Critical Care Medicine最新文献

Objectives: Concise definitive review of anemia of critical illness.

Data sources: Available literature on PubMed and MEDLINE databases.

Study selection: Available preclinical studies, clinical trials, observational studies addressing the diagnosis, pathophysiology, and treatment of anemia of critical illness were included.

Data extraction: Eligible studies were identified, and recommendations were summarized.

Data synthesis: Anemia of critical illness is highly prevalent, persists after ICU discharge and is associated with adverse outcomes. Most ICU patients have anemia of inflammation (high hepcidin, low erythropoietin, low erythroferrone, iron-restricted erythropoiesis) or iron deficiency anemia (low hepcidin). Dysregulation of iron homeostasis can also lead to the release of nontransferrin bound iron (catalytic iron), which catalyzes reactive oxygen species and is associated with organ failure in ICU patients. With significant advances in the understanding of the pathophysiology of anemia in the critically ill, new approaches to anemia management have emerged. Patient blood management, involving an evidence-based multidisciplinary approach with early diagnosis and diagnosis-specific treatment of anemia, optimizing hemostasis, and blood conservation including phlebotomy reduction, has become an increasingly important approach to patient care and represents a strategy that can result in improved patient outcomes in the critically ill.

Conclusions: The high prevalence of anemia in ICU patients warrants a decisive shift from RBC transfusion as treatment to early proactive pathophysiology-based personalized treatment of anemia.

Objectives: Candida species are one of the most common causes of ICU-onset bloodstream infection (BSI). Yet, there is no robust guidance on when to initiate empiric antifungals for ICU patients suspected of BSI. We compared patients with ICU-onset candidemia vs. ICU-onset bacteremia to determine which patients may benefit from empiric antifungals.

Design: We compared characteristics between patients with bacteremia vs. candidemia at time of culture. We determined risk factors for death and constructed a multivariable regression to determine if candidemia is an independent risk factor for death.

Setting/patients: We included ICU patients from a hospital system in Houston, Texas (n = 8 hospitals) with a BSI from 2016 to 2023 and validated our findings using ICU patients with a BSI in the publicly available Medical Information Mart for Intensive Care (MIMIC)-IV cohort.

Interventions: None.

Measurements and main results: Of 1509 total patients in our primary cohort, 290 (19.2%) had candidemia and 1219 (80.8%) had bacteremia. Patients with candidemia were more likely to be on invasive mechanical ventilation (72.8% vs. 52.8%; p < 0.001), vasopressors (39.3% vs. 24.0%; p < 0.001), and continuous renal replacement therapy (15.2% vs. 9.4%; p = 0.006) at the time of culture. They contracted infection later in ICU stay than bacteremia patients (7.2 vs. 5.0 d; p < 0.001) and were more likely to die within 30 days of culture (unadjusted odds ratio [OR], 1.62; 95% CI, 1.25-2.09). After adjusting for ICU interventions (invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy) and baseline parameters, candidemia was not independently associated with mortality compared with bacteremia in our primary cohort (OR, 1.21; 95% CI, 0.92-1.60) but was in the MIMIC-IV cohort (OR, 1.48; 95% CI, 1.003-2.17).

Conclusions: Patients with significant ICU resource utilization are at increased risk for candidemia. Our data suggest that when initiating empiric antibiotics in patients requiring high-resource ICU care, empiric antifungal therapy should be considered.

Objectives: Most ICUs use protocolized magnesium supplementation, yet the clinical effect of this practice is unknown.

Design: Pseudo-randomized retrospective study comparing patients who were and were not assigned to receive magnesium supplementation, using a protocol where supplementation occurs when serum levels are less than or equal to 0.95 mmol/L (2.31 mg/dL). Primary outcome was atrial fibrillation or flutter within 24 hours. Secondary outcomes were tachyarrhythmia (supraventricular tachycardia or ventricular arrhythmia) and death within 24 hours.

Setting: ICUs with a shared magnesium supplementation protocol, in five hospitals in Ontario, Canada, from January 1, 2022, to December 31, 2024.

Patients: Adults (18 yr old or older) admitted to ICU with a magnesium protocol order, at their first magnesium level of 0.92-0.99 mmol/L (2.24-2.41 mg/dL). To minimize confounding, we included only patients with a level near the supplementation threshold.

Interventions: None.

Exposure: Magnesium level 0.92-0.95 mmol/L (2.24-2.31 mg/dL, supplementation group) vs. 0.96-0.99 mmol/L (2.32-2.41 mg/dL, no supplementation group).

Measurements and main results: We identified 4198 patients; median age 70 years, 41% female, 39% invasively ventilated; 2144 (51%) in the supplementation group, of whom 77% received magnesium, and 2054 (49%) in the no supplementation group, of whom 9% received magnesium. Atrial fibrillation or flutter occurred within 24 hours in 355 (16.6%) in the supplementation group and 375 (18.3%) in the no supplementation group. Bayesian logistic regression, adjusted for hospital, showed a 1.6% absolute risk reduction associated with supplementation (95% credible interval, 3.8% reduction to 0.8% increase; probability of reduction, 0.91). For the composite outcome of atrial fibrillation and flutter, tachyarrhythmia, and death, the absolute risk reduction associated with supplementation was 2.2% (CrI, 4.3% reduction to 0.1% increase; probability of risk reduction, 0.97).

Conclusions: Protocolized magnesium supplementation at a threshold of 0.95 mmol/L (2.31 mg/dL) may be associated with reduced 24-hour incidence of atrial fibrillation and flutter in critically ill patients.

