Critical Care Medicine最新文献

Objectives: To evaluate the efficacy and safety of conservative (oxygen saturation [Spo2] 88-94% or Pao2 < 80 mm Hg) vs. liberal oxygen targets (Spo2 ≥ 94% or Pao2 ≥ 90 mm Hg) in mechanically ventilated critically ill adults.

Data sources: PubMed, Cochrane CENTRAL, Embase, and ClinicalTrials.gov.

Study selection: We conducted the OXY-BREATHES, a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing conservative vs. liberal oxygen targets in mechanically ventilated ICU patients. Primary outcomes were 90-day mortality and ICU length of stay. Secondary outcomes included ventilator- and vasopressor-free days, renal replacement therapy, nosocomial pneumonia, and cardiac or cerebral ischemic events. Subgroup analyses included patients with sepsis/septic shock and post-cardiac arrest.

Data extraction: Data were collected according to study selection criteria. Certainty of evidence was appraised with Grading of Recommendations, Assessment, Development, and Evaluation, and risk of bias with the Cochrane tool. Data were analyzed using a random-effects model.

Data synthesis: Nine RCTs enrolling 20,447 patients were included. Conservative and liberal targets showed no substantial differences in 90-day (risk ratio [RR], 1.01; 95% CI, 0.94-1.09) or ICU length of stay (mean difference [MD], -0.17; 95% CI, -0.41 to 0.06). Secondary outcomes, including organ support-free days and the incidence of adverse events, were comparable between groups. In subgroup analyses, conservative targets yielded more vasopressor-free days in septic patients (MD, 2.0; p = 0.008) and a potential survival benefit in post-cardiac arrest patients (RR, 0.89; p = 0.05). Certainty of evidence was rated moderate for 90-day mortality, ICU length of stay, vasopressor-free days, and ventilator-free days; low for renal replacement therapy and nosocomial pneumonia; and very low for cerebral and cardiac ischemia due to imprecision and open-label trial designs.

Conclusions: Conservative oxygenation is comparable to liberal oxygen targets in mechanically ventilated critically ill patients, with possible advantages in sepsis and post-cardiac arrest. Future condition-specific RCTs are warranted to define optimal ICU oxygen strategies.

Objectives: To evaluate whether early measurement of quadriceps response to neuromuscular electrical stimulation (NMES) on mechanically ventilated patients could predict future ICU-acquired weakness (ICU-AW).

Design: Prospective observational study.

Setting: Le Havre Hospital medico-surgical ICU.

Patients: All mechanically ventilated patients (> 24 hr), with no prospect of extubation in the following 24 hours.

Interventions: None.

Measurements and main results: Eighty patients were enrolled in the study. Quadriceps response to NMES was measured using ultrasound and shear wave elastography (SWE) after 24 hours of mechanical ventilation, or on the day of neuromuscular blocker cessation if any (baseline). Stimulation intensity was adjusted to induce a quadriceps contraction causing knee extension (heel lifting). Changes in thickness (ultrasound) and stiffness (SWE) of the quadriceps during NMES were collected. An Medical Research Council sum score less than 48 within 24 hours of extubation diagnosed ICU-acquired weakness. A predictive model A, based on the quadriceps response to NMES at baseline, was compared with a model B, derived from identified risk factors, and a combined model (A + B). Of the 80 individuals, 39 (49%) developed ICU-AW. Time delay between intubation and baseline was 3.0 days, and between baseline and extubation was 7.5 days. Stimulation intensity at baseline showed an area under the curve (AUC) of 0.77, with a higher intensity required in individuals who developed ICU-AW (+21.6 mA; p < 0.001). Quadriceps thickness and stiffness during NMES at baseline were 3.83 ± 2.35 cm and 102.76 ± 74.1 kPa, respectively. Model A reached an AUC of 0.87 (95% CI, 0.79-0.95), which was not statistically different from model B. The combined model had the largest AUC (0.94; 95% CI, 0.89-0.99).

