Critical Care Medicine最新文献

Objectives: Evaluate the predictive and prognostic performance of the Phoenix Sepsis Criteria (PSC) and Phoenix Sepsis Score (PSS) compared with International Pediatric Sepsis Consensus Conference (IPSCC) criteria and other organ dysfunction scores in children admitted to the PICU with suspected infection.

Design: Multicenter, prospective cohort study.

Setting: Eight PICUs within the Italian Network of PICU Study Group (TIPNet).

Patients: Patients younger than 18 years admitted with suspected infection (from February 2022 to April 2024).

Interventions: None.

Measurements and main results: Vital signs, organ dysfunction markers, and organ support requirements were collected during day 1 and day 2 of PICU admission. Sepsis was assessed using IPSCC criteria and PSC. IPSCC Severe Sepsis, PSS, Phoenix-8, Pediatric Logistic Organ Dysfunction-2 (PELOD-2), pediatric Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Score were calculated as organ dysfunction scores. Sepsis criteria predictive performance was assessed using sensitivity and positive predictive value (PPV). Organ dysfunction scores prognostic performance was assessed using the area under the precision-recall curve (AUPRC). Primary outcome was PICU mortality. Among 687 patients, PSC showed higher predictive performance than IPSCC sepsis criteria, with improved sensitivity and PPV for mortality on day 1 (PSC: sensitivity, 96.4%; 95% CI, 95.0-97.8%; PPV, 7.6%; 95% CI, 5.6-9.6% and IPSCC: sensitivity, 82.1%; 95% CI, 79.3-85.0%; PPV, 6.2%; 95% CI, 4.4-8.0%) and day 2 (PSC: sensitivity, 100.0%; 95% CI, 100.0-100.0%; PPV, 10.0%; 95% CI, 7.6-12.5% and IPSCC: sensitivity, 75.0%; 95% CI, 71.5-78.5%; PPV, 9.0%; 95% CI, 6.7-11.3%). PELOD-2 exhibited the highest AUPRC for mortality (day 1, 0.45; 95% CI, 0.26-0.63 and day 2, 0.59; 95% CI, 0.38-0.77). IPSCC Severe Sepsis score was outperformed by all other organ dysfunction scores, including PSS and Phoenix-8. All prognostic performances improved from day 1 to day 2.

Conclusions: PSC and PSS performed superior to IPSCC criteria in diagnosing and prognosticating pediatric sepsis, with improved performance at day 2 of PICU admission. This study first validated PSC and PSS in a European cohort.

Objectives: Despite advances in critical care medicine, many questions remain unanswered, and existing guidelines are often based on low-quality evidence. This priority setting partnership (PSP), following the James Lind Alliance (JLA) methodology, aimed to identify the top ten research priorities for critical care medicine in Canada based on input from patients, families, and healthcare providers.

Design: Three-phase, national, JLA PSP.

Setting: Canada-wide, involving adult and PICUs.

Subjects: Patients with lived experience of critical illness, family members of ICU patients, and healthcare providers (physicians, nurses, and allied health professionals).

Interventions: None.

Measurements and main results: Participants contributed uncertainties through open surveys (phase 1), ranked questions through a national survey (phase 2), and achieved consensus on the final priorities during a virtual workshop (phase 3). Phase 1 included 154 respondents (44 patients/family members, 110 healthcare providers) submitting 509 in scope questions, resulting in 64 unique indicative questions. Phase 2 included 244 participants (63 patients/families, 191 healthcare providers), prioritizing 20 questions to advance to the final workshop. Phase 3 involved 24 individuals (12 with lived experience, 12 healthcare providers) from six provinces, who reached consensus on the top ten research priorities. Briefly, the top three priorities were: 1) improving physical, cognitive, and mental health outcomes post-ICU/PICU; 2) supporting goals-of-care conversations with families; and 3) characterizing short- and long-term post-ICU outcomes and predictors. The full top ten priorities are presented in the article.

Conclusions: This national JLA PSP identified the top ten patient, family, and healthcare provider-driven research priorities for critical care medicine in Canada. These priorities aim to guide future research that is meaningful, inclusive, and evidence-informed.

