Critical Care Medicine最新文献

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 review the systems of care, logistics, staffing considerations, and best practices to facilitate safe interhospital transfer of critically ill patients with cardiac pathology.

Data sources: Publications were identified using a Medline search using terms related to interhospital transfer, systems of care, published guidelines, and cardiac conditions.

Study selection: A screening and shortlisting process was carried out by three of the authors to identify relevant studies, case reports, and guidelines.

Data extraction: Data from relevant articles were qualitatively evaluated.

Data synthesis: The interhospital transfer of critically ill cardiac patients presents significant clinical and logistical challenges. These patients benefit from access to specialized care but require meticulous physiologic management during transport and are at risk of deterioration. Structured communication systems, telemedicine, and specialized critical care transfer teams enhance patient selection, pre-transfer optimization, and in-transit management. The use of mechanical circulatory support devices, such as intra-aortic balloon pumps and microaxial flow pumps, adds further complexity.

Conclusions: Despite the high-acuity nature of these transfers, evidence from case series and observational studies demonstrates that, with appropriately trained teams and rigorous protocols, critically ill cardiac patients can be safely transported between facilities. This review highlights the importance of structured protocols, telemedicine, and specialized transport teams.

Objective: Severe infections can lead to substantial reductions in T cell counts, yet its prognostic relevance and potential cytokine-mediated mechanisms remain poorly defined in pediatric populations. This study aimed to investigate whether T cell counts are associated with mortality, and to what extent this association is mediated by circulating cytokines.

Design: Prospective cohort study.

Setting: A 55-bed PICU.

Patients: Children 28 days to 18 years old admitted to the PICU due to infections, excluding those with preexisting conditions known to potentially impact T cell counts.

Interventions: None.

Measurements and main results: A total of 252 patients were enrolled, with a median age of 4.16 years (interquartile range: 1.18-7.73), and 56.35% were male. CD3+ T cell count was nonlinearly associated with mortality (p overall = 0.027; p nonlinear = 0.013), with a risk plateau beyond the inflection point at 705.14 cells/μL in restricted cubic spline models. The lower T cell group had markedly increased 30-, 60-, and 90-day mortality (p < 0.05). Kaplan-Meier analysis showed that patients in the lower T cell group had significantly higher mortality (p = 0.011). Multivariable Cox models confirmed an independent association between low T cell group and increased mortality risk, with a hazard ratio of 2.62 (95% CI, 1.12-6.14) for 90-day mortality. Mediation analysis showed that platelet-derived growth factor (PDGF)-AA mediates a substantial portion of this effect, accounting for 71.19% of the total pathway.

Conclusions: Early T cell depletion independently predicts mortality in critically ill children with severe infections. These findings support the prognostic value of early immune profiling and suggest a potential immunoregulatory role for PDGF-AA.

Objective: Volatile anesthetics (VAs) are gaining renewed interest as a sedation strategy in the intensive care, offering an alternative to traditional IV agents. VAs provide several pharmacologic advantages, including rapid onset and offset, minimal systemic metabolism, and favorable recovery profiles. Advances in delivery systems enabled the safe and practical administration of volatile agents in the ICU. Thus, we aimed to describe the pharmacology and safety aspects of inhaled agents as well as the systems designed to deliver VAs in the ICU.

Data sources: Relevant literature was identified through PubMed and MEDLINE databases.

Study selection: Original research, review articles, commentaries, and guidelines addressing safety, efficacy, and use of VAs in adult ICU patients were included.

Data extraction: Studies were reviewed by the authors, with key findings summarized and organized by pharmacologic properties, delivery systems, and safety domains.

Data synthesis: VAs are halogenated hydrocarbons whose mechanism of action is not fully understood. Although the CNS is the primary site of action, the end-tidal concentration of exhaled anesthetic is used to monitor clinical effects such as immobility to a noxious stimulus. Inhaled agents have unique pharmacokinetics, minimal metabolisms, and distinct recovery. The side effect profile is also unique, with malignant hyperthermia being the most feared, yet rare complication. Two systems for inhalational sedation delivery are available internationally, with one currently under evaluation in the United States. The systems are composed of a miniature vaporizer, delivery controller, and a monitor. The systems have distinct safety considerations, such as tidal volume limits.

