Critical Care Medicine最新文献

Objectives: To characterize experiences with family contestation of brain death/death by neurologic criteria (BD/DNC) and collate strategies for navigating contested cases.

Data sources: PubMed, EMBASE, PsychInfo (EBSCO), Scopus, CINAHL Complete (EBSCO), and Web of Science were searched in consultation with an informationist for terms related to BD/DNC and contestation. The search was updated through January 2025.

Study selection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews methodology was used. Eligible manuscripts detailed experiences with a contested BD/DNC case(s). Empirical research examining clinical or legal aspects of BD/DNC contestation was eligible, as were professional society guidelines. Two authors independently screened abstracts and full texts. Exclusion criteria included fictionalized cases, case commentaries from authors without direct involvement in the case, publications before 2014, and cases involving pregnant patients.

Data extraction: We created a data extraction tool in Covidence to organize and store data.

Data synthesis: We screened 10,577 abstracts and identified 26 eligible publications, including eight case reports or case series, 13 research studies, and five professional society guidelines or position papers. Twenty publications came from the United States. The circumstances of BD/DNC contestation varied, ranging from hours-long requests to permit the arrival of family members to protracted litigation. Primary teams consulted multidisciplinary personnel when conflict arose, including palliative care, ethics, social work, legal, hospital chaplaincy, and community religious support. However, few details were provided regarding the perceived utility of these services. Clinicians and hospital personnel desired concrete institutional and legal guidance for addressing contestation.

Conclusions: Clinicians report encountering BD/DNC contestation. Detailed, flexible management approaches are necessary, but data and recommendations to guide management are lacking. Understanding optimal responses is impeded by the variable circumstances and family actions that are described as contestation. Adequately developing and disseminating management strategies will require consistent definitions and usage of key terms, as well as additional multidisciplinary and participatory scholarship.

Objectives: Differences in mechanical ventilation strategies between patients with and without acute brain injury (ABI) remain incompletely characterized. We aimed to compare ventilation approaches in patients with and without ABI over a 10-year period and to investigate impacts of practice changes on Pa o2 and Pa co2 .

Design: Retrospective registry-based cohort study involving prospectively collected data from nine ICUs across Toronto, Ontario, Canada.

Setting and patients: Adult patients (≥ 18 yr) receiving invasive ventilation for at least 48 hours from 2014 to 2023 were included. Patients were classified as having ABI (exposure) or non-ABI (comparator) conditions. Between-group differences in tidal volume (V t ), positive end-expiratory pressure (PEEP), Pa co2 , and Pa o2 were summarized using adjusted linear mixed-effects regression. Six additional ventilation and gas exchange variables were evaluated in unadjusted analyses.

Interventions: None.

Measurements and main results: Thirteen thousand nine hundred twenty-five patients were included. Mean age ( sd ) was 59.1 years (17.5 yr), 38.1% of patients ( n = 5305) were female, and 25.2% had ABI ( n = 3503). Over the first 7 ventilation days, V t was comparable between groups, with a daily median close to 6 mL/kg (interquartile range, 6-7 mL/kg) predicted body weight. PEEP was significantly lower in patients with ABI (median 5 vs. 8 cm H 2 O in non-ABI patients; p < 0.001). Among patients with hypoxemic respiratory failure, PEEP remained significantly lower in the ABI subset. From 2014 to 2023, V t decreased slightly in both groups, while PEEP remained unchanged. Pa co2 was largely maintained within 35-45 mm Hg in ABI patients and Pa o2 remained largely within 80-120 mm Hg. Differences in six additional ventilation parameters between groups were minimal.

Conclusions: Both ABI and non-ABI patients received comparable V t that trended downwards over time. Pa co2 and Pa o2 remained largely within guideline-recommended ranges. However, PEEP was significantly lower in ABI patients, including among those with hypoxemic respiratory failure, highlighting potential opportunities to improve PEEP application in relevant subsets.