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.

Objectives: Establishing an effective "chain of survival" for out-of-hospital cardiac arrest (OHCA) requires addressing gender disparities, which have been reported in both prehospital and in-hospital treatments. However, evidence of gender disparity in extracorporeal cardiopulmonary resuscitation (ECPR), which might contribute to differences in outcomes between sexes, remains limited. We aimed to investigate gender disparities in the administration of ECPR for OHCA.

Design: A secondary analysis of a prospective nationwide database.

Setting: The Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry, a multicenter database from 164 hospitals with emergency departments in Japan, collected data between June 2014 and December 2022.

Patients: Adult patients (≥ 18 yr) with OHCA from nonexternal causes who did not achieve return of spontaneous circulation before or upon hospital arrival and were transported to facilities with 24-hour ECPR availability within 60 minutes of emergency call.

Interventions: None.

Measurements and main results: The primary outcome was receiving ECPR, defined as emergent venoarterial extracorporeal membrane oxygenation implementation before return of spontaneous circulation within 60 minutes after hospital arrival. Multilevel logistic regression analysis was used to estimate the probability of receiving ECPR, adjusting for center-level and patient-level variables. Among 47,965 eligible patients, 28,754 (60.0%) were male and 19,211 (40.0%) were female. The median age was 78.0 years. ECPR was performed in 1713 male patients (6.0%) compared with 344 female patients (1.8%). After adjusting for potential confounders, male sex was associated with significantly higher odds of receiving ECPR (odds ratio, 1.68; 95% CI, 1.46-1.93). This male predominance was consistent across most subgroups but was not observed in patients with unequivocally eligible or ineligible for ECPR.

Conclusions: ECPR was significantly more frequently performed in male patients with OHCA. Subgroup analyses suggest that gender disparity is particularly evident in cases where indications for ECPR are not clearly defined. Further research is needed to explore the underlying causes of this disparity.

Objectives: To evaluate whether remimazolam besylate could provide noninferior sedation to dexmedetomidine in patients under mechanical ventilation (MV) in the ICU.

Design: A multicenter, single-blind, randomized, noninferiority trial.

Setting: Fifteen ICUs across China between October 2021 and November 2023.

Patients: Adults under endotracheal intubation MV who were expected to require sedation for 8-48 hours.

Interventions: Three hundred fourteen patients were randomly assigned at a 1:1 ratio to the remimazolam besylate or dexmedetomidine group. Analgesia was provided via a continuous IV infusion of remifentanil at 1.2-9.0 µg/kg/hr. Remimazolam besylate or dexmedetomidine was administered IV at an initial loading dose of 0.1 mg/kg followed by a maintenance dose of 0.10-0.30 mg/kg/hr or at an initial loading dose of 0.20 µg/kg followed by a maintenance dose of 0.2-0.70 µg/kg/hr to achieve the targeted sedation range on the Richmond Agitation-Sedation Scale of -2 to +1.

Measurements and main results: Of the 314 patients enrolled, 299 completed the study. The sedation efficacy rates, as the primary endpoint, were 82.6% and 83.2% in remimazolam besylate and dexmedetomidine groups, respectively, in the per-protocol set (PPS), whereas the rate was 72.9% in both groups in the intention-to-treat (ITT) set. The noninferiority margin was set as 10%, and the lower limits of the two-sided 95% CI for the intergroup difference were -3.0% and -2.6% in the PPS and ITT sets, respectively. The dexmedetomidine group had a higher incidence of bradycardia than the remimazolam besylate group (4.7% vs. 0.7%; p = 0.029), whereas no intergroup differences were noted for the remaining secondary endpoints and adverse events.

Conclusions: Remimazolam besylate could provide noninferior sedation as dexmedetomidine with a lower risk of bradycardia for 48 hours in mechanically ventilated patients in the ICU.

Objectives: We sought to determine trends in use of IV vitamin C for hospitalized patients with sepsis in the context of evolving evidence, including a single-center before-after study in late 2016 and several trials in 2019-2021.

Design: Retrospective cohort study.

