Critical Care Medicine最新文献

Objectives: To investigate the optimal duration of venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock refractory to medical therapies after cardiac surgery and whether its prolonged use is justified.

Data sources: Previously published articles on postcardiotomy venoarterial ECMO.

Study selection: Articles reporting on the early outcome after postcardiotomy venoarterial ECMO in adult patients were identified through a systematic review of the literature.

Data extraction: Data on prespecified patients' characteristics, operative variables, and outcomes were provided by the authors of previous studies on this topic.

Data synthesis: Individual data of 1267 patients treated at 25 hospitals from ten studies were included in this meta-analysis. In-hospital mortality rates were lowest among patients treated 3-6 days with venoarterial ECMO. Multilevel mixed-effects logistic regression considering the cluster effect of the participating hospitals adjusted for individual patient's risk profile and operative variables showed that the risk in-hospital mortality did not significantly increase in patients treated more than 6 days up to 20 days.

Conclusions: The present study demonstrated that prolonged venoarterial ECMO support after adult cardiac surgery may be justified. However, the analysis was limited by the knowledge of only those circumstances known at the start of ECMO.

Objectives: To conduct a Geospatial Information System analysis of extracorporeal membrane oxygenation (ECMO) centers in the United States utilizing data from the U.S. Census Bureau to better understand access to ECMO care and identify potential disparities.

Design: A cross-sectional descriptive and statistical analysis of geospatial access to ECMO-capable centers in the United States, accounting for demographic variables.

Setting: The unit of analysis were U.S. Census block groups and demographic variables of interest obtained from the American Community Survey.

Patients: Patients accounted for in the U.S. Census data.

Interventions: None.

Measurements and main results: Sixty-seven percent of the U.S. population had direct access to ECMO-capable centers. Disparities were present, with Puerto Rico, Wyoming, North Dakota, and Alaska having no access. Poverty, increased age, and lower population density consistently correlated with limited access. We identified significant racial and ethnic disparities in the Midwest and Northeast.

Conclusions: While 67% of the U.S. population had access to ECMO-capable centers by ground transportation, significant disparities in access exist. These findings emphasize the need for thoughtful implementation of ECMO systems of care to ensure equitable access. Future work should focus on developing novel systems of care that increase access utilizing advanced technology, such as aeromedical transport services.

Objective: Differences in socioeconomic status (SES) may influence long-term physical, psychological, and cognitive health outcomes of ICU survivors. However, the relationship between SES and these three long-term health outcomes is rarely studied. The aim of this study was to investigate associations between SES and the occurrence of long-term outcomes 1-year post-ICU.

Design: Prospective cohort study.

Setting: Seven Dutch ICUs.

Patients: Patients 16 years old or older and admitted for greater than or equal to 12 hours to the ICU between July 2016 and March 2020 completed questionnaires, or relatives if patients could not complete them themselves, at ICU admission and 1 year after ICU admission.

Interventions: None.

Measurements and main results: Validated scales were used for the outcomes: physical problems (fatigue or ≥ 3 new physical symptoms), psychological problems (anxiety, depression, or post-traumatic stress), cognitive impairment, and a composite score. Occurrence of outcomes were calculated for: origin, education level, employment status, income, and household structure. Adjusted odds ratios (aORs) were calculated with covariates age, gender, admission type, severity-of-illness, and pre-ICU health status. Of the 6555 patients included, 3246 (49.5%) completed the questionnaires at admission and after 1 year. Low education level increased the risk of having health problems in the composite score 1-year post-ICU (aOR 1.84; 95% CI, 1.39-2.44; p < 0.001). Pre-ICU unemployment increased the risk of having physical problems (aOR 1.98; 95% CI, 1.31-3.01; p = 0.001). Migrants and low income was associated with more psychological problems (aOR 2.03; 95% CI, 1.25-3.24; p < 0.01; aOR 1.54; 95% CI, 1.10-2.16; p = 0.01, respectively), and unpaid work with less psychological (aOR 0.26; 95% CI, 0.08-0.73; p = 0.02) and cognitive (aOR 0.11; 95% CI, 0.01-0.59; p = 0.04) problems.

Conclusions: Indicators of lower SES, including low education level, low income, unemployment and migrants were associated with an increased risk of post-ICU health problems. Gaining insight into the complex relationship between SES and long-term health problems is necessary to decrease disparities in healthcare.

Objectives: To examine the association between social vulnerability index (SVI) and social deprivation index (SDI) with critical illness-related mortality in the United States and to guide future research and interventions aimed at reducing disparities in outcomes in patients with critical illness.

