Critical Care Medicine最新文献

Objectives: To explore the association between a prolonged emergency department (ED) length of stay and the deployment of process of care measures (e.g., low tidal volume ventilation) for critically ill patients.

Design: Retrospective cohort study.

Setting: Eight academic ICUs in Toronto.

Patients: Mechanically ventilated adult patients who were directly admitted to the ICU from the ED from June 2014 to February 2023.

Interventions: None.

Measurements and main results: The cohort was divided into a short ED stay group (i.e., < 6 hr) and a prolonged ED stay group (i.e., from 6 to 24 hr). We used propensity score methods and multivariable logistic regression models to estimate the association between a prolonged ED stay and the receipt of process of care measures on day 2 after ICU admission, adjusting for baseline characteristics. Associations were reported as odds ratios (ORs) and 95% CIs. We included 7072 patients, of whom 1462 (21%) had a prolonged ED stay. Both groups had comparable severity of illness at baseline. There was no difference in the deployment of processes of care measures on day 2 after ICU admission between the two groups. The adjusted OR for the prolonged ED stay group compared with a short ED stay group for each measure were as follows: low tidal volume ventilation 0.92 (95% CI, 0.68-1.22), spontaneous breathing trial 1.12 (95% CI, 0.92-1.35), extubation among those eligible 0.78 (95% CI, 0.55-1.12), deep vein thrombosis prophylaxis 1.13 (95% CI, 0.95-1.34), and continuous sedation 0.92 (95% CI, 0.81-1.06).

Conclusions: In this multicenter study of critically ill adult patients, a prolonged ED stay was not associated with a significant difference in the deployment of evidence-based process of care measures for critically ill adult patients.

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.

Objectives: To characterize the performance of an electronic health record (EHR) data-based classifier of persistent moderate-to-severe acute respiratory distress syndrome (ARDS).

Design: Retrospective observational study.

Setting: Six ICUs from two health systems.

Patients: We included adults receiving greater than or equal to 24 hours of invasive mechanical ventilation (IMV) with a Pa o2 /F io2 of less than or equal to 150 mm Hg on F io2 greater than or equal to 0.6 in the first 72 hours of IMV. We evaluated classifier performance in two temporally and geographically distinct cohorts: a development cohort including patients in one of two academic medical or three mixed community ICUs in the first 3 months of 2021 or in 2022-2023, and a validation cohort from a different academic medical ICU in 2017.

Interventions: None.

Measurements and main results: In both cohorts, study physicians assessed patients for clinical ARDS criteria. We retrospectively applied the EHR classifier, which required a persistent Pa o2 /F io2 of less than or equal to 150 mm Hg or receipt of interventions to address severe hypoxemia (i.e., prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators) in the 24 hours after initially meeting hypoxemia criteria. We also evaluated classifier definitions that used peripheral oxygen saturation (Sp o2 )/F io2 of less than or equal to 162 to indicate persistent hypoxemia. Of 924 patients in the development cohort, 504 (55%) had clinician-adjudicated ARDS. Of 90 patients in the validation cohort, 48 (53%) had clinician-adjudicated ARDS. In the development and validation cohorts, the primary EHR-based classifier identified 382 and 38 patients as having persistent moderate-to-severe ARDS, respectively (positive predictive value [PPV], 71%; 95% CI, 66-75% and PPV, 66%; 95% CI, 50-81%). When Sp o2 /F io2 was used as the second hypoxemia marker more patients were classified as ARDS in both development and validation cohorts but with lower PPVs (67% and 62%, respectively.).

Conclusions: An EHR-based classifier using readily available data had acceptable performance for identifying patients with persistent moderate-severe ARDS. This open-source tool could be used for retrospective or prospective identification of this vulnerable population for research and quality improvement initiatives.

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.

Objectives: To identify factors associated with short-term mortality among patients receiving microaxial flow pump (mAFP) therapy for acute myocardial infarction-related cardiogenic shock (AMI-CS).

Data sources: We searched four databases (MEDLINE, Embase, CENTRAL, and Scopus) from January 1, 2004, to January 1, 2025.

Study selection: We selected English-language studies that included adults with AMI-CS receiving mAFP and evaluated factors associated with short-term mortality. We excluded patients receiving concurrent venoarterial extracorporeal membrane oxygenation, as well as studies that solely included patients presenting with out-of-hospital cardiac arrest.

Data extraction: Two authors performed citation screening and data extraction. For each factor evaluated in at least two studies, we performed meta-analyses of adjusted odds ratios (aORs) using a random-effects model. Risk of bias was evaluated using the Quality in Prognosis Studies tool, and the certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations methodology.

Data synthesis: Our primary analysis included 18 studies, encompassing 20,617 patients. Median short-term mortality across studies was 50.7% (interquartile range 38.4-55.3%). Factors associated with short-term mortality based on high-certainty evidence included: increased age (aOR, 1.04 per year [95% CI, 1.03-1.05 per year] or ≥ 65 yr (aOR, 2.42 yr [95% CI, 0.77-7.64 yr]), female sex (aOR, 1.26 [95% CI, 1.09-1.45]), higher body mass index (aOR, 1.05 per point [95% CI, 1.04-1.07 per point]), higher heart rate (aOR, 1.02 per beats/min [95% CI, 1.01-1.02 per beats/min]), higher serum creatinine (aOR, 1.35 per mg/dL [95% CI, 1.08-1.70 per mg/dL]), mechanical ventilation (aOR, 2.53 [95% CI, 1.82-3.53]), vasopressors (aOR, 1.52 [95% CI, 1.11-2.08] for any vasopressors and aOR, 1.37 [95% CI, 1.18-1.58] per each vasopressor), presentation with ST-elevation myocardial infarction (aOR, 1.59 [95% CI, 1.11-2.26]), cardiac arrest (aOR, 2.85 [95% CI, 2.22-3.64]), and hypoxic-ischemic brain injury (aOR, 5.36 [95% CI, 3.03-9.47]).