Conclusions: A model based on the quadriceps response to NMES after 24 hours of mechanical ventilation, or on the day of neuromuscular blocker cessation seems promising to anticipate future ICU-AW.

Objectives: The impact of acute kidney injury (AKI) on long-term outcomes of hospital survivors is controversial. We conducted a systematic review and meta-analysis of all studies reporting such outcomes in patients with AKI and including a control population.

Data sources: We included original studies published in peer-reviewed journals that compared long-term outcomes (survival, need for dialysis, chronic kidney disease [CKD]) among hospitalized patients with vs. without AKI.

Study selection: Pertinent articles enrolled patients who experienced and survived a defined episode of AKI, included a control group without AKI, and reported at least one long-term outcome (mortality, dialysis, or CKD), with a minimum follow-up of 1 year.

Data extraction: Two independent investigators extracted data on study characteristics, patient populations, follow-up duration, and long-term outcomes. Discrepancies were resolved by consensus.

Data synthesis: We identified 14 studies for a total of 1,058,109 overall matched patients with a median duration of follow-up of 3 years. Patients who experienced an episode of AKI and survived hospital discharge had a significant increase in long-term mortality at the longest follow-up available for each study (137,506/519,672 [26.4%] vs. 93,702/530,663 [17.6%]; relative risk [RR], 1.42; 95% CI, 1.13-1.78; p = 0.002), compared with controls. They also had a greater risk of receiving dialysis (1,928/42,529 [4.5%] vs. 854/42,529 [2.0%]; RR, 2.48; 95% CI, 1.79-3.43; p < 0.001), and of developing CKD (2,956/5,739 [51.5%] vs. 2,902/7,781 [37.3%]; RR, 1.71; 95% CI, 1.33-2.19; p < 0.001).

Conclusions: Compared with controls, patients who experienced an episode of AKI and survived to hospital discharge have an increased risk of death, dialysis, and CKD.

Objectives: Delays in emergency medical care (EMC) can increase sepsis mortality. Sepsis symptoms, however, are less known in the public compared with signs of stroke and myocardial infarction. Using case vignettes, we investigated the decision to seek EMC in sepsis-related compared with other emergencies.

Design: Cross-sectional survey.

Settings and subjects: A representative nationwide survey was conducted in December 2023 among 1013 persons in Germany.

Interventions: None.

Measurements and main results: A standardized questionnaire was administered via face-to-face interviews to assess perceived urgency, the tendency to seek EMC, sepsis knowledge, and barriers to EMC utilization. Multiple regression analyses were conducted to identify predictors for the perceived urgency and the tendency to seek EMC. Across ten case vignettes, the perceived urgency was lower for sepsis-related (mean = 3.93, sd = 0.64) than for nonsepsis-related emergencies (mean=4.15, sd = 0.67). In sepsis-related vignettes, the immediate EMC option ("Call emergency medical services or go to the emergency department [ED] immediately") was chosen by 18.3-43.2% of respondents, compared with 20.1-71.9% in nonsepsis-related vignettes. Even when situations were rated as very urgent, EMC use was less likely for sepsis-related emergencies (35%) than for nonsepsis-related emergencies (17%). In regression analyses, sepsis knowledge was the only predictor of perceived urgency, and perceived urgency was the strongest predictor of EMC use. The likelihood of EMC use in sepsis-related emergencies was 14.9 percentage points lower ( p < 0.01) than in nonsepsis-related emergencies; "long waiting times in the ED" was the only significant barrier for EMC use.

Conclusions: Compared with nonsepsis emergencies, sepsis-related emergencies are perceived as less urgent and less often lead to EMC use, even if the level of perceived urgency is the same. As the perceived urgency is associated with sepsis knowledge, this underlines the need to increase efforts to improve sepsis knowledge and the awareness that sepsis requires timely emergency care in the general public.