Critical Care Medicine最新文献

Objective: To assess the impact of the presence of an intermediate care unit (IMCU) on ICU patient-level clinical outcomes as well as hospital-level utilization and cost measures by comparing those with vs without an IMCU, using Japan's nationwide inpatient database.

Design: Nationwide retrospective cohort study.

Setting: Acute-care hospitals in Japan participating in the Diagnosis Procedure Combination Study Group database and Hospital Bed Function Reports from 2016 to 2022.

Patients: A total of 2,278,521 adult patients admitted to the ICU between April 2016 and March 2023.

Interventions: ICU admission to hospitals with vs without an IMCU.

Measurements and main results: Outcomes included patient-level (in-hospital and ICU mortality, ICU readmission, and length of ICU stay) and hospital-year level (resource utilization and hospitalization costs) measures. Among the 2,278,521 eligible ICU patients from 557 hospitals across 2,953 hospital-years, 1,771,000 (77.7%) patients were admitted to hospitals with both an ICU and IMCU. Overall, 14.3% of patients were transferred between the ICU and IMCU, with large variability between hospitals. When estimating participant-average treatment effect for patient-level outcomes, ICU patients in IMCU-equipped hospitals had lower in-hospital mortality (adjusted odds ratio [aOR] 0.94; 95% CI, 0.89-0.99), ICU mortality (aOR 0.87; 0.83-0.92), fewer ICU readmissions (aOR 0.92; 95% CI, 0.85-1.00), and shorter ICU stays (adjusted rate ratio 0.98; 95% CI, 0.98-0.99). When estimating cluster-average treatment effect for hospital-level outcomes, IMCU-equipped hospitals had higher ICU bed occupancy (mean difference: 5.5%, 95% CI, 3.3-7.7%), higher occupancy for life-sustaining therapies (8.6%, 95% CI, 7.7-9.5%), increased reimbursement rates (5.4%, 95% CI, 4.0-6.8%), and increased annual revenue per ICU bed (25 million JPY, 19-31 million JPY).

Conclusions: The presence of an IMCU in ICU-equipped hospitals was associated with improved patient outcomes and more efficient ICU utilization, with only modest increase in hospitalization costs. These findings support integration of the IMCU into critical care systems.

Objectives: To identify the impact of early hypothermic temperature control (HTC) initiation and achievement on neurologic outcomes after cardiac arrest. Secondary endpoints assessed: 1) overall survival, 2) body temperature at hospital admission, 3) time taken to reach targeted temperature, and 4) adverse events. Subgroup analyses assessed: 1) HTC induction method, 2) presenting rhythms (shockable vs. nonshockable), and 3) timing of HTC initiation (during cardiopulmonary resuscitation [CPR] vs. post-return of spontaneous circulation [ROSC]).

Data sources: PubMed, Cochrane Library, U.S. National Library of Medicine, MedRxiv, BioRxiv.

Study selection: Prospective randomized controlled trials enrolling comatose adult cardiac arrest patients that assessed the efficacy of early cooling (defined by initiation of HTC within 30 min of ROSC) against late cooling.

Data extraction: Two reviewers independently conducted study selection, data extraction, and assessment of evidence quality. Full texts were jointly reviewed, with discrepancies resolved by a third reviewer through discussion and consensus.

Data synthesis: Of 7269 citations, 11 met the inclusion criteria. Early cooling did not improve neurologic outcomes (risk ratio [RR], 1.01; 95% CI, 0.94-1.14) nor survival (RR, 1.01; 95% CI, 0.92-1.11). Nasal evaporative cooling initiated during resuscitation may benefit patients with shockable rhythms (RR, 1.40; 95% CI, 1.00-1.96), while administering cold fluid during CPR was associated with a higher risk of rearrest. Cooling was initiated in the prehospital phase in ten studies, nine of which failed to achieve target temperature (32-34°C) by hospital admission. The median time to reach target temperature ranged from 38 to 360 minutes.

Conclusions: Early HTC showed no neurologic nor survival benefit in cardiac arrest survivors. Nasal evaporative cooling during CPR may benefit those with shockable rhythms. Delays in reaching the target temperature may underlie the failure of HTC. Future studies should evaluate whether achieving target temperature, for example, within 30 minutes, rapidly improves outcomes.

