Critical Care Medicine最新文献

Background: Sex-related discrepancies concerning the treatment of patients in intensive care are increasingly described. However, information about management and outcome of critically ill patients undergoing electroencephalography is scarce.

Objectives: This study explores sex-related disparities in management and clinical outcomes in critically ill patients needing electroencephalography for clinical purposes.

Design, setting, patients, and interventions: In this post hoc analysis of the multicenter Continuous Electroencephalography Randomized Trial in Adults (CERTA), which included patients with impaired consciousness requiring electroencephalography, we explored correlations between sex and the timing of electroencephalography, detection of electroencephalography abnormalities, mechanical ventilation, sedation, antiseizure therapy, mortality, and favorable functional outcome (Cerebral Performance Category [CPC] 1-2) at 6 months, using univariable and multivariable analyses.

Measurements and main results: Among 364 patients (33.8% women), women showed a higher prevalence of intracranial hemorrhage (women 30.9%, men 19.5%; p = 0.015) and epileptiform electroencephalography discharges (women 27.6%, men 21.2%; p = 0.008), but use of sedation, antiseizure medication and mechanical ventilation was similar between sexes. Although mortality was similar (adjusted odds ratio [OR], 0.70; 95% CI, 0.39-1.28), women were less likely to reach CPC 1-2 (adjusted OR, 0.50; 95% CI, 0.28-0.90).

Conclusions: Critically ill women and men requiring electroencephalography appear to receive similar clinical management and have comparable mortality, although long-term functional outcome in surviving women is worse. These findings warrant further investigation to identify modifiable factors contributing to sex-related outcome differences.

Objectives: Blood electrolyte panels, especially sodium ion (Na+) and potassium ion (K+), are fundamental and routine tests. In critical care settings, these measurements are typically performed by central laboratories using indirect potentiometry (IP) or via point-of-care blood gas analyzers using direct potentiometry (DP). Discrepancies between the two methods exist, and clinicians often have limited knowledge regarding the strengths and weaknesses of each technique. We wanted to quantify these observations.

Design: We compared prospectively Na+ and K+ measurements obtained from the same blood draw using both IP and DP (including analyses of correlation, agreement, and discrepancies). We also conducted a brief survey among physicians to assess their knowledge regarding IP and DP.

Settings: A tertiary hospital.

Patients: A total of 501 paired measurements were prospectively collected from an ICU population.

Interventions: None.

Measurements and main results: We assessed the degree of agreement between the two methods. We also examined the impact of proteinemia and hemolysis on Na+ and K+ values, respectively. Only 31.1% of the 103 responding physicians were aware of the analytical bias in Na+ measurements obtained by IP, and 45.6% considered K+ measurements from DP to be as reliable or more reliable than those obtained by IP. The agreement between the two methods was moderate (Lin's concordance correlation coefficient: 0.90 for Na+ and 0.93 for K+). The 95% limit of agreement for Na+ was particularly large (10.48 mmol/L). The divergence between the two methods, defined as a discrepancy in classification (within, below, or above the normal range), occurred in approximately 10% of cases, for both Na+ and K+.

Conclusions: IP and DP were not interchangeable, each exhibiting distinct strengths and limitations. Enhancing physician awareness of the differences between these methods could improve the quality of care.

Objectives: To determine the relationships between subprophylactic anti-Xa levels and low-molecular-weight heparin (LMWH) thromboprophylaxis regimens with venous thromboembolism (VTE) risk, and to identify predictors of subprophylactic anti-Xa levels in critically ill adults.

Data sources: Medline and Embase were searched from inception to May 7, 2025.

Study selection: We included studies enrolling critically ill adults receiving LMWH thromboprophylaxis and assessing the relationship between anti-Xa levels and risk of subprophylactic measurements associated with: 1) standard dosing strategies; 2) VTE risk; or 3) predisposing factors.

Data extraction: We extracted or calculated mean, sd, median, interquartile range, mean difference (MD), unadjusted odds ratios (uORs), and adjusted odds ratios (aORs), when available. Risk of bias was evaluated using Cochrane tools. We assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Data synthesis: We included 39 studies (7124 patients). The proportion of patients receiving LMWH prophylaxis achieving target anti-Xa levels was 47% (95% CI, 36-57%). Subprophylactic anti-Xa levels were associated with an increased risk of VTE (uOR, 2.87; 95% CI, 1.42-5.81; low certainty). Variables with a moderate certainty association with subprophylactic anti-Xa levels include male sex (aOR, 2.65; 95% CI, 1.07-6.56), increased weight (MD, 4.90 kg higher weight compared with those with target levels; 95% CI, 2.78-7.02), and elevated body mass index (MD, 1.36 per kg/m2 higher compared with those with target levels; 95% CI, 0.64-2.09).

Conclusions: Less than half of critically ill patients achieved their prophylactic anti-Xa targets despite LMWH thromboprophylaxis. Subprophylactic anti-Xa levels may be associated with an increased risk of VTE. Male sex, increased weight, and elevated body mass index have a moderate certainty association with developing subprophylactic anti-Xa levels. This study highlights the clinical importance of anti-Xa level monitoring in critically ill adults and the need for a future randomized controlled trial to further evaluate this topic.

Objectives: Catatonia occurs in critical illness, however, underlying causal mechanisms are unknown. We aim to determine if exposure to antipsychotic medication is associated with less days alive and free from catatonia in critically ill adults.

Design: The Delirium and Catatonia Prospective Cohort Investigation is a prospective cohort.

Setting: Single academic medical center's medical, surgical, and trauma ICUs.