Conclusions: VAs can be used as sedative agents in the ICU. This article comprehensively reviews the pharmacology of VAs along with their safety profile and describes the structure and function of miniature vaporizers currently available on the world market.

Objectives: Venovenous extracorporeal membrane oxygenation (ECMO) represents a standard and well-accepted modality of treating patients with refractory respiratory failure. Nevertheless, some patients might develop refractory hypoxemia, hemodynamic compromise or end-organ perfusion requiring a change. This study analyzed characteristics and outcomes of patients requiring a change from venovenous to a different ECMO configuration.

Design: Multicenter, retrospective, observational analysis of the Extracorporeal Life Support Organization Registry (2010-2020) in adult patients (≥ 18 yr old) underwent venovenous ECMO as initial cannulation strategy.

Setting and patients: Comparison of patients who remained on venovenous ECMO vs. those who underwent configuration conversion and multivariable analysis to assess variables associated with configuration change.

Interventions: None.

Measurements and main results: Among 28,888 eligible venovenous ECMO runs, 702 (2.4%) received a change from the original configuration, including 399 (56.8%) conversions to venoarterial and 303 (43.2%) to hybrid ECMO configurations. Variables associated with conversion included: pre-ECMO cardiac conditions, bridge to lung transplant as indication, use of milrinone, epinephrine, sildenafil, bicarbonate, and 24-hour Pao2 value. Conversion occurred at a median of 56 hours (interquartile range, 11.5-210 hr) after ECMO initiation, with earlier conversion to hybrid configuration. Increased rates of cardiovascular, hemorrhagic, vascular, renal, metabolic, infective, and circuit-related complications were reported in converted patients. In-hospital mortality was higher in converted patients (60.8%) overall, and highest for venovenous to venoarterial patients (63.2%).

Conclusions: The venovenous patients converted to other ECMO configurations were 2.4% and experienced higher complication and mortality rates. Variables associated with conversion highlight the importance of initial configuration selection and should be considered as part of the risk stratification framework when evaluating a patient for individualized ECMO support mode/configuration.

Objectives: To evaluate the prognostic accuracy of glial fibrillary acidic protein (GFAP) levels in predicting poor neurologic outcomes in adult patients after cardiac arrest, across different post-resuscitation timepoints.

Data sources: PubMed, Scopus, Web of Science, and Google Scholar were systematically searched up to June 12, 2025.

Study selection: Eligible studies included randomized controlled or observational studies enrolling adult or pediatric patients with in- or out-of-hospital cardiac arrest who achieved return of spontaneous circulation (ROSC), measured GFAP in any biofluid, and reported neurologic outcomes.

Data extraction: Three independent reviewers extracted data on study design, population, arrest characteristics, GFAP sampling methods, outcome definitions, and prognostic performance. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Data synthesis: Twenty studies were included in the systematic review; 12 contributed to meta-analyses. Median GFAP levels were significantly higher in patients with poor neurologic outcomes at 24 hours (Δ = 138.1 pg/mL), 48 hours (Δ = 471.1 pg/mL), and 72 hours (Δ = 745.7 pg/mL) post-ROSC. Summary area under the curve values for prognostic accuracy improved over time: 0.76 at 24 hours, 0.84 at 48 hours, and 0.88 at 72 hours. Subgroup analyses limited to 6-month outcomes and out-of-hospital arrests showed consistent results. Quality assessment revealed low applicability concerns but moderate risk of bias in patient selection and flow/timing.

Conclusions: GFAP demonstrates time-dependent prognostic utility in predicting poor neurologic outcomes after cardiac arrest in adults, with optimal performance at 48-72 hours post-ROSC. These findings support suggest that GFAP shows potential as a time-dependent biomarker but remains investigational. Further prospective studies are needed to validate its clinical utility and to determine standardized cutoff values before routine implementation.

