Pub Date : 2024-09-01Epub Date: 2024-08-15DOI: 10.1097/CCM.0000000000006331
Daniel De Backer, Ashish K Khanna
{"title":"The Ideal Mean Arterial Pressure Target Debate: Heterogeneity Obscures Conclusions.","authors":"Daniel De Backer, Ashish K Khanna","doi":"10.1097/CCM.0000000000006331","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006331","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-06-04DOI: 10.1097/CCM.0000000000006339
Raymond Liu, Tanmay Majumdar, Monique M Gardner, Ryan Burnett, Kathryn Graham, Forrest Beaulieu, Robert M Sutton, Vinay M Nadkarni, Robert A Berg, Ryan W Morgan, Alexis A Topjian, Matthew P Kirschen
Objective: Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest.
Design: Retrospective observational study.
Setting: Academic PICU.
Patients: Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care.
Interventions: None.
Measurements and main results: High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner.
Conclusions: High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.
目的: 利用高分辨率连续动脉血压 (ABP) 数据量化低血压负担,并确定其与小儿心脏骤停后的预后之间的关系:利用高分辨率连续动脉血压 (ABP) 数据量化低血压负担,并确定其与小儿心脏骤停后的预后之间的关系:设计:回顾性观察研究:患者患者:18 岁或以下因院内或院外心脏骤停而入院的儿童,在心脏骤停后护理期间接受有创 ABP 监测:测量和主要结果:对循环恢复(ROC)后 24 小时内的高分辨率连续 ABP 进行分析。低血压负担是平均动脉压 (MAP) 与年龄第五百分位数 MAP 之间的时间归一化积分面积。主要结果是出院时的不良神经功能状态(小儿脑功能类别≥3,与基线相比有变化)。Mann-Whitney U 检验比较了有利和不利患者的低血压负担、持续时间和程度。多变量逻辑回归确定了不利预后与低血压负担、持续时间和程度在不同百分位数阈值(从年龄的第 5 百分位数到第 50 百分位数)之间的关系。在 140 名患者中(中位年龄为 53 [四分位间范围为 11-146] 个月,61% 为男性),63% 的患者出现了不良后果。监测持续时间为 21(7-24)小时。以年龄的第五百分位数为 MAP 临界值,低血压负担的中位数为每小时 0.01 (0-0.11) mm Hg-小时,不利预后患者的低血压负担高于有利预后患者(每小时 0 [0-0.02] mm Hg-hr vs. 0.02 [0-0.27] mm Hg-hr,P <0.001)。与预后良好的患者相比,预后不良患者的低血压持续时间和程度更长(0.03 [0-0.77] vs. 0.71 [0-5.01]%,p = 0.003;0.16 [0-1.99] vs. 2 [0-4.02] mm Hg,p = 0.001)。在逻辑回归中,低血压负担每增加 1 个百分点,低于年龄的第五个百分位数(相当于每记录 1 小时低血压负担增加 1 mm Hg-hr),不利预后的几率就会增加(调整后的几率比 [aOR] 14.8;95% CI,1.1-200;p = 0.040)。在MAP阈值为年龄的第10-50百分位数时,与预后良好的患者相比,预后不良患者的MAP负荷低于阈值的几率更大,且呈剂量依赖性:高分辨率连续 ABP 数据可用于量化小儿心脏骤停后的低血压负担。结论:高分辨率连续 ABP 数据可用于量化小儿心脏骤停后的低血压负担,低血压的负担、持续时间和程度与不利的神经系统预后有关。
{"title":"Association of Postarrest Hypotension Burden With Unfavorable Neurologic Outcome After Pediatric Cardiac Arrest.","authors":"Raymond Liu, Tanmay Majumdar, Monique M Gardner, Ryan Burnett, Kathryn Graham, Forrest Beaulieu, Robert M Sutton, Vinay M Nadkarni, Robert A Berg, Ryan W Morgan, Alexis A Topjian, Matthew P Kirschen","doi":"10.1097/CCM.0000000000006339","DOIUrl":"10.1097/CCM.0000000000006339","url":null,"abstract":"<p><strong>Objective: </strong>Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest.</p><p><strong>Design: </strong>Retrospective observational study.</p><p><strong>Setting: </strong>Academic PICU.</p><p><strong>Patients: </strong>Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner.</p><p><strong>Conclusions: </strong>High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11326994/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141237291","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-08-15DOI: 10.1097/CCM.0000000000006372
Brian L Edlow, David K Menon
Objectives: For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries.
