Critical Care Medicine最新文献

Objective: Acute pancreatitis (AP) complicated by disseminated intravascular coagulation (DIC) is associated with high mortality. Although recombinant human soluble thrombomodulin (rTM) is commonly used in clinical practice, its association with outcomes in AP has not been established.

Design: A nationwide, propensity score-matched, retrospective cohort study.

Setting: The Japanese Diagnosis Procedure Combination national inpatient database.

Patients: Adult patients hospitalized with AP and DIC between July 2010 and March 2022, who survived at least 3 days. Patients were divided into those receiving rTM within three days of admission and those who did not. Propensity score matching compared in-hospital mortality.

Interventions: None.

Measurements and main results: The analysis included 10,238 patients with AP and DIC, of whom 2,001 (19.5%) received rTM and 8,237 (80.5%) did not. Propensity score matching yielded 1,868 well-balanced pairs. In-hospital mortality was lower in the rTM group (15.5% [290/1,868]) compared with the non-rTM group (19.7% [368/1,868]; risk difference: -4.2%, 95% CI, -6.6% to -1.7%; risk ratio: 0.79, 95% CI, 0.69 to 0.91).

Conclusions: Administration of rTM in patients with AP complicated by DIC was associated with lower in-hospital mortality.

Objective: Hyperthermia is common in brain-injured patients and is considered a systemic secondary brain injury. Paracetamol is most often administered as first-line treatment, although its efficacy in controlling cerebral temperature (CT) has never been evaluated, which is the aim of this study.

Design: Pharmacodynamic prospective randomized double-blind placebo-controlled study.

Setting: Neuro-ICU.

Patients: Brain-injured patients who were febrile (CT ≥ 38.5°C for > 30 min) and monitored with an intracerebral pressure sensor including a thermal probe.

Interventions: Patients received paracetamol or placebo (only one IV administration). CT and systemic temperature (ST) were recorded every 10 minutes over 6 hours.

Measurements and main results: The primary endpoint was the difference in mean CT over 6 hours after treatment. The primary endpoint was the difference in mean CT over6 hours after treatment. We included 99 patients (mean age 55 ± 13 yr, 24% female): 49 in the paracetamol group and 50 in the placebo group. Mean CT during the 6-hour follow-up was significantly lower in the paracetamol than placebo group: 38.4 ± 0.5 vs. 39.0 ± 0.5°C ( p < 0.001). In both groups, mean CT was always higher than mean ST: 38.7 ± 0.6 vs. 38.4 ± 0.6°C ( p < 0.001). Median time with CT less than 38.5°C was 215 minutes (interquartile range 0-290) in the paracetamol group vs. 0 minutes (0-5) in the placebo group ( p < 0.001). One-third (30%) of patients in the paracetamol group did not respond to treatment. In the responder group paracetamol lowered the mean CT by 1°C. The paracetamol group exhibited a moderate decrease in systolic arterial pressure and heart rate, without any other significant effect.

Conclusions: Paracetamol significantly reduced CT in febrile brain-injured patients (overall mean reduction of 0.6°C), maintaining temperatures less than 38.5°C for a median of 3.6 hours. The gradient between CT and ST was consistently about 0.3°C in both groups.

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.