Setting: One thousand one hundred fifteen U.S. hospitals contributing to the Premier Healthcare Database, 2008-2021.

Patients: Eleven million three hundred seventy-five thousand three hundred twenty-six adult inpatients with sepsis.

Interventions: IV vitamin C, at any point of the hospital stay.

Measurements and main results: Patients had a median (interquartile range [IQR]) age of 71 years (59-81 yr) and a median (IQR) of 5 comorbidities (4-7 comorbidities); 53.0% were female; on hospital day 1, 6.9% were mechanically ventilated and 7.5% received a vasopressor. Overall, 32,131 patients (0.3%) received IV vitamin C at any point during hospitalization. During the study period, administration fell from 2008, quarter 1 (0.5%) through 2017, quarter 1 (< 0.1%), then rose and peaked in 2020, quarter 1 (0.6%), and fell through 2021, quarter 4 (0.1%). Examining three time periods defined by predetermined cutpoints (2015 quarter 4, when International Classification of Diseases coding for sepsis changed, and 2020 quarter 1, when the COVID-19 pandemic began), vitamin C use also varied ( p < 0.001): 0.2% (2008 quarter 1 to 2015 quarter 3); 0.3% (2015 quarter 4 to 2019 quarter 4); and 0.3% (2020-2021). Temporal trends were similar in sicker subcohorts defined by early mechanical ventilation, early vasopressor use, and diagnosis of COVID-19 (2020-2021). A multilevel logistic regression model with data from 91 hospitals that contributed at least 1 sepsis case per quarter showed a similar utilization pattern, with substantial between-hospital variability (median odds ratio, 7.78; 95% CI, 5.45-11.58).

Conclusions: IV vitamin C prescription for hospitalized patients with sepsis in the United States was overall infrequent over the 14-year study period, rising after the publication of a before-after study and declining in the COVID-19 pandemic as clinical trial results emerged.

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.

Objectives: Trauma-induced coagulopathy biomarkers may be influenced by injury mechanism. We sought to identify differences in patterns of coagulopathy with and without severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting: Harmonized database composed of six major hemorrhagic shock trials: Control of Major Bleeding After Trauma (COMBAT), Cold-stored Platelet Early Intervention in Hemorrhagic Shock (CriSP-HS), Prehospital Air Medical Plasma (PAMPer), Prehospital Whole Blood in Emergency Resuscitation (PPOWER), Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR), and Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport (STAAMP).

Patients: All subjects randomized to placebo or standard-of-care groups with complete data for international normalized ratio (INR), thromboelastography values (alpha angle [AA], K time, maximum amplitude [MA], and lysis in 30 min), and Abbreviated Injury Scores (AISs). Subjects from COMBAT and CriSP-HS were screened and ultimately excluded from the final analysis as they did not meet eligibility criteria.

Interventions: None.

Measurements and main results: Stratified principal component (PC) analysis was performed for INR and thromboelastography values. Strata were defined based on AIS scores as: 1) isolated severe TBI (iTBI); 2) severe polytrauma (POLY), those with both major head injury and torso/extremity trauma; and 3) isolated severe torso/extremity trauma (iTRUNK). We identified 506 subjects with complete data: 51 iTBI, 115 POLY, and 340 iTRUNK. For each stratum, two PCs were identified that accounted for more than 65% of the variance. Associations between PC scores and outcomes, including need for blood product transfusion within 24 hours as a surrogate marker for early coagulopathy and bleeding, were examined with logistic regression. For both iTBI and POLY, PC1 included INR, AA, K time, and MA, and was associated with greater odds of early transfusion (odds ratio [OR], 3.57; 95% CI, 1.50-8.45; p = 0.004 for iTBI and OR, 2.29; 95% CI, 1.11-4.75; p = 0.026 for POLY). For iTRUNK, PC1 included INR, AA, and MA and was protective with reduced odds of early transfusion (OR, 0.51; 95% CI, 0.37-0.70; p < 0.001).

Conclusions: PC analysis demonstrated a unique pattern of coagulation biomarkers common to patients with severe TBI, irrespective of other injuries.

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.