Data sources: We reviewed salient medical literature regarding covert consciousness.
Study selection: We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness.
Data extraction and data synthesis: We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries.
Conclusions: Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.
{"title":"Covert Consciousness in the ICU.","authors":"Brian L Edlow, David K Menon","doi":"10.1097/CCM.0000000000006372","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006372","url":null,"abstract":"<p><strong>Objectives: </strong>For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries.</p><p><strong>Data sources: </strong>We reviewed salient medical literature regarding covert consciousness.</p><p><strong>Study selection: </strong>We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness.</p><p><strong>Data extraction and data synthesis: </strong>We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries.</p><p><strong>Conclusions: </strong>Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-08-15DOI: 10.1097/CCM.0000000000006352
Todd A Miano, Erin F Barreto, Molly McNett, Niels Martin, Ankit Sakhuja, Adair Andrews, Rajit K Basu, Enyo A Ablordeppey
{"title":"The authors reply.","authors":"Todd A Miano, Erin F Barreto, Molly McNett, Niels Martin, Ankit Sakhuja, Adair Andrews, Rajit K Basu, Enyo A Ablordeppey","doi":"10.1097/CCM.0000000000006352","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006352","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-06-20DOI: 10.1097/CCM.0000000000006347
Amy Freeman-Sanderson, Martin B Brodsky, Craig Dale, Anushua Gupta, Kimberley Haines, Mary Beth Happ, Nicholas Hart, Bronwyn Hemsley, Laura Istanboulian, Peter Spronk, Rebecca Sullivan, Anna-Liisa Sutt, Louise Rose
Objectives: Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population.
Design: 1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages.
Setting: Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting.
Subjects: Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field.
Intervention: None.
Measurements and main results: We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention.
Conclusions: This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity.
{"title":"A Core Outcome Set for Research Evaluating Interventions to Enable Communication in Patients With an Artificial Airway: An International Delphi Consensus Study (Comm-COS).","authors":"Amy Freeman-Sanderson, Martin B Brodsky, Craig Dale, Anushua Gupta, Kimberley Haines, Mary Beth Happ, Nicholas Hart, Bronwyn Hemsley, Laura Istanboulian, Peter Spronk, Rebecca Sullivan, Anna-Liisa Sutt, Louise Rose","doi":"10.1097/CCM.0000000000006347","DOIUrl":"10.1097/CCM.0000000000006347","url":null,"abstract":"<p><strong>Objectives: </strong>Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population.</p><p><strong>Design: </strong>1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages.</p><p><strong>Setting: </strong>Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting.</p><p><strong>Subjects: </strong>Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field.</p><p><strong>Intervention: </strong>None.</p><p><strong>Measurements and main results: </strong>We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention.</p><p><strong>Conclusions: </strong>This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11321605/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141426565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-06-04DOI: 10.1097/CCM.0000000000006334
Martha F Kienzle, Ryan W Morgan, Ron W Reeder, Tageldin Ahmed, Robert A Berg, Robert Bishop, Matthew Bochkoris, Joseph A Carcillo, Todd C Carpenter, Kellimarie K Cooper, J Wesley Diddle, Myke Federman, Richard Fernandez, Deborah Franzon, Aisha H Frazier, Stuart H Friess, Meg Frizzola, Kathryn Graham, Mark Hall, Christopher Horvat, Leanna L Huard, Tensing Maa, Arushi Manga, Patrick S McQuillen, Kathleen L Meert, Peter M Mourani, Vinay M Nadkarni, Maryam Y Naim, Murray M Pollack, Anil Sapru, Carleen Schneiter, Matthew P Sharron, Sarah Tabbutt, Shirley Viteri, Heather A Wolfe, Robert M Sutton
Objectives: Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared with greater than or equal to 3 minutes.