Conclusions: We identified several prognostic factors associated with short-term mortality in AMI-CS patients receiving mAFP support. This work may help inform clinicians, patients, and families regarding utilization of mAFP in AMI-CS.

Rationale: Efficient distribution of scarce critical care resources is essential to save the most lives in times of crisis. Evidence-based practices and processes enhance clinical decision-making.

Objectives: The objective of these guidelines was to develop evidence-based, rather than expert-based, recommendations for triaging critically ill patients eligible for ICU admission during times of crisis-level shortages in ICU capacity.

Design: The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel, comprising doctors in medicine, nursing, and law; advanced practice providers; respiratory therapists; ethicists; and patient/family representatives. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting.

Methods: The panel members identified and formulated five fundamental Patient, Intervention, Comparator, and Outcomes questions. The panel conducted a systematic review for each question to identify the best available evidence, analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional guidance.

Results: The panel generated one conditional recommendation and five no recommendation statements.

Conclusions: Crisis-level shortages significantly disrupt patient care. Despite the role of triage in minimizing adverse outcomes, there is a lack of evidence, as opposed to expert opinion, to guide practice recommendations in the critical clinical scenarios considered by the panel.

Objectives: To compare the effectiveness of histamine-2 receptor antagonists (H2RAs) vs. proton pump inhibitors (PPIs) for stress ulcer prophylaxis on the occurrence of upper gastrointestinal bleeding (UGIB) and other clinical outcomes in hospitalized patients with septic shock.

Design: Retrospective, multicenter, propensity-weighted cohort study.

Setting: Conducted across 220 geographically diverse community and teaching hospitals in the United States.

Patients: Adult patients (age ≥ 18 yr) with septic shock who were initiated on either H2RAs or PPIs on the day of hospital admission.

Interventions: H2RAs (famotidine) or PPIs (pantoprazole, omeprazole, esomeprazole, or lansoprazole).

Measurements and main results: The primary outcome was the occurrence of UGIB during hospitalization. Secondary outcomes included in-hospital mortality, ventilator-associated pneumonia, Clostridioides difficile infection, and hospital length of stay. Propensity scores with inverse probability of treatment weighting (IPTW) were used to control for confounding. Among 15,102 patients (5,492 H2RA, 9,610 PPI), the mean age was 65.8 ± 14.9 years, 47.8% were female, and 58.1% received invasive mechanical ventilation during hospitalization. After IPTW adjustment, PPI use was associated with a lower occurrence of UGIB compared with H2RA (odds ratio [OR], 0.78; 95% CI, 0.64-0.96; p = 0.016). A sensitivity analysis comparing famotidine to pantoprazole confirmed this finding (OR, 0.80; 95% CI, 0.65-0.97; p = 0.025). No significant differences were observed in in-hospital mortality (OR, 0.98; 95% CI, 0.91-1.06; p = 0.691), ventilator-associated pneumonia (OR, 0.93; 95% CI, 0.83-1.04; p = 0.188), C. difficile infection (OR, 1.32; 95% CI, 0.82-2.13; p = 0.246), or hospital length of stay (incidence rate ratio, 1.01; 95% CI, 0.98-1.05; p = 0.417).

Conclusions: In this large, diverse cohort of U.S. hospitalized adults with septic shock, PPI use for stress ulcer prophylaxis was associated with a significantly lower occurrence of UGIB compared with H2RA, with no significant differences in mortality, ventilator-associated pneumonia, C. difficile infection, or hospital length of stay.

Objectives: To summarize knowledge and identify gaps in evidence regarding the effects of vasoactive medications on microvascular perfusion in septic shock.

Data sources: We conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials.

Study selection: Studies included adult patients with septic shock who received vasoactive therapy with corresponding microcirculatory measurements between 1946 and May 7, 2025.

Data extraction: Data extraction was performed in Covidence by two independent reviewers. Data items included study design, patient population, vasoactive medication, macrohemodynamics, and microcirculation measurements and techniques.

Data synthesis: Thirty-three studies were included evaluating several vasoactive medications and microvascular measurement techniques. Despite heterogeneous study design, studies that recruited patients within 24 hours tended to report more significant microcirculatory changes. Microcirculatory changes and cardiac index only aligned in 39% of cases, highlighting a disconnect between global hemodynamics and microvascular perfusion. Several vasoactives, including norepinephrine, vasopressin, terlipressin, and levosimendan demonstrated context-dependent improvements in peripheral/sublingual microcirculation. Despite limitations in directly monitoring gastric microcirculation, dobutamine may enhance perfusion; however, further studies are needed to support dobutamine and other vasoactive agents' impacts on clinical outcomes.

Conclusions: Despite growing interest in perfusion-guided care, significant challenges remain in understanding how vasoactive agents affect the microcirculation. Clarifying these effects through standardized research and point-of-care perfusion monitoring remains a challenge in advancing outcome-driven resuscitation strategies.