Design: A cross-sectional study using county-level data.

Setting: United States with data sourced from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research and the American Community Survey.

Patients: County-level populations of all ages across the United States from 2015 to 2019.

Interventions: None.

Measurements and main results: Age-adjusted mortality rates for four categories of critical illnesses (respiratory, cardiac, neurologic, and renal/gastrointestinal) were analyzed against the county-level SVI and SDI. We assessed critical illness-related mortality associated with SVI and SDI through negative binomial regression models. Mortality rates per 100,000 were highest for cardiac (212.4; 95% CI, 212.2-212.6), followed by respiratory (116.8; 95% CI, 116.7-117.0), neurologic (30.8; 95% CI, 30.8-30.9), and renal/gastrointestinal illnesses (25.2; 95% CI, 25.1-25.3). Mortality was greater among adults 65 years old and older, males, Black or African American individuals, and those living in rural areas. Higher SVI and SDI were associated with increased mortality, with the strongest correlation found for cardiac critical illnesses, showing rate ratios of 1.52 (95% CI, 1.48-1.57) for SDI and 1.43 (95% CI, 1.39-1.47) for SVI. Specific diagnoses with the highest incidence rate ratios included sepsis (1.63 [95% CI, 1.58-1.69] for SVI and 1.75 [95% CI, 1.70-1.80] for SDI), cardiac arrest (1.92 [95% CI, 1.80-2.04] for SVI and 1.98 [95% CI, 1.86-2.10] for SDI), anoxic brain damage (1.62 [95% CI, 1.45-1.81] for SVI and 1.60 [95% CI, 1.45-1.76] for SDI), and acute hepatic failure (1.51 [95% CI, 0.92-2.46] for SVI and 1.49 [95% CI, 1.08-2.05] for SDI). The SDI demonstrated a stronger correlation with mortality compared with the SVI, with socioeconomic status, poverty, education, and unemployment being the most impactful indicators.

Conclusions: Critical illness mortality is significantly associated with indicators of socioeconomic disadvantage. The SDI appears to be a more effective tool than the SVI for guiding resource allocation. Targeted interventions to address social determinants of health, including poverty, education, and unemployment, are essential to reduce disparities and improve outcomes in patients with critical illness. Public health strategies should focus on addressing these social determinants and enhancing support for vulnerable populations and areas.

Objectives: Ableism-discrimination and social prejudice against people with disabilities-defines people by their disability and assumes that disabled people require fixing. We sought to characterize ableism after critical illness and to describe its relationship with care delivery.

Design: A secondary analysis of semi-structured individual interviews (n = 42) and ten group interviews (n = 68 participants) using modified grounded theory. We identified categories of ableism informed by existing disability studies literature and used patterns in the analysis to describe overarching themes.

Setting: A large healthcare system in western Pennsylvania.

Participants: Critical illness survivors, family members, clinicians, and administrators.

Interventions: None.

Measurements and main results: Two overarching themes emerged: ableism presents multifaceted barriers to participation in meaningful activities after critical illness, and it is endemic. We observed examples of ableism in all interviews. The quotes characterizing ableism fell into six categories: 1) infantilization and patronization; 2) disability leading to inability; 3) denial of disability experience; 4) invasion of privacy and denial of meaningful relationships; 5) being ignored and excluded; and 6) pushing care providers beyond their perceived capacity. When participants expressed ableism toward others, it was typically matter-of-fact; however, when participants described experiencing or witnessing ableism, they expressed feelings ranging from anxiety to outrage. Participants explicitly and implicitly connected expressions of ableism to broader policies and practices, providing evidence that ableism is endemic to this healthcare system.

Conclusions: Ableism presents multifaceted barriers to participation after critical illness, undermining resilience and wellbeing. We hypothesize that anti-ableist interventions could reduce disability-related barriers to resilience to optimize recovery after critical illness.

Objectives: Evaluate prediction models designed or used to identify patients with sepsis in the prehospital setting.

Design: Nested case-control study.

Setting: Four emergency departments (EDs) in Utah.

Patients: Adult nontrauma patient with available prehospital care records who received ED treatment during 2018 after arrival via ambulance.

Interventions: None.