Design: This study is a secondary analysis of The ICU-RESUScitation Project (NCT028374497), a multicenter trial of a quality improvement bundle of physiology-directed CPR training and post-cardiac arrest debriefing.
Setting: Eighteen PICUs and pediatric cardiac ICUs in the United States.
Patients: Subjects were 18 years young or younger and 37 weeks old or older corrected gestational age who had an index cardiac arrest. Patients who received less than two doses of epinephrine, received extracorporeal CPR, or had dosing intervals greater than 8 minutes were excluded.
Interventions: The primary exposure was an epinephrine dosing interval of less than 3 vs. greater than or equal to 3 minutes.
Measurements and main results: The primary outcome was survival to discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1-2 or no change from baseline. Regression models evaluated the association between dosing intervals and: 1) survival outcomes and 2) CPR duration. Among 382 patients meeting inclusion and exclusion criteria, median age was 0.9 years (interquartile range 0.3-7.6 yr) and 45% were female. After adjustment for confounders, dosing intervals less than 3 minutes were not associated with survival with favorable neurologic outcome (adjusted relative risk [aRR], 1.10; 95% CI, 0.84-1.46; p = 0.48) but were associated with improved sustained return of spontaneous circulation (ROSC) (aRR, 1.21; 95% CI, 1.07-1.37; p < 0.01) and shorter CPR duration (adjusted effect estimate, -9.5 min; 95% CI, -14.4 to -4.84 min; p < 0.01).
Conclusions: In patients receiving at least two doses of epinephrine, dosing intervals less than 3 minutes were not associated with neurologic outcome but were associated with sustained ROSC and shorter CPR duration.
{"title":"Epinephrine Dosing Intervals Are Associated With Pediatric In-Hospital Cardiac Arrest Outcomes: A Multicenter Study.","authors":"Martha F Kienzle, Ryan W Morgan, Ron W Reeder, Tageldin Ahmed, Robert A Berg, Robert Bishop, Matthew Bochkoris, Joseph A Carcillo, Todd C Carpenter, Kellimarie K Cooper, J Wesley Diddle, Myke Federman, Richard Fernandez, Deborah Franzon, Aisha H Frazier, Stuart H Friess, Meg Frizzola, Kathryn Graham, Mark Hall, Christopher Horvat, Leanna L Huard, Tensing Maa, Arushi Manga, Patrick S McQuillen, Kathleen L Meert, Peter M Mourani, Vinay M Nadkarni, Maryam Y Naim, Murray M Pollack, Anil Sapru, Carleen Schneiter, Matthew P Sharron, Sarah Tabbutt, Shirley Viteri, Heather A Wolfe, Robert M Sutton","doi":"10.1097/CCM.0000000000006334","DOIUrl":"10.1097/CCM.0000000000006334","url":null,"abstract":"<p><strong>Objectives: </strong>Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared with greater than or equal to 3 minutes.</p><p><strong>Design: </strong>This study is a secondary analysis of The ICU-RESUScitation Project (NCT028374497), a multicenter trial of a quality improvement bundle of physiology-directed CPR training and post-cardiac arrest debriefing.</p><p><strong>Setting: </strong>Eighteen PICUs and pediatric cardiac ICUs in the United States.</p><p><strong>Patients: </strong>Subjects were 18 years young or younger and 37 weeks old or older corrected gestational age who had an index cardiac arrest. Patients who received less than two doses of epinephrine, received extracorporeal CPR, or had dosing intervals greater than 8 minutes were excluded.</p><p><strong>Interventions: </strong>The primary exposure was an epinephrine dosing interval of less than 3 vs. greater than or equal to 3 minutes.