Patients: Critically ill adult patients on mechanical ventilation or vasopressors without a major neurocognitive disorder, severe psychiatric disorder, or catatonia at baseline.

Interventions: The primary exposure was antipsychotic administration and cumulative dosage during the first 5 and 14 days from enrollment.

Measurements and main results: Catatonia was evaluated with the Bush-Francis Catatonia Rating Scale mapped to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. The primary outcome was catatonia-free days (CFDs), defined as the number of days the patient was alive and free from catatonia. Adjusted proportional odds logistic regression was used to estimate the odds ratio (OR) of outcome events. Patients (n = 270) were enrolled with a median (interquartile range) age of 54.5 years (36.7-67.2 yr). Of patients who were exposed to antipsychotic medication (n = 102), 27 (26%) experienced catatonia. Compared with patients who were never exposed to antipsychotics, those exposed in both the 5- and 14-day models had a 74% and 51% reduction in the odds of more CFD (OR, 0.2568; 95% CI, 0.1580-0.4173) and (OR, 0.4939; 95% CI, 0.3857-0.6325), respectively. Furthermore, those exposed to higher dosages had a 97% reduction in the odds of more CFD (OR, 0.0281; 95% CI, 0.0142-0.0556) and (OR, 0.0335; 95% CI, 0.0166-0.0673) compared with those exposed to lower dosages in both the 5- and 14-day models, respectively.

Conclusions: This study may influence how intensivists approach the use of antipsychotic medications and may build upon existing evidence that dopamine blockade is an underlying biologic mechanism underlying catatonia.

Objectives: Older adults hospitalized to the ICU are at risk for functional decline. In-hospital rehabilitation can mitigate functional decline; however, its association with long-term outcomes is unknown. Our objective was to describe days alive and at home (DAAH) in the 100 days (DAAH100) after ICU hospitalization among older adults and evaluate whether in-hospital rehabilitation is associated with improved DAAH100.

Design: Retrospective cohort study.

Setting: National Health and Aging Trends Study linked with Medicare claims (2011-2019).

Patients: Community-dwelling Medicare beneficiaries 65 years old or older who survived ICU hospitalization.

Interventions: None.

Measurements and main results: The outcome DAAH100 was calculated by subtracting all post-discharge days in any of emergency department, observation unit, inpatient medical, psychiatric, rehabilitation unit, skilled nursing or hospice facility, and post-death from 100. The exposure was units of in-hospital rehabilitation, that is, physical and/or occupational therapy. We constructed a proportional odds logistic regression model of DAAH100 (ordinal) adjusted for demographics, pre-hospitalization frailty and functional status, and hospitalization characteristics. We identified 884 ICU hospitalizations (weighted n = 5,330,486) of older adults discharged alive (age, median [interquartile range (IQR)]: 81 yr [75-86]; 50.5% female). Median DAAH100 was 95 (IQR: 58.4-100) with median of 4 units (~1 hr) of in-hospital rehabilitation delivered over 6 days. After adjustment, each hour of in-hospital rehabilitation was associated with 8% higher odds of experiencing any of the three highest levels of DAAH100 after discharge (adjusted odds ratio [95% CI], 1.08 [1.04-1.08]).

Conclusions: In this nationally representative study of older ICU survivors, the average patient spent 95 of the first 100 post-discharge DAAH; delivery of greater amounts of in-hospital rehabilitation was associated with increased DAAH100 after discharge. These findings highlight the substantial heterogeneity in time spent at home by older ICU survivors and the potential for in-hospital rehabilitation to improve this important patient-centered outcome.

Objectives: The mortality among patients admitted with sepsis remains high and varies depending on the site of infection. The impact of hypercapnia and acidemia on clinical outcomes in mechanically ventilated patients with sepsis is not well understood.

Design: Multicenter, binational, retrospective study assessed the association of compensated hypercapnia, hypercapnic acidemia, and nonrespiratory acidemia, in mechanically ventilated patients with mortality in sepsis.

Setting: Data were extracted from the "Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation adult patient" database over a 17-year period (from January 2006 to December 2022) from 201 ICUs.

Patients: Patients were classified into four mutually exclusive groups based on a combination of arterial pH and arterial Co2 recorded during the first 24 hours of ICU stay: normocapnia with normal pH, fully compensated hypercapnia, hypercapnic acidemia, and nonrespiratory acidemia. Logistic regression and Cox proportional hazards regression were used to examine the association of compensated hypercapnia, hypercapnic, and nonrespiratory academia to hospital mortality.

Interventions: None.

Measurements and main results: Fifty-two thousand four hundred five patients were included. Overall compensated hypercapnia (odds ratio [OR], 1.39; 95% CI, 1.24-1.55; p < 0.001), hypercapnic acidemia (OR, 1.68; 95% CI, 1.57-1.80; p < 0.001), and nonrespiratory acidemia (OR, 1.75; 95% CI, 1.61-1.90; p < 0.001) was associated with increased risk of hospital mortality as compared with patients with normocapnia and normal pH. The risk of increased hospital mortality associated with hypercapnic and nonrespiratory acidemia persisted in all prespecified diagnostic subgroups when compared with patients who had normal pH and normocapnia. Compensated hypercapnia was associated with increased mortality risk in neurologic and unspecified subgroups of sepsis.

Conclusions: Hypercapnic acidemia and nonrespiratory acidemia within the first 24 hours of ICU admission are associated with increased risk of hospital mortality in mechanically ventilated patients with sepsis. This association remains consistent in all diagnostic subgroups of sepsis.