Critical Care Explorations最新文献

Competing definitions of sepsis have significant clinical implications and impact both medical coding and hospital payment. Although clinicians may prefer Sepsis-2, payer use of Sepsis-3 to validate clinical diagnoses may result in denial of payment or requests to recoup previously paid funds from healthcare providers. The Sepsis-2.5 project was a cooperative effort between a hospital system and a private payer to develop a community-based, literature-supported consensus definition for sepsis characterized by the presence of clinical illness, a source of infection, and evidence of organ dysfunction. This new definition ("Sepsis-2.5") has been instrumental in resolving provider-payer conflicts in defining clinical sepsis and reimbursing care.

Objectives: Transcranial Doppler (TCD) has been evaluated as a noninvasive intracranial pressure (ICP) assessment tool. Correction for insonation angle, a potential source of error, with transcranial color-coded sonography (TCCS) has not previously been reported while evaluating ICP with TCD. Our objective was to study the accuracy of TCCS for detection of ICP elevation, with and without the use of angle correction.

Design: Prospective study of diagnostic accuracy.

Setting: Academic neurocritical care unit.

Patients: Consecutive adults with invasive ICP monitors.

Interventions: Ultrasound assessment with TCCS.

Measurements and main results: End-diastolic velocity (EDV), time-averaged peak velocity (TAPV), and pulsatility index (PI) were measured in the bilateral middle cerebral arteries with and without angle correction. Concomitant mean arterial pressure (MAP) and ICP were recorded. Estimated cerebral perfusion pressure (CPP) was calculated as estimated CPP (CPPe) = MAP × (EDV/TAPV) + 14, and estimated ICP (ICPe) = MAP-CPPe. Sixty patients were enrolled and 55 underwent TCCS. Receiver operating characteristic curve analysis of ICPe for detection of invasive ICP greater than 22 mm Hg revealed area under the curve (AUC) 0.51 (0.37-0.64) without angle correction and 0.73 (0.58-0.84) with angle correction. The optimal threshold without angle correction was ICPe greater than 18 mm Hg with sensitivity 71% (29-96%) and specificity 28% (16-43%). With angle correction, the optimal threshold was ICPe greater than 21 mm Hg with sensitivity 100% (54-100%) and specificity 30% (17-46%). The AUC for PI was 0.61 (0.47-0.74) without angle correction and 0.70 (0.55-0.92) with angle correction.

Conclusions: Angle correction improved the accuracy of TCCS for detection of elevated ICP. Sensitivity was high, as appropriate for a screening tool, but specificity remained low.

Objectives: We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury.

Design: Retrospective cohort study.

Setting: ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

Patients: Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI.

Interventions: None.

Measurements: Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction.

Main results: Of the 450 eligible participants, 57 (13%) received early beta blockers (BB⁺ group). The BB⁺ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB⁺ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB⁺ group and BB^- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes.

Conclusions: About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.

Objectives: To identify factors associated with antibiotic treatment delay in patients admitted with bloodstream infections (BSIs).

Design: Retrospective cohort study.

Setting: North Zealand Hospital, Denmark.

Patients: Adult patients with positive blood cultures obtained within the first 48 hours of admission between January 1, 2015, and December 31, 2015 (n = 926).

Measurements and main results: First recorded Early Warning Score (EWS), patient characteristics, time to antibiotic treatment, and survival at day 60 after admission were obtained from electronic health records and medicine module. Presence of contaminants and the match between the antibiotic treatment and susceptibility of the cultured microorganism were included in the analysis. Data were stratified according to EWS quartiles. Overall, time from admission to prescription of antibiotic treatment was 3.7 (3.4-4.0) hours, whereas time from admission to antibiotic treatment was 5.7 (5.4-6.1) hours. A gap between prescription and administration of antibiotic treatment was present across all EWS quartiles. Importantly, 23.4% of patients admitted with BSI presented with an initial EWS 0-1. Within this group of patients, time to antibiotic treatment was markedly higher among nonsurvivors at day 60 compared with survivors. Furthermore, time to antibiotic treatment later than 6 hours was associated with increased mortality at day 60. Among patients with an initial EWS of 0-1, 51.3% of survivors received antibiotic treatment within 6 hours, whereas only 19.0% of nonsurvivors received antibiotic treatment within 6 hours.

Conclusions: Among patients with initial low EWS, delay in antibiotic treatment of BSIs was associated with increased mortality at day 60. Lag from prescription to administration may contribute to delayed antibiotic treatment. A more frequent reevaluation of patients with infections with a low initial EWS and reduction of time from prescription to administration may reduce the time to antibiotic treatment, thus potentially improving survival.

Objectives: To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures.

Design: Retrospective observational study.

Setting: Single-center level 1 trauma center.

Patients: Trauma patients, admitted to ICU with palliative care consultation.

Intervention: None.

Measurements and main results: The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics.

Conclusions: EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients' preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.

Background: Ingestion and aspiration of caustic substances is a common problem in pediatrics and carries the risk of associated aspiration pneumonitis, laryngeal injury, and esophageal injury. Extracorporeal membrane oxygenation (ECMO) has been used to support adults with acute respiratory distress syndrome (ARDS) from aspiration of cement dust, however, literature outlining pediatric management in cases of alkali lung and airway injuries is lacking.

Case summary: A 6-year-old boy presented with ARDS from cement aspiration requiring high-pressure ventilation. He had further complications of tracheal injury with subsequent pneumomediastinum secondary to the alkali burn. He required ECMO to facilitate repeat bronchoscopy for cement particle washout and to enable recovery from ARDS and tracheal injury.

