Critical Care Medicine最新文献

Objectives: To identify and describe trajectories of functional status in children with repeated PICU admissions and to describe clinical and demographic characteristics of each trajectory.

Design: Retrospective, cross-sectional study.

Setting: Twenty-four U.S. PICUs participating in the Virtual Pediatric Systems, LLC database.

Patients: Patients younger than 21 years old discharged from an index admission between April 2017 and December 2020, followed through December 2022.

Interventions: None.

Measurements and main results: Functional status, a multidimensional marker of a child's physiologic and cognitive status, was measured using the Functional Status Scale (FSS). FSS scores were collected by trained abstractors to reflect pre-illness baseline and status at PICU discharge for each encounter. We performed latent trajectory analysis to examine longitudinal patterns in patient FSS categories and identify trajectory classes, with classes selected by the minimum Bayesian Information Criterion. We performed Kruskal-Wallis rank-sum test and chi-square testing to assess differences between groups. The analytic cohort included 6038 children with greater than 1 PICU encounter. Using a linear trajectory model, we identified six latent classes: three stable over time (good [46.6%], moderate [18.7%], and severe dysfunction [15.5%]), two with worsening over time (good/mild dysfunction with significant decline [7.9%], good/mild dysfunction with moderate decline [5.7%]), and one with improvement over time (mild dysfunction with improvement [5.6%]). In univariable analysis, trajectory classes differed based on age, race and ethnicity, diagnosis category, procedural exposure, severity of illness, and length of stay for the index admission. These associations were also present when assessed using multinomial regression and random forest classification.

Conclusions: In this multi-institutional database study using FSS scores to describe a contemporary, heterogeneous patient population with recurrent PICU-based observations of functional status, we identified six classes of outcome trajectories with different clinical and demographic characteristics.

Objectives: To determine whether treatment targeting improving tissue perfusion while allowing lower than recommended blood pressure (targeted tissue perfusion [TTP]) improves outcome compared with mean arterial pressure (MAP)-guided standard care (SC).

Design: A randomized, parallel-group, open-label clinical trial with 30-day follow-up. Allocation was stratified according to trial site and presence of chronic arterial hypertension.

Setting: Three European university hospital ICUs with enrollment from 2016 to 2022.

Patients: Two hundred nineteen patients with septic shock and blood lactate greater than 3 mmol/L allocated to TTP ( n = 111) vs. SC ( n = 108).

Interventions: The TTP protocol comprised capillary refill time, peripheral skin temperature, arterial lactate concentrations, and MAP 50-65 mm Hg. The SC protocol comprised the hemodynamic targets of 2012 Surviving Sepsis Campaign.

Measurements and main results: Ninety-seven (87.4%) in TTP and 97 (89.8%) in SC group (total n = 194) were analyzed for the primary outcome. The median (interquartile range) of days alive in 30 days with normal lactate and without vasopressor/inotropic drugs (primary outcome) was 23 (10-27) in TTP group and 22 (1-27) in SC group (difference in medians, 0.59; 95% CI, -3 to 4). Secondary outcomes (single components of the primary outcome, days alive without organ support and mortality, all at 30 d) and serious adverse reactions were not significantly different between intervention groups. At day 30, 24 patients (24.7%) in TTP group vs. 27 patients (27.8%) in SC group had died. MAP levels were lower in the TTP group vs. the SC group.

Conclusions: In ICU patients with septic shock and lactate greater than 3 mmol/L, targeting tissue perfusion and allowing lower than recommended MAP did not increase the number of days alive with normal lactate and without vasopressor/inotropic drugs at 30 days. No additional safety concerns with the TTP strategy were detected compared with SC.

Objectives: Acute kidney injury (AKI) occurs frequently in ICUs and is associated with poor outcomes. However, little is known about AKI in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Our aims were to identify real-world data on AKI in the early phase of intensive care, examine the relationship between AKI and outcomes, and identify factors contributing to the occurrence of AKI in patients undergoing ECPR for OHCA.

Design: A secondary analysis of the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan (SAVE-J II study), a retrospective multicenter study involving patients 18 years old or older who experienced OHCA and received ECPR between 2013 and 2018.

Setting: Thirty-six ICUs that participated in the SAVE-J II study in Japan.

Patients: Adult patients with OHCA of presumed cardiac etiology who received ECPR and were admitted to the ICU.

Interventions: None.