Measurements and main results: Of 16,620 patients arriving to a study ED via ambulance, 1,037 (6.2%) met Sepsis-3 criteria in the ED. Complete prehospital care data was available for 434 case patients with sepsis and 434 control patients without sepsis. Model discrimination for the outcome of meeting Sepsis-3 criteria in the ED was quantified using the area under the precision-recall curve (AUPRC), which yields a value equal to outcome prevalence for a noninformative model. Of 21 evaluated prediction models, only the Prehospital Early Sepsis Detection (PRESEP) model (AUPRC, 0.33 [95% CI, 0.27-0.41) outperformed unaided infection assessment by emergency medical services (EMS) personnel (AUPRC, 0.17 [95% CI, 0.13-0.23]) for prehospital prediction of patients who would meet Sepsis-3 criteria in the ED (p < 0.001). PRESEP also outperformed the quick Sequential Organ Failure Assessment score (AUPRC, 0.13 [95% CI, 0.11-0.16]; p < 0.001). Among 28 evaluated dichotomous predictors of ED sepsis, sensitivity ranged from 6% to 91% and positive predictive value 8-100%. PRESEP exhibited modest sensitivity (60%) and positive predictive value (20%).

Conclusions: PRESEP was the only evaluated prediction model that demonstrated better discrimination than unaided EMS infection assessment for the identification of ambulance-transported adult patients who met Sepsis-3 criteria in the ED.

Objectives: To describe a novel approach to the requirement for public disclosure under regulations for Exception From Informed Consent (EFIC) in an inpatient clinical trial.

Design: Single-arm intervention study within a clinical trial.

Setting: Medical and medical/surgical PICUs at an academic children's hospital.

Participants: Families of children and young adults younger than 26 years old receiving care in a PICU.

Interventions: As part of a multipronged approach to meeting requirements for public disclosure for EFIC, we developed and implemented a process termed "personal public disclosure," in which a member of the study team notifies all potentially eligible patients/families in-person or by phone about the trial as soon as possible upon PICU admission. Patients/families may choose to opt out of future participation in the trial.

Measurements and main results: Over a 16-month period, 1577 potentially eligible patients/families were successfully contacted for personal public disclosure. Of these, 473 (30%) opted out of future participation in the trial. In the same period, 64 patients developed the emergent event of interest for the primary trial. Of these, only 9 (14%) were enrolled. Upon notification of enrollment, all 9 (100%) agreed to continue in the data collection phase of the study. Of the remaining 55 missed enrollments, 38 (69%) were due to the event occurring before personal public disclosure had been completed.

Conclusions: Personal public disclosure supports patient/family autonomy within an EFIC trial; however, this approach is limited by low cost-effectiveness, feasibility and appropriateness in many circumstances.

Objectives: Globally, the burden of sepsis is highest in malaria endemic areas of sub-Saharan Africa. The influence of malaria on biological heterogeneity inherent to sepsis in this setting is poorly understood. We sought to determine shared and distinct features of the host response in malarial and non-malarial sepsis in sub-Saharan Africa.

Design and setting: Analysis of Olink proteomic data from prospective observational cohort studies of sepsis conducted at public hospitals in Uganda (discovery cohort [Entebbe, urban], n = 238; validation cohort [Tororo, rural], n = 253).

Patients: Adults (age ≥ 18 yr) hospitalized with sepsis.

Interventions: None.

Measurements and main results: The frequency of malaria-associated (malarial) sepsis was 20% in the discovery cohort and 28% in the validation cohort. In both cohorts, a shared host response was predominant, with less than or equal to 8% of proteins differentially expressed (Benjamini-Hochberg-adjusted p ≤ 0.05) between malarial and non-malarial sepsis, after adjustment for demographic variables and HIV and tuberculosis coinfection. In both cohorts, malarial sepsis was associated with increased expression of immunosuppressive proteins (interleukin-10, leukocyte immunoglobulin-like receptor B1, killer cell immunoglobulin-like receptor 3DL1), including those associated with Tcell exhaustion and apoptosis (lymphocyte activation gene 3, T cell immunoglobulin and mucin domain containing 4). A classifier model including these immunosuppressive proteins showed reasonable discrimination (area under the receiver operating characteristic curves, 0.73 [95% CI, 0.65-0.81] and 0.72 [0.65-0.79]) and calibration (Brier scores 0.14 and 0.18) for stratification of malarial sepsis in the discovery and validation cohorts, respectively.

Conclusions: Host responses are largely conserved in malarial and non-malarial sepsis but may be distinguished by a signature of relative immunosuppression in the former. Further investigations are needed to differentiate mechanisms of malarial and non-malarial sepsis, with the goal of informing pathogen-stratified and pathogen-agnostic treatment strategies.