Objectives: In the United States, training for physicians who manage critically ill adult patients (intensivists) evolved through parallel subspecialty critical care medicine (CCM) pathways with significant commonality. The Society of Critical Care Medicine Adult Critical Care Physician Core Knowledge and Skills Task Force aimed to delineate the common core knowledge and skills required of all intensivists.

Design: A master list of content areas and procedural skills was compiled from all CCM subspecialty program requirements and blueprints of the certification examinations. Using a modified Delphi approach, participants were asked to categorize the knowledge items as "advanced knowledge is essential," "general, but not advanced, knowledge is essential," or "knowledge is not essential." Procedures were categorized as "intensivist performs routinely," "intensivist only performs in an emergency," or "intensivist knows" about the procedure.

Setting: Representatives from CCM stakeholder organizations, including accreditation and certification organizations, critical care societies, and program directors' societies, were invited to participate.

Subjects: Members of the Adult Critical Care Physician Core Knowledge and Skills Task Force of the Society of Critical Care Medicine.

Interventions: For the first two rounds of the modified Delphi process, Research Electronic Data Capture was used. For the third and fourth rounds, the process was completed through online meetings with Zoom (Zoom Video Corporations, San Jose, CA) utilizing Zoom's polling feature.

Measurements and main results: A total of 541 items were determined to be essential, with 145 requiring advanced knowledge and 323 requiring general knowledge. For 73 items, consensus regarding advanced vs. general could not be achieved, but they remained essential. Only eight items were felt to be nonessential. Of the 16 procedures, most were categorized as "intensivist performs."

Conclusions: The large number of items included in the list of essential knowledge and skills demonstrates the complexity of modern CCM. Utilization of a common framework across the subspecialties of CCM could lead to greater harmonization among the fellowship program requirements and certification examinations.

Objectives: To determine whether high-resolution (HighRes) and multimodal integration of physiologic signals improve prediction of return of spontaneous circulation (ROSC) during pediatric cardiopulmonary resuscitation (CPR) compared with low-resolution (LowRes) and single-modality approaches.

Design: Retrospective analysis of experimental data using machine learning models for outcome prediction.

Setting: Laboratory setting with pediatric swine models of cardiac arrest.

Subjects: A total of 187 pediatric swine undergoing standardized cardiac arrest and CPR protocols.

Interventions: Animals were monitored using multiple physiologic signals during CPR, including aortic blood pressure (ABP), right atrial pressure (RAP), capnography, and electrocardiography. No therapeutic interventions were evaluated.

Measurements and main results: Four data approaches were evaluated: 1) Waveform-HighRes (100 Hz waveforms); 2) Compression-HighRes (compression-by-compression physiologic series); 3) Waveform-LowRes (15-s averaged waveforms); and 4) Compression-LowRes (15-s averaged compression-by-compression series). Models were developed to predict ROSC using segments 2-4, 2-6, 2-8, and 2-10 minutes of CPR, using both single and combined signal modalities. Area under the receiver operating characteristic curve (AUROC) was used to evaluate models' performance. In early CPR (2-4 min), Compression-HighRes outperformed both LowRes approaches for ABP (AUROC, 0.74 [0.65-0.82] vs. 0.65 [0.55-0.74] and 0.54 [0.44-0.64]) and RAP (0.70 [0.62-0.79] vs. 0.61 [0.51-0.70] and 0.57 [0.48-0.66]; p < 0.05). In multimodal models, LowRes data performed comparably to HighRes models (AUROC, 0.76-0.79). Across time points, ABP-based model performance improved, reaching AUROC 0.90 (0.84-0.95) for the full CPR period (2-10 min)-comparable to the multimodal model (0.89 [0.83-0.95]).

Conclusions: HighRes monitoring improved early ROSC prediction for individual signals, especially ABP and RAP. However, combining multiple modalities compensates for lower resolution, enabling comparable predictive performance. These findings support data-driven strategies for selecting physiologic targets and technical requirements in physiology-directed CPR.