Critical Care Explorations最新文献

Objectives: It is unclear whether IV milrinone relaxes spasmed cerebral arteries and therefore reduces cerebral blood mean velocity (V_mean). In patients treated for cerebral vasospasm, we aimed to assess and delineate the respective impacts of induced hypertension and its combination with IV milrinone on cerebral hemodynamics as assessed with transcranial Doppler.

Design: Observational proof-of-concept prospective study.

Setting: ICU in a French tertiary care center.

Patients: Patients with aneurysmal subarachnoid hemorrhage who received induced hypertension (mean arterial blood pressure [MBP] of 100-120 mm Hg) and IV milrinone (0.5 µg/kg/min) for moderate-to-severe cerebral vasospasm. We excluded patients who underwent invasive angioplasty or milrinone discontinuation within 12 hours after the diagnosis of vasospasm.

Interventions: None.

Measurements and main results: V_mean was measured at vasospasm diagnosis (T_DIAGNOSIS), after the induction of hypertension (T_HTN), and 1 (T_{HTN+MILRINONE_H1}) and 12 hours after the adjunction of IV milrinone (T_{HTN+MILRINONE_H12}). Thirteen patients were included. Median V_mean was significantly lower (p < 0.01) at T_{HTN+MILRINONE_H1} (99 [interquartile range (IQR) 89; 134] cm.s^-1) and T_{HTN+MILRINONE_H12} (85 [IQR 73-127] cm/s) than at T_DIAGNOSIS (136 [IQR 115-164] cm/s) and T_HTN (148 [IQR 115-183] cm/s), whereas T_DIAGNOSIS and T_HTN did not significantly differ. In all patients but one, V_mean at T_{HTN+MILRINONE_H1} was lower than its value at T_DIAGNOSIS (p = 0.0005). V_mean-to-MBP and V_mean-to-cardiac output (CO) ratios (an assessment of V_mean regardless of the level of MBP [n = 13] or CO [n = 7], respectively) were, respectively, similar at T_DIAGNOSIS and T_HTN but were significantly lower after the adjunction of milrinone (p < 0.01).

Conclusions: The induction of arterial hypertension was not associated with a significant decrease in V_mean, whereas the adjunction of IV milrinone was, regardless of the level of MBP or CO. This suggests that IV milrinone may succeed in relaxing spasmed arteries.

Objectives: To describe our institutional experience utilizing adjunctive synthetic angiotensin II in critically ill children with catecholamine-resistant vasodilatory shock (CRVS).

Design: Single-center, retrospective case series.

Setting: PICU and cardiac ICU (CICU) at a large, quaternary children's hospital in the United States.

Patients: Twenty-three pediatric patients with CRVS who were prescribed synthetic angiotensin II at the discretion of bedside clinicians from January 2018 to April 2023.

Interventions: None.

Measurements and main results: Twenty-three patients (20 in PICU, 3 in CICU) with a median age of 10.4 years (interquartile range [IQR] 1.5-18.5) received angiotensin II over the study period, 70% of whom died. At the time of angiotensin II initiation, 17 patients (74%) were receiving one or more forms of extracorporeal therapy, and median Pediatric Logistic Organ Dysfunction-2 Score-2 in the prior 24 hours was 9 (IQR 7-11). The median time between initiation of the first vasoactive agent and angiotensin II was 127 hours (IQR 13-289), and the median total norepinephrine equivalent (NED) at initiation was 0.65 μg/kg/min (IQR 0.36-0.78). The median duration of therapy was 27 hours (IQR 4-68), and at each timepoint assessed, patients had median improvement in NED and mean arterial pressure (MAP) with treatment. Survivors initiated angiotensin II nearly 3 days earlier in vasoactive course (91.5 hr vs 161 hr, p = 0.23), and had both greater reduction in NED (-75% [IQR -96 to -50] vs +2.1% [IQR -55 to 33], p = 0.008) and greater increase in MAP (+15 mm Hg [IQR 10-27] vs -1.5 mm Hg [IQR -27 to 18], p = 0.052) at angiotensin II discontinuation.

Conclusions: We demonstrate reduction in NED and improved MAP following initiation of angiotensin II in critically ill children with CRVS. Further prospective work is needed to examine optimal timing of angiotensin II initiation, appropriate patient selection, and safety in this population.

Transfer of select, medically refractory acute respiratory distress syndrome patients to lung transplant centers requires extensive resources. Here, we report 270 consecutive lung transplant patient referrals to our center for medically refractory ARDS from June 2021 to April 2022, following the implementation of clinical care pathways for intake of these patients. Eighty-seven of 270 patients (32.2%) met screening criteria and were evaluated for transfer within a median of 12 days, during which 38 of 87 patients (43.7%) died and 12 of 87 patients (13.8%) transferred elsewhere. Thirty-seven of 87 patients (42.5%) were accepted for transfer of which 16 of 37 patients (43.2%) successfully transferred to our center with a median transfer waiting period of 12 days. Because of resource constraints, 21 of 37 accepted patients (56.8%) could not be transferred of which 9 of 21 patients (42.9%) died while waiting. Nine of 16 transferred patients (56.2%) eventually underwent lung transplantation with over 80% 6-month survival. ARDS patients referred for transplantation have high risk of mortality and, therefore, require well-described pathways for evaluation and transfer.

Objectives: We analyzed whether patients with the International Classification of Diseases, 10th Edition (ICD-10) discharge diagnosis code for sepsis are different in regard to demographics and outcome variables when comparing those with sepsis only to those also diagnosed with COVID-19 or those with a COVID-19 diagnosis alone.

Design: Retrospective cohort study.

Setting: Nine hospitals in an academic health system.

Patients: Patients with a final ICD-10 discharge diagnostic code for sepsis only, a diagnosis of COVID-19-only, or a final sepsis ICD-10 discharge code + a diagnosis of COVID-19 admitted to the hospital were analyzed for demographic and outcome differences between the cohorts.

Interventions: None.

Measurements and main results: A total of 11,395 patients met inclusion criteria: 6,945 patients (60.9%) were ICD-10 sepsis code only, 3,294 patients (28.9%) were COVID-19 diagnosis-only, and 1,153 patients (10.1%) were sepsis ICD-10 code + COVID-19 diagnosis. Comparing sepsis ICD-10 code + COVID-19 diagnosis patients to sepsis ICD-10 code only and COVID-19 diagnosis-only patients, the sepsis ICD-10 code + COVID-19 diagnosis patients were: older (69 [58-78] vs 67 [56-77] vs 64 [51-76] yr), less likely to be female (40.3% vs 46.7% vs 49.5%), more frequently admitted to the ICU (59.3% [684/1,153] vs 54.9% [1,810/3,297] vs 15% [1,042/6,945]), more frequently required ventilatory support (39.3% [453/1,153] vs 31.8% [1,049/3,297] vs 6.0% [417/6,945]), had longer median hospital length of stay (9 [5,16] vs 5 [3,8] vs 7. [4,13] d), and were more likely to die in the hospital (39.2% [452/1,153] vs 22.3% [735/3,297] vs 6.4% [444/6,945]).

Conclusions: During the COVID-19 pandemic the sickest cohort of patients was those receiving an explicit ICD-10 code of sepsis + a COVID-19 diagnosis. A significant percentage of COVID-19 diagnosis-only patients appear to have been under-coded as they received a level of critical care (ICU admission; intubation) suggestive of the presence of acute organ dysfunction during their admission.