Conclusion: This case highlights the need to perform early bronchoscopy and gastrointestinal endoscopy for injury assessment and foreign body removal in alkali burns. It also emphasizes the value of ECMO support for respiratory failure and facilitating bronchoalveolar lavage when it is not otherwise tolerated.

Objectives: Clinical decision support systems (CDSSs) are used in various aspects of healthcare to improve clinical decision-making, including in the ICU. However, there is growing evidence that CDSS are not used to their full potential, often resulting in alert fatigue which has been associated with patient harm. Clinicians in the ICU may be more vulnerable to desensitization of alerts than clinicians in less urgent parts of the hospital. We evaluated facilitators and barriers to appropriate CDSS interaction and provide methods to improve currently available CDSS in the ICU.

Design: Sequential explanatory mixed-methods study design, using the BEhavior and Acceptance fRamework.

Setting: International survey study.

Patient/subjects: Clinicians (pharmacists, physicians) identified via survey, with recent experience with clinical decision support.

Interventions: An initial survey was developed to evaluate clinician perspectives on their interactions with CDSS. A subsequent in-depth interview was developed to further evaluate clinician (pharmacist, physician) beliefs and behaviors about CDSS. These interviews were then qualitatively analyzed to determine themes of facilitators and barriers with CDSS interactions.

Measurements and main results: A total of 48 respondents completed the initial survey (estimated response rate 15.5%). The majority believed that responding to CDSS alerts was part of their job (75%) but felt they experienced alert fatigue (56.5%). In the qualitative analysis, a total of five facilitators (patient safety, ease of response, specificity, prioritization, and feedback) and four barriers (excess quantity, work environment, difficulty in response, and irrelevance) were identified from the in-depth interviews.

Conclusions: In this mixed-methods survey, we identified areas that institutions should focus on to improve appropriate clinician interactions with CDSS, specific to the ICU. Tailoring of CDSS to the ICU may lead to improvement in CDSS and subsequent improved patient safety outcomes.

Objectives: Inotropic support is commonly used in patients with cardiogenic shock (CS). High-quality data guiding the use of dobutamine or milrinone among this patient population is limited. We compared the efficacy and safety of these two inotropes among patients with low cardiac output states (LCOS) or CS.

Data sources: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched up to February 1, 2023, using key terms and index headings related to LCOS or CS and inotropes.

Data extraction: Two independent reviewers included studies that compared dobutamine to milrinone on all-cause in-hospital mortality, length of ICU stay, length of hospital stay, and significant arrhythmias in hospitalized patients.

Data synthesis: A total of eleven studies with 21,084 patients were included in the meta-analysis. Only two randomized controlled trials were identified. The primary outcome, all-cause mortality, favored milrinone in observational studies only (odds ratio [OR] 1.19 (95% CI, 1.02-1.39; p = 0.02). In-hospital length of stay (LOS) was reduced with dobutamine in observational studies only (mean difference -1.85 d; 95% CI -3.62 to -0.09; p = 0.04). There was no difference in the prevalence of significant arrhythmias or in ICU LOS.

Conclusions: Only limited data exists supporting the use of one inotropic agent over another exists. Dobutamine may be associated with a shorter hospital LOS; however, there is also a potential for increased all-cause mortality. Larger randomized studies sufficiently powered to detect a difference in these outcomes are required to confirm these findings.

Objectives: To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes.

Design: Retrospective cohort study.

Setting: Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina).

Patients: Subjects with arterial pressure of oxygen (AHRF to Fio₂ [Pao₂/Fio₂] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV).

Interventions: None.

Measurements and main results: We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao₂/Fio₂ (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence (p < 0.001), MV duration (p < 0.0001), and ICU stay (p = 0.001). Patients who failed had higher mortality in COVID-19 group (p < 0.001) but not in the non-COVID-19 (p = 0.083).

Conclusions: In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes.

Objective: To explore the interdisciplinary team members' beliefs and attitudes about sedation when caring for mechanically ventilated patients in the ICU.

Design: Cross-sectional survey.

Setting: A 17-bed cardiothoracic ICU at a tertiary care academic hospital in Colorado.

Subjects: All nurses, physicians, advanced practice providers (APPs), respiratory therapists, physical therapists (PTs), and occupational therapists (OTs) who work in the cardiothoracic ICU.

Interventions: None.

Measurements and main results: We modified a validated survey instrument to evaluate perspectives on sedation across members of the interdisciplinary ICU team. Survey responses were collected anonymously from 111 members (81% response rate). Respondents were predominantly female (70 [63%]). Most respondents across disciplines (94%) believed that their sedation practice made a difference in patients' outcomes. More nurses (48%), APPs (62%), and respiratory therapists (50%) believed that sedation could help alleviate the psychologic stress that patients experience on the ventilator than physicians (19%) and PTs/OTs (0%) (p = 0.008). The proportion of respondents who preferred to be sedated if they were mechanically ventilated themselves varied widely by discipline: respiratory therapists (88%), nurses (83%), APPs (54%), PTs/OTs (38%), and physicians (19%) (p < 0.001). In our exploratory analysis, listeners of an educational podcast had beliefs and attitudes more aligned with best evidence-based practices than nonlisteners.

Conclusions: We discovered significant interdisciplinary differences in the beliefs and attitudes regarding sedation use in the ICU. Since all ICU team members are involved in managing mechanically ventilated patients in the ICU, aligning the mental models of sedation may be essential to enhance interprofessional collaboration and promote sedation best practices.