Critical Care Medicine最新文献

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.

Objective: To develop, apply, and validate a system for evaluating critical care guideline adherence, and to identify factors influencing real-world adherence across hospitals.

Design: Retrospective, multicenter observational study evaluating guideline adherence over 3.5 years and comparing automated adherence monitoring against expert human review.

Setting: Five university hospitals with different clinical information systems and data infrastructures.

Patients: A total of 82,000 intensive care episodes (2.2 million patient days). Six representative recommendations were selected from 41 intensive care guidelines and translated into a standardized digital format. Expert review encompassed more than 18,000 patient days.

Interventions: An automated system that applies digitally encoded guideline recommendations to standardized patient data extracted from hospital information systems.

Measurements and main results: The system determined, for each patient and recommendation, whether the recommendation applied (applicability) and whether treatment followed it (adherence). The primary outcome was the system's accuracy in identifying guideline applicability and adherence compared with manual clinician reviews. The secondary outcome was an analysis of how adherence to these recommendations varied and which factors influenced their real-world implementation. The system achieved 97.0% accuracy in identifying guideline applicability and adherence, significantly outperforming human reviewers (86.6% accuracy, p < 0.001; McNemar's test). The processing speed of the system exceeded 2000 patient days per second, compared with manual review at 2 patient days per minute. Adherence rates varied substantially across participating sites and over time, reflecting documentation inconsistencies, evolving clinical knowledge, and challenges in maintaining strict compliance.

Conclusions: The guideline adherence monitoring system was successfully applied in multiple hospitals, demonstrating higher accuracy and efficiency compared with human review. Limitations of the system included dependence on consistent and structured documentation, as inconsistencies significantly complicate adherence monitoring. As the system is designed to support any guideline in the digital format used here, it provides a scalable solution for automated quality management in critical care.

Objective: Guidelines recommend implementing early enteral nutrition (EN) (EEN) in critically ill children. The aim of the study was to determine if EEN for critically ill children is associated with improved clinical outcomes compared with delayed enteral nutrition (DEN), prioritizing associations adjusted for severity of illness. PROSPERO (CRD42021286271).

Data sources: MEDLINE, Embase, CINAHL, and CENTRAL databases to October 2024.

Study selection: The population was critically ill children, the intervention was EEN, the comparator was DEN, the outcome was mortality or clinical outcomes, and the study designs included randomized control trials (RCTs), quasi-experimental, observational cohort, or case-control.

Data extraction: Screening, extraction, and risk of bias assessment using the Newcastle-Ottawa Scale and Cochrane Risk of Bias and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment were conducted in duplicate by two reviewers. Eighteen of 8478 screened studies were included.

Data synthesis: Mortality outcomes were pooled and meta-analyzed using random-effects models. Secondary outcomes were described qualitatively, and directions of associations were reported. Thirteen studies (1 RCT, 12 cohort) reported mortality; however, only three adjusted for illness severity. In the adjusted analysis, receiving EEN was associated with reduced mortality (adjusted odds ratio 0.36 (95% CI, 0.14-0.91), I2 = 78.6%, n = 5864). The certainty of evidence, as assessed by GRADE, was very low due to indirectness. In the qualitative review of 18 studies (1 RCT, 17 cohort studies, n = 9829), EEN had an association with reduced length of stay, length of invasive respiratory support, improved nutrition adequacy, reduced maximum pediatric logistic organ dysfunction score, and infection. No harmful effects of EEN were found after adjusting for confounding variables.

Conclusions: EEN was associated with beneficial outcomes. However, the inclusion of mostly cohort studies with limited confounding adjustment, the small number of studies, the presence of between-study heterogeneity and residual confounding, and heterogeneity in measured outcomes and assessment methods resulted in very low certainty of evidence.

Objectives: Cardiogenic shock is a time-critical emergency requiring aggressive therapeutic interventions, yet prognostication remains challenging with no consensus on the comparative applicabilities of risk scores. Our study aims to evaluate the capacities of existing risk scores for efficient, effective, and generalizable prognostication of mortality across various patient demographic cohorts.

Data sources: We searched MEDLINE, Embase, and Scopus databases up to June 15, 2024.

Study selection: We included articles developing, redeveloping, or validating a multivariable model predicting all-cause mortality in adults with cardiogenic shock.

Data extraction: We pooled area under the curve (AUC) statistics and observed: expected (O:E) ratios as an assessment of discrimination and calibration, respectively. We conducted random-effects inverse-variance weighted meta-analyses on prespecified prediction models (Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock [IABP-SHOCK II], CardShock, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Survival After Venoarterial Extracorporeal Membrane Oxygenation) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity.

Data synthesis: We included 102 studies comprising 126 study cohorts in our final analysis (89,546 patients), with 40 unique prediction models identified. There were no significant differences between the performances of all included scores. However, in terms of absolute pooled values, CardShock score had the highest pooled discrimination (AUC, 0.73 [95% CI, 0.70-0.76]) and best calibration (O:E, 1.06 [95% CI, 0.79-1.41]) among other widely used scores. Subgroup analyses were highly variable between studies and again did not reveal a superior prediction model. Unique prediction models developed by authors were found to be superior to existing prediction models, yet lacked generalizability.

Conclusions: Meta-analysis of six included scores revealed no clear "gold standard" prediction model, although the CardShock score had the highest discrimination and most accurate calibration. The degree of variability between studies precluded in-depth assessment of subgroup analysis. Further research into novel risk scores can be conducted to better inform clinicians on their utility.