</p><p><strong>Measurements and main results: </strong>The primary outcome was survival to discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1-2 or no change from baseline. Regression models evaluated the association between dosing intervals and: 1) survival outcomes and 2) CPR duration. Among 382 patients meeting inclusion and exclusion criteria, median age was 0.9 years (interquartile range 0.3-7.6 yr) and 45% were female. After adjustment for confounders, dosing intervals less than 3 minutes were not associated with survival with favorable neurologic outcome (adjusted relative risk [aRR], 1.10; 95% CI, 0.84-1.46; p = 0.48) but were associated with improved sustained return of spontaneous circulation (ROSC) (aRR, 1.21; 95% CI, 1.07-1.37; p < 0.01) and shorter CPR duration (adjusted effect estimate, -9.5 min; 95% CI, -14.4 to -4.84 min; p < 0.01).</p><p><strong>Conclusions: </strong>In patients receiving at least two doses of epinephrine, dosing intervals less than 3 minutes were not associated with neurologic outcome but were associated with sustained ROSC and shorter CPR duration.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11326980/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141247999","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-08-15DOI: 10.1097/CCM.0000000000006325
G Jan Zijlstra, Arne J van Tienhoven, Matijs van Meurs
{"title":"Do Not Estimate, When You Can Measure.","authors":"G Jan Zijlstra, Arne J van Tienhoven, Matijs van Meurs","doi":"10.1097/CCM.0000000000006325","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006325","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-08-15DOI: 10.1097/CCM.0000000000006343
Yang Zhao, Da Chen, Qian Wang
{"title":"Lower Versus Higher Blood Pressure Targets in Critically Ill Patients.","authors":"Yang Zhao, Da Chen, Qian Wang","doi":"10.1097/CCM.0000000000006343","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006343","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-23DOI: 10.1097/CCM.0000000000006394
Keith A Corl, Mitchell M Levy, Andre L Holder, Ivor S Douglas, Walter T Linde-Zwirble, Aftab Alam
Objectives: Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation.
Design: Retrospective analysis of the Premier Healthcare Database.
Setting: Six hundred twelve U.S. hospitals.
Patients: Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019.
Interventions: The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality.
Measurements and main results: In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation.
Conclusions: Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials.
{"title":"Moderate IV Fluid Resuscitation Is Associated With Decreased Sepsis Mortality.","authors":"Keith A Corl, Mitchell M Levy, Andre L Holder, Ivor S Douglas, Walter T Linde-Zwirble, Aftab Alam","doi":"10.1097/CCM.0000000000006394","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006394","url":null,"abstract":"<p><strong>Objectives: </strong>Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation.</p><p><strong>Design: </strong>Retrospective analysis of the Premier Healthcare Database.</p><p><strong>Setting: </strong>Six hundred twelve U.S. hospitals.</p><p><strong>Patients: </strong>Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019.</p><p><strong>Interventions: </strong>The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality.</p><p><strong>Measurements and main results: </strong>In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation.</p><p><strong>Conclusions: </strong>Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142035448","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-23DOI: 10.1097/CCM.0000000000006391
Eleftheria Kranidioti, Isis Ricaño-Ponce, Nikolaos Antonakos, Evdoxia Kyriazopoulou, Antigone Kotsaki, Iraklis Tsangaris, Dimitra Markopoulou, Nikoleta Rovina, Eleni Antoniadou, Ioannis Koutsodimitropoulos, George N Dalekos, Glykeria Vlachogianni, Karolina Akinosoglou, Vasilios Koulouras, Apostolos Komnos, Theano Kontopoulou, George Dimopoulos, Mihai G Netea, Vinod Kumar, Evangelos J Giamarellos-Bourboulis
Objective: To investigate the metabolomic profiles associated with different immune activation states in sepsis patients.