Measurements and main results: In this study, AKI was defined based on the Kidney Disease: Improving Global Outcomes criteria with regard to serum creatinine level during the 4 days after ICU admission. The primary outcome was in-hospital mortality, and the secondary outcome was an unfavorable neurologic outcome (Cerebral Performance Category scores of 3-5 at discharge). Among the 943 patients, AKI occurred in 66.9% ( n = 631). Multivariable analysis showed that AKI was significantly associated with in-hospital mortality (odds ratio [OR], 4.15; 95% CI, 3.05-5.66; p < 0.001) and with unfavorable neurologic outcomes (OR, 3.43; 95% CI, 2.42-4.87; p < 0.001). Furthermore, age, time course, pH level at hospital arrival, creatinine level at hospital admission, and blood pressure on ICU admission were significantly associated with the occurrence of AKI.

Conclusions: This large cohort study revealed that AKI was commonly observed during the early phase after ECPR for OHCA and was associated with in-hospital mortality and unfavorable neurologic outcomes.

Objectives: While potential risks for limb ischemia have been explored in studies of venoarterial extracorporeal membrane oxygenation (ECMO), they remain inadequately defined for patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). We identified risk factors for the development of lower limb ischemia during ECPR using a large nationwide ECPR cohort.

Design: A post hoc analysis was conducted using a nationwide, multicenter, retrospective study (Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan II [SAVE-J II]).

Setting: Thirty-six institutions from 2013 to 2018.

Patients: Adult patients who underwent ECPR for out-of-hospital cardiac arrest.

Interventions: None.

Measurements and main results: Lower limb ischemia was defined as the requirement for a therapeutic distal perfusion catheter (DPC), fasciotomy, or amputation. Risk factors for lower limb ischemia were assessed using multivariate logistic regression models that included patient characteristics, ECPR-related information, and resuscitation content as potential confounders. Of the 969 patients, 72 (7.4%) developed lower limb ischemia. No significant differences were observed regarding background characteristics, cannulation location, puncture method, or venoarterial ECMO catheter size between patients with and without limb ischemia. However, a prophylactic DPC was less frequently employed in patients with lower limb ischemia than in those without (4 [5.6%] vs. 219 [24.4%]; p < 0.001). Higher incidences of cannulation-related bleeding and cannula malposition were observed in patients with limb ischemia than in those in patients without limb ischemia (22 [30.6%] vs. 162 [18.1%]; p = 0.009 and 9 [12.5%] vs. 29 [3.2%]; p < 0.001, respectively). Multivariable analyses revealed that prophylactic DPC placement was associated with a lower risk of limb ischemia (0.20 [0.07-0.55]; p = 0.002), whereas cannulation-related bleeding and cannula malposition were linked to an increased risk of lower limb ischemia (1.83 [1.06-3.14]; p = 0.030 and 3.81 [1.68-8.64]; p = 0.001, respectively).

Conclusions: Lower limb ischemia during ECPR would be anticipated in patients with cannulation-related complications, and prophylactic DPC placement may be considered to mitigate the risk of lower limb ischemia.

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 Pao2/Fio2 of less than or equal to 150 mm Hg on Fio2 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 Pao2/Fio2 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 (Spo2)/Fio2 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 Spo2/Fio2 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.

Objectives: To evaluate evolving management, ICU admission, and outcomes for critically ill chimeric antigen receptor (CAR) T-cell patients over a 6-year period.

Design: Multicenter retrospective cohort study from January 2018 to September 2023.

Setting: Eight U.S. centers.

Patients: Adult CAR T-cell patients requiring ICU admission.

Interventions: None.

Methods: Summary statistics included mean, sd, median, and interquartile range (IQR). Fisher exact test or chi-square test were used to evaluate association between year treated and other categorical variables. Cochran-Armitage test was performed to assess significance of trends across years. Multivariable logistic regression was performed to assess covariates associated with mortality.