Objectives: The overall goal of this work is to discuss the various topics associated with critical care advanced practice provider (APP) postgraduate training programs and provide resources for new, developing and existing programs.

Design: Three rounds of voting until consensus achieved.

Setting: Electronic surveys, followed by virtual meeting.

Subjects: Critical care APPs, physicians, a pharmacist, and a nurse were also included to ensure multidisciplinary representation. All subjects resided and practiced in the United States with a history of education scholarship or post-graduate training leadership.

Interventions: None.

Measurements and main results: The workgroup included 14 APPs (ten nurse practitioners and four physician associates), three physicians, one pharmacist, and one registered nurse from 14 institutions across the United States. The workgroup identified six areas of concentration: administration, audience, program structure, curriculum, procedural competence, and accreditation. A survey was generated and employed in three rounds. The first two rounds of voting were completed anonymously, the third round was completed as a live meeting until consensus recommendations, defined as 75% agreement or more, were achieved.

Conclusions: Expert consensus was used to generate consensus recommendations for critical care postgraduate training programs based upon 3 rounds of voting.

Objectives: Sepsis survivors worldwide face a high risk of death after hospitalization. In sub-Saharan Africa, where nearly 40% of all sepsis cases occur, post-discharge mortality is a major contributor to poor sepsis outcomes. In this context, stratification of sepsis survivors at high risk for post-discharge mortality is needed to guide targeted follow-up care. We sought to determine the performance of Karnofsky Performance Status (KPS)-based risk stratification for predicting post-discharge mortality among adults surviving sepsis hospitalization in Uganda.

Design: Analysis of two prospective observational cohorts in Uganda.

Setting: Two public hospitals in Entebbe and Tororo, Uganda.

Patients: Adults (≥ 18 yr) hospitalized with sepsis, defined by signs of infection and quick Sepsis-related Organ Failure Assessment score greater than or equal to 1, who were discharged or transferred alive from the hospital.

Interventions: None.

Measurements and main results: KPS was assessed on the day of discharge or transfer by study clinicians. Vital status was ascertained at 30 and 60 days post-discharge in the Entebbe ( n = 217) and Tororo ( n = 251) cohorts, respectively. In both cohorts, higher KPS scores at discharge or transfer were significantly associated with reduced odds of post-discharge mortality after adjustment for demographics, inpatient physiologic severity, high-burden co-infections and duration of hospitalization (adjusted odds ratios, 0.95 [95% CI, 0.93-0.98] and 0.96 [95% CI, 0.94-0.98] in Entebbe and Tororo, respectively). Adding KPS to a baseline risk model including the above variables significantly improved post-discharge mortality prediction in both cohorts; predictive discrimination and calibration were also improved.

Conclusions: KPS assessed at hospital discharge significantly improves prediction of post-discharge mortality among acute sepsis survivors in sub-Saharan Africa. Incorporating KPS into discharge planning may help guide targeted interventions to improve sepsis survivorship in low- and middle-income countries.

Due to its nonspecific clinical criteria, sepsis is clinically, microbiologically, pathophysiologically and immunologically highly heterogeneous. Consequently, despite hundreds of clinical trials, no host-targeted therapy has been shown to be ubiquitously efficacious, leading investigators to pursue more precision-based approaches for enriching sepsis populations through the identification of subgroups or phenotypes. Here, we review the myriad domains in which heterogeneity is observed in sepsis and the challenges and opportunities they offer to improve outcomes. We review current strategies used by investigators leveraging novel biological measurements and/or computational algorithms to identify more homogeneous subgroups either based on pathogen or host characteristics or both. Finally, we review some of the most promising recent advances that seek to bring these complex and innovative discoveries to the bedside to facilitate precision medicine in sepsis.

Objective: Determine the lowest level of functional recovery after severe traumatic brain injury (TBI) that is perceived to be acceptable by persons with TBI and TBI caregivers.

Design: Cross-sectional crowdsourcing online survey disseminated May-July 2024.

Setting: United States.

Subjects: Persons with a history of TBI requiring assistance with basic daily activities and TBI caregivers.

Interventions: None.

Measurements and main result: We developed an expanded version of the Glasgow Outcome Scale-Extended to determine the acceptability of 11 TBI outcome milestones and identify the minimally acceptable outcome (MAO). The survey was completed by 252 persons with TBI (mean [ sd ] 39.8 [13.5] yr old; 67% female; 75% White; 11.9 [12.0] yr post-TBI) and 256 TBI caregivers (41.0 [12.1] yr old; 57% female; 65% White). Among the outcomes selected most frequently as the MAO by persons with TBI ("recovery of basic yes/no communication" and "conscious, but does not communicate") and TBI caregivers ("recovery of basic yes/no communication" and "alive, but permanently unconscious"), recovery of yes/no communication was rated as acceptable by more respondents (persons with TBI: 36% vs. 12%; Z = -7.1, p < 0.0001; TBI caregivers: 40% vs. 14%; Z = -7.1, p < 0.0001). Recovery of communication was therefore identified as the MAO by both cohorts. This outcome was rated as acceptable or somewhat acceptable by 65% of persons with TBI and 72% of caregivers. All outcomes ranging from "alive, but permanently unconscious" to "partially independent in the home" were selected as the MAO significantly more frequently than "completely independent in the home," a common "favorable" recovery cutoff.

Conclusions: Persons with TBI and TBI caregivers identified recovery of communication as the MAO. Persons with lived experience appear more accepting of a greater burden of disability than TBI investigators and providers. Recognizing this disparity in perspectives may influence clinical decision-making regarding goals of care and suggests the need for a more person-centered approach to TBI outcome assessment.