Design: Subgroup analysis of the PROVIDE (a Personalized Randomized trial of Validation and restoration of Immune Dysfunction in severe infections and Sepsis) prospective clinical study.
Setting: Results of the PROVIDE study showed that patients with sepsis may be classified into three states of immune activation: 1) macrophage-activation-like syndrome (MALS) characterized by hyperinflammation, sepsis-induced immunoparalysis, and 3) unclassified or intermediate patients without severe immune dysregulation.
Patients or subjects: Two hundred ten patients from 14 clinical sites in Greece meeting the Sepsis-3 definitions with lung infection, acute cholangitis, or primary bacteremia.
Interventions: During our comparison, we did not perform any intervention.
Measurements and main results: Untargeted metabolomics analysis was performed on plasma samples from 210 patients (a total of 1394 products). Differential abundance analysis identified 221 significantly different metabolites across the immune states. Metabolites were enriched in pathways related to ubiquinone biosynthesis, tyrosine metabolism, and tryptophan metabolism when comparing MALS to immunoparalysis and unclassified patients. When comparing MALS to unclassified, 312 significantly different metabolites were found, and pathway analysis indicated enrichment in multiple pathways. Comparing immunoparalysis to unclassified patients revealed only two differentially regulated metabolites.
Conclusions: Findings suggest distinct metabolic dysregulation patterns associated with different immune dysfunctions in sepsis: the strongest metabolic dysregulation is associated with MALS.
{"title":"Modulation of Metabolomic Profile in Sepsis According to the State of Immune Activation.","authors":"Eleftheria Kranidioti, Isis Ricaño-Ponce, Nikolaos Antonakos, Evdoxia Kyriazopoulou, Antigone Kotsaki, Iraklis Tsangaris, Dimitra Markopoulou, Nikoleta Rovina, Eleni Antoniadou, Ioannis Koutsodimitropoulos, George N Dalekos, Glykeria Vlachogianni, Karolina Akinosoglou, Vasilios Koulouras, Apostolos Komnos, Theano Kontopoulou, George Dimopoulos, Mihai G Netea, Vinod Kumar, Evangelos J Giamarellos-Bourboulis","doi":"10.1097/CCM.0000000000006391","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006391","url":null,"abstract":"<p><strong>Objective: </strong>To investigate the metabolomic profiles associated with different immune activation states in sepsis patients.</p><p><strong>Design: </strong>Subgroup analysis of the PROVIDE (a Personalized Randomized trial of Validation and restoration of Immune Dysfunction in severe infections and Sepsis) prospective clinical study.</p><p><strong>Setting: </strong>Results of the PROVIDE study showed that patients with sepsis may be classified into three states of immune activation: 1) macrophage-activation-like syndrome (MALS) characterized by hyperinflammation, sepsis-induced immunoparalysis, and 3) unclassified or intermediate patients without severe immune dysregulation.</p><p><strong>Patients or subjects: </strong>Two hundred ten patients from 14 clinical sites in Greece meeting the Sepsis-3 definitions with lung infection, acute cholangitis, or primary bacteremia.</p><p><strong>Interventions: </strong>During our comparison, we did not perform any intervention.</p><p><strong>Measurements and main results: </strong>Untargeted metabolomics analysis was performed on plasma samples from 210 patients (a total of 1394 products). Differential abundance analysis identified 221 significantly different metabolites across the immune states. Metabolites were enriched in pathways related to ubiquinone biosynthesis, tyrosine metabolism, and tryptophan metabolism when comparing MALS to immunoparalysis and unclassified patients. When comparing MALS to unclassified, 312 significantly different metabolites were found, and pathway analysis indicated enrichment in multiple pathways. Comparing immunoparalysis to unclassified patients revealed only two differentially regulated metabolites.</p><p><strong>Conclusions: </strong>Findings suggest distinct metabolic dysregulation patterns associated with different immune dysfunctions in sepsis: the strongest metabolic dysregulation is associated with MALS.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":7.7,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142043871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}