Measurements and main results: Demographics, toxicity management, ICU admission, support modalities, toxicity severity, and survival (ICU, hospital, and 3-mo) were compared year-to-year. From 2018 to 2023, 2238 patients received CAR T cells, with increasing number of patients treated yearly; 398 (17.8%) required ICU care. Of those admitted to the ICU, 66.1% were male, 89.2% had lymphoma, and median age was 64 years (53-71 yr). ICU admission rates declined from 38.5% (95% CI, 31.6-45.8%) in 2018 to 16.4% in 2023 (95% CI, 13.5-19.7%; p < 0.0001). Cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome was the reason for ICU admission in 87.9%. In 2023 vs. 2018, ICU patients were older (median, 65 yr [IQR, 55-73 yr] vs. 58 yr [48-67 yr]; p = 0.003) with higher comorbidity indices (4 [4-6] vs. 3 [2-4]; p = 0.005) and more severe toxicities (≥ grade 3: 90.1% vs. 69.9%; p = 0.004). Corticosteroid use for less severe toxicities (≤ grade 2 toxicity: 73.8% vs. 40.6%; p = 0.0001) and anakinra use (56% vs. 5.5%; p < 0.0001) increased throughout the years. Mortality from cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome remained low (5.5%). Age, Sequential Organ Failure Assessment greater than or equal to 10 at ICU admission, and ICU admission for noncytokine release/neurotoxicity syndrome reasons were associated with hospital mortality (odds ratios, 1.02 [95% CI, 1-1.04; p = 0.046], 4.69 [2.44-9.01; p < 0.0001], and 3.74 [1.91-7.3; p = 0.0001], respectively).

Conclusions: ICU admission rates after CAR T-cell treatment are declining. Although ICU patients are older with higher severity of illness and toxicity grades, ICU mortality after CAR T-cell therapy remains low.

Objectives: To examine how accurately ICU clinicians perceived family-reported prognostic expectations (FPEs) for patients with prolonged mechanical ventilation (PMV).

Design: A cross-sectional, exploratory design using secondary analysis.

Setting: Thirteen ICUs across five hospitals in the United States.

Subjects: Family members of patients with PMV and ICU clinicians, including physicians and nurses.

Interventions: None.

Measurements and main results: Latent profile analysis was used to identify profiles of accuracy in clinician perception of FPE, followed by bivariate analyses and multinomial logistic regression to examine associations between patient, family, and clinician characteristics and profile membership. A total of 554 participants (239 family members, 150 physicians, and 165 nurses) were included. Five distinct latent profiles of accuracy in clinician perception of FPE were identified: 1) clinician underestimation of FPE; 2) clinician overestimation of FPE; 3) accurate perception: low prognosis; 4) accurate perception: moderate prognosis; and 5) accurate perception: high prognosis. Families in profile 1 (clinician underestimation of FPE) were more likely to be spouses/partners of patients and reported higher levels of hope and optimism, whereas those in profile 2 (clinician overestimation of FPE) reported lower levels. Patient characteristics, including age, employment status, admission to medical ICU, and pulmonary-related hospital diagnosis, were statistically significantly associated with the profile membership.

Conclusions: Understanding how accurately clinicians perceive FPE is vital to improving shared decision-making and developing goal-concordant care for patients with PMV. Further research examining strategies for clinicians to accurately perceive what families believe about prognosis is needed to identify potential misalignment, initiate timely and empathetic conversations, and build toward shared decision-making and goal-concordant care.

Objectives: To evaluate the feasibility of randomizing children on extracorporeal membrane oxygenation (ECMO) to one of two prophylactic platelet transfusion thresholds.

Design: Randomized controlled trial.

Setting: Ten ECMO centers (nine in United States, one in Israel).

Patients: Critically ill children (0 to younger than 18 yr), supported on ECMO, with no or minimal bleeding within 24 hours of cannulation.

Interventions: Children were randomized to a higher platelet threshold (transfused when platelet count < 90 × 109/L) or a lower platelet threshold (transfused when platelet count < 50 × 109/L). Primary feasibility outcome was pre-transfusion platelet count to test for a difference between strategies. Primary safety outcome was progression to severe bleeding, severe clotting, and/or all-cause mortality.

Measurements and main results: Of 159 patients screened for eligibility, 77% (123/159) met eligibility criteria. Sixty-five percent (80/123) of caregivers were approached for consent. Consent was obtained in 63% (50/80). Enrolled children had a median age of 0.2 years (interquartile range 0.0; 1.7) and 88% (44/50) were supported by veno-arterial (V-A) ECMO. The model-adjusted mean difference in pre-transfusion platelet count between the groups was 32 × 109/L (p < 0.001). Compliance with assigned transfusion threshold was 99.2%. Eleven (22%) children experienced the primary safety outcome. Progression to severe bleeding occurred in 14% (7/50) of patients, whereas progression to severe clotting was observed in 4% (2/50).

Conclusions: Non-bleeding children on ECMO can be screened, enrolled and randomized to different platelet transfusion strategies within 24 hours of cannulation. Compliance with the protocol was excellent with significant separation in pre-transfusion platelet counts between the arms. Severe bleeding and severe clotting occurred at similar rates in both thresholds. A larger, definitive trial is feasible and needed.