitment, endothelial dysfunction, and epithelial injury, which are all affected by fever. Fever is common in the intensive care unit, but the relationship between fever and outcomes in ALI has not yet been studied. We evaluated the association of temperature dysregulation with time to ventilator liberation, ventilator-free days, and in-hospital mortality. ⋯ Fever and hypothermia are associated with worse clinical outcomes in ALI, with fever being independently associated with delayed ventilator liberation.
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Airway oxidative stress is broadly defined as an imbalance between prooxidative and antioxidative processes in the airway. Given its direct exposure to the environment, the lung has several mechanisms to prevent an excessive degree of oxidative stress. Both enzymatic and nonenzymatic systems can buffer a wide range of reactive oxidative species and other compounds with oxidative potential. ⋯ Therefore, more than being an imbalance with a predictable threshold after which disease or injury ensues, oxidative stress is a dynamic and continuous process. This might explain why supplementing antioxidants has largely failed to improve diseases such as asthma and chronic obstructive pulmonary disease. However, the therapeutic potential of antioxidants could be greatly improved by taking an approach that considers individual and environmental risk factors, instead of treating oxidative airway stress broadly.
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About 20% of patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations are readmitted within 30 days. High 30-day risk-standardized readmission rates after COPD exacerbations will likely place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services starting in fiscal year 2015. Factors contributing to hospital readmissions include healthcare quality, access to care, coordination of care between hospital and ambulatory settings, and factors linked to socioeconomic resources (e.g., social support, stable housing, transportation, and food). ⋯ We recommend research that will provide the evidence base for strategies to reduce readmissions at minority-serving institutions. Promising innovative approaches include using a nontraditional healthcare workforce, such as community health workers and peer-coaches, and telemedicine. These strategies have been successfully used in other conditions and need to be studied in patients with COPD.