Objectives: We know little of the impact that pre-critical illness physical function plays in the recovery from critical illness. The agreement between patients and surrogates on physical function questionnaires is unclear.

Design, setting, and patients: Prospective observational cohort conducted at a tertiary medical center. We enrolled patient-participants who were treated for respiratory failure, shock, and/or sepsis and their well-chosen surrogates.

Interventions: None.

Measurements and main results: We assessed patient-participant physical function anchored on the 4 weeks before admission using the virtual Short Physical Performance Battery (vSPPB); Strength, Assistance in Walking, Rising from a Chair, Climbing Stairs, Falls (SARC-F) questionnaire; and Fatigue, Resistance, Ambulation, Illness, and Loss of weight (FRAIL) questionnaire completed by both patient and surrogate participants. The primary outcome was agreement between patient and surrogate responses on composite scores from each questionnaire. Secondary outcomes included correlations between patient and surrogate responses, and the relationship between surrogate and patient responses. We enrolled 75 patient-surrogate dyads. Patient-participants had a median (interquartile range) age of 61 (52-69), a Charlson Comorbidity Index of 2 (1-2), and a baseline activities of daily living disability score of 3 (1-7). Most surrogates were spouses (68%), who spent an average of 20 hours per day (12-24 hr/d) with patients. We found fair agreement between patient and surrogate scores on the vSPPB (intraclass correlation coefficient [ICC], 0.52; 95% CI, 0.31-0.69), SARC-F (ICC, 0.43; 95% CI, 0.22-0.60), and FRAIL (ICC, 0.45; 95% CI, 0.24-0.63). We found moderate correlation between patient and surrogate scores on the vSPPB, SARC-F, and FRAIL (Spearman r 0.60, 0.46, and 0.53, respectively [p < 0.001]).

Conclusions: We found fair agreement and moderate correlation on previously validated self-report questionnaires of physical function. Patients reported better function than their surrogates particularly at lower levels of function. Our findings highlight the need for further development of tools to assess pre-critical illness physical function.

Objectives: The evidence supporting the use of noninvasive positive pressure ventilation (NPPV) during severe asthma exacerbations is limited. We determined the annual trend in NPPV use, endotracheal intubations, and in-hospital mortality among all hospitalizations for an asthma exacerbation. We additionally evaluated the association between NPPV use and subsequent endotracheal intubation and in-hospital mortality.

Design: Retrospective, propensity-score-matched cohort study.

Setting: Administrative data from Healthcare Cost and Utilization Project's State Inpatient Databases for New York and Florida, 2006-2019.

Patients: Patients 5-80 years old hospitalized with an asthma exacerbation.

Interventions: Receipt of NPPV.

Measurements and main results: Among 296,788 hospitalizations for an asthma exacerbation between 2006 and 2018, NPPV use for an asthma exacerbation increased from 1.2% to 7.4% (absolute difference, 6.1%; 95% CI, 5.6-6.7%) in adults and from 0.7% to 7.1% (absolute difference, 6.4%; 95% CI, 5.5-7.3%) in pediatric patients. Among 41,902 ICU encounters, we propensity-score matched 1,972 adult and 1,622 pediatric patients who received NPPV with 6,510 adults and 4,766 pediatric patients who did not receive NPPV. NPPV use was associated with a decreased risk of subsequent intubation (risk ratio [RR], 0.48; 95% CI, 0.40-0.57) and improved in-hospital mortality (RR, 0.33; 95% CI, 0.21-0.54) in adults. In pediatric patients, use of NPPV was associated with a decreased risk of intubation (RR, 0.50; 95% CI, 0.29-0.89), but not significant for an improvement in in-hospital mortality (RR, 0.41; 95% CI, 0.15-1.11).

Conclusions: NPPV use for asthma exacerbations has increased. In adult and pediatric patients, NPPV use for an asthma exacerbation was associated with a decreased risk of endotracheal intubation. Furthermore, NPPV use for an asthma exacerbation was associated with improved in-hospital mortality in adult patients.