Objectives: Acute respiratory distress syndrome (ARDS) represents a significant complication in trauma patients. Yet the epidemiology of ARDS in trauma remains incompletely characterized. We sought to define trends in ARDS frequency and the effect of temporal, patient, and center-level factors on outcomes with the hypothesis that ARDS independently predicts mortality.

Design: Retrospective cohort study.

Setting: Hospitals submitting data to the American College of Surgeons National Trauma Data Bank.

Patients: Injured patients 18 years old or older from 2007 to 2019 on mechanical ventilation (MV) for greater than or equal to 2 days were included, and patients with ARDS were compared with those without ARDS. A subgroup with transfusion data was also identified. Multivariable logistic regression models by year adjusted for patient demographics, center characteristics, and blood products identified factors independently associated with ARDS diagnosis and 30-day hospital mortality.

Interventions: None.

Measurements and main results: Of 384,032 injured patients on MV, ARDS was documented in 29,359 (8 per 100 MV patients) with a significant decrease over the study period (22 in 2007 vs. 3 in 2019, p < 0.001). Patient-level risk factors independently associated with ARDS were blunt injury (odds ratio [OR] 1.25; 95% CI, 1.20-1.30), severe sepsis (OR 2.16; 95% CI, 2.06-2.27), ventilator-associated pneumonia (OR 2.91; 95% CI, 2.82-3.00), and acute kidney injury (AKI, OR 2.98; 95% CI, 2.85 to 3.12). In the transfusion subset, 24-hour plasma (OR 1.02; 95% CI, 1.01-1.04) and platelets (OR 1.03; 95% CI, 1.02-1.05) were independently associated with ARDS. Crude ARDS mortality increased over the study period (2007, 15.1% vs. 2019, 29.7%, p < 0.001), and after adjusting for significant differences, ARDS was independently associated with 30-day hospital mortality (OR 1.32; 95% CI, 1.27-1.37). Independent risk factors for 30-day mortality in patients with ARDS included head injury (OR 1.54; 95% CI, 1.43-1.66), severe sepsis (OR 1.48; 95% CI, 1.34-1.63), and AKI (OR 2.72; 95% CI, 2.50-2.96). Patients with ARDS managed in Prevention and Early Treatment of Acute Lung Injury and the Extracorporeal Life Support Organization centers were less likely to die (OR 0.78; 95% CI, 0.72-0.84).

Conclusions: From 2007 to 2019, ARDS decreased significantly in trauma patients. Over the same time, mortality increased to nearly 30%, and after adjusting for other risks factors, ARDS was strongly associated with 30-day mortality. Future studies should examine modifiable patient and center-level factors to improve mortality in these high-risk patients.

Objectives: To evaluate the current evidence, clinical indications, methodologies, outcomes, and challenges associated with tandem extracorporeal blood purification/support therapies (EBP/STs) in critically ill children.

Data sources: A literature review of peer-reviewed articles, clinical guidelines, and existing literature related to continuous renal replacement therapy, therapeutic plasma exchange, extracorporeal membrane oxygenation, and their concurrent use in critically ill children.

Study selection: Studies were included if they described tandem use of EBP/ST modalities in children, including case series, observational studies, and expert reviews. Studies focusing exclusively on adult populations or single modality therapy were excluded.

Data extraction: Key data points extracted were patient population, clinical indication for tandem therapy, type and sequence of EBP/ST modality used, reported outcomes, and complications. Emphasis was placed on child-specific applications, safety profiles, and treatment protocols.

Data synthesis: Tandem EBP/ST are increasingly used to treat children with complex conditions such as sepsis-induced multiple organ failure, acute liver failure, and thrombocytopenia-associated multiple organ dysfunction syndrome. This review synthesizes the reported risks, benefits, and proposed protocols for tandem therapy use in PICUs. Benefits include reduced procedural downtime, optimized vascular access, and enhanced therapeutic efficiency. However, tandem therapies remain off-label, with widely variable clinical protocols, lack of children-specific guidelines, and increased risk of complications such as hypocalcemia and hemodynamic instability, limiting their widespread adoption.

Conclusions: Tandem EBP/STs remain an emerging but incompletely standardized intervention in pediatric critical care. While they offer potential benefits such as improved procedural efficiency and reduced vascular access requirements, their use is limited by heterogeneous protocols, off-label application, and risk of complications. Efforts toward developing standardized guidelines, enhancing multidisciplinary training, and establishing multicenter registries may help optimize their safe and effective use in critically ill children.

Objectives: Determine if previously described sepsis survivor subtypes can be applied outside of their derivation cohort using a parsimonious algorithm. Test the association between subtype and the primary outcome of 3-month mortality, and secondary outcomes of readmission, physical function, and health-related quality of life through 1 year of follow-up.

Design: Retrospective cohort study.

Setting: Participants enrolled in the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial, a multisite trial in the United States that enrolled patients with sepsis-induced hypotension.

Patients: All participants who were alive on day 28 after enrollment and had nonmissing data for outcome and subtype-defining variables (Charlson Comorbidity Index, length of stay, discharge destination). Participants were retrospectively assigned at time of discharge to one of five previously derived survivor subtypes: low risk, healthy with severe disease, multimorbidity, low functional status, and unhealthy baseline with severe disease.

Interventions: None.

Measurements and main results: Of 1563 participants, 1368 were eligible and assigned a subtype. Three-month mortality was 13.1% and varied significantly between subtypes (5.1-45.5%; p < 0.001). In age-adjusted logistic regression, odds ratios for 3-month mortality were 11.1 in the low functional status and 9.7 in the unhealthy baseline with severe illness subtypes, compared with the low-risk subtype ( p < 0.001). Participant subtype was a significant predictor of 6- and 12-month EuroQol 5D five level score and limitations in activities of daily living, but not readmission.

Conclusions: Sepsis survivor subtypes that are readily identifiable at hospital discharge are significantly associated with mortality at 3 months, and patient-important outcomes through 12 months. Using subtypes to predict a patient's risk of adverse outcomes could aid the discharge planning and recovery process.

Objectives: Emergency medicine (EM) surgical critical care (SCC) trained physicians offer many advantages to SCC. However, several fields of critical care (CC) compete with SCC for EM intensivists. We hypothesized that there are definable and potentially modifiable factors related to the pathway selection.

Design: Cross-sectional survey.

Setting: Four national EM societies.

Subjects: EM trainees (residents and fellows).

Interventions: None.

Measurements and main results: The primary outcome included the top factors leading to pathway selection. Secondary outcomes included influential factors for entering CC and individual components of a CC fellowship that interest the EM trainee. One hundred eleven EM trainees responded-42 fellows and 69 residents. Median age was 32 (interquartile range, 30-35). Sixty-seven were matched (fellows + matched residents). Intended fields of practice: 49 anesthesiology CC (26 matched), 58 medicine CC (29 matched), two neurology CC (1 matched), six resuscitation (one matched), 15 SCC (eight matched), and five non-CC (two matched). Top factors for pathway selection included exposure to specialty units, geography and specialty multidisciplinary teams ( p < 0.05). Ease of board certification was not influential. Only 28% of trainees had exposure to EM-SCC fellowships at their residency institution and only 42% had exposure to surgical intensivists during training. However, 41% envisioned practicing in a surgical ICU. Before application season, 8.2% did not have exposure to a surgical ICU/trauma ICU/trauma service that managed their ICU patients in contrast to the 3.2% of applicants not having medical ICU exposure. The highest-ranking factor for entering CC was intellectual appeal over job opportunities and lifestyle ( p < 0.05). When assessing components of individual fellowship programs, CC knowledge, the institutional value of EM/critical care medicine, and extracorporeal membrane oxygenation exposure ranked highly.

Conclusions: Given the complexity of the modifiable barriers for EM-SCC matriculation, a multifaceted approach is necessary to increase matriculants. Interventions specific to the specialty are required at professional societal, institutional, and training program levels.