Critical Care Medicine最新文献

Objective: To evaluate whether systemic anticoagulation therapy affects the survival of adult patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) for acute respiratory distress syndrome (ARDS).

Design: Multicenter retrospective study.

Setting: Twenty-four ICUs in Japan.

Patients: Six hundred and ninety-five patients received VV-ECMO for ARDS. Patients were divided into the anticoagulation group and the no-anticoagulation group according to whether or not they received anticoagulant therapy.

Interventions: None.

Measurements and main results: In the propensity score-overlap-weighted analysis, there was no significant difference in the 28-day survival (85.8% vs. 81.5%, p = 0.50) between the two groups. The 60-day survival, ECMO duration, circuit exchanges, bleeding complications, and transfusion volumes were also comparable. The anticoagulation group had a significantly higher average activated partial thromboplastin time during ECMO (51.3 s vs. 39.3 s, p < 0.01). These findings remained consistent in the sensitivity analysis using inverse probability of treatment weighting.

Conclusions: Systemic anticoagulation was not associated with short-term survival. Anticoagulation-free VV-ECMO may be feasible in patients at high-bleeding risk, but safety remains uncertain. Further studies should clarify optimal anticoagulation strategies.

Objectives: The goal of this study was to assess the effect of enteral feeding on aspiration risk and progression of respiratory failure in adults on high-flow nasal cannula (HFNC) oxygen therapy.

Design: Single-center retrospective cohort study.

Setting: Keck Hospital of the University of Southern California, a tertiary care academic hospital.

Patients: Hospitalized adults treated with HFNC between January 1, 2020, and December 31, 2022, were included. Exclusion criteria were chronic total parenteral nutrition, chronic tracheostomy, history of total laryngectomy, and "Do Not Intubate" code status.

Interventions: None.

Measurements and main results: The primary outcome was the progression of respiratory failure from HFNC to noninvasive positive pressure ventilation, mechanical ventilation, or extracorporeal membrane oxygenation. We included 220 patients in the primary analysis. The median age was 62.6 years, 54.1% of patients were male, and 43.6% of patients were White. The primary outcome of progression of respiratory failure occurred in 57 patients, of whom 19 (33.3%) were feeding enterally and 38 (66.7%) were NPO at the time of progression. Patients feeding enterally were less likely than those who were NPO to have progression of respiratory failure in a multivariate mixed effects linear regression model (odds ratio [OR], 0.33; 95% CI, 0.18-0.58; p < 0.001). Patients feeding enterally remained less likely to have progression of respiratory failure in a propensity score-matched analysis (OR, 0.30; 95% CI, 0.15-0.58; p < 0.001).

Conclusions: In this single-center, retrospective cohort, enteral nutrition in patients on HFNC was associated with lower risk of progression of respiratory failure and was not associated with increased risk of poor clinical outcomes. Prospective multicenter studies are needed to confirm these findings.

Objectives: In the United States, in-hospital cardiac arrest (IHCA) affects about 290,000 adults per year. This study provides an updated and expanded analysis of the epidemiology, resuscitative response, and outcomes following IHCA in various hospital locations.

Design: This observational cohort study used the prospectively collected nationwide Get With The Guidelines-Resuscitation (GWTG-R) registry.

Setting: GWTG-R registry.

Patients: All adult patients with an index cardiac arrest in the emergency department (ED), ICU, or ward (telemetry or nontelemetry) between 2010 and 2021 were included.

Interventions: None.

Measurements and main results: A total of 235,560 IHCA events were included, of which 53.4% (n = 125,798) occurred in the ICU, 14.0% (n = 32,862) in the ED, 16.0% (n = 37,780) on telemetry wards, and 16.6% (n = 39,120) on nontelemetry wards. Shockable initial rhythms were identified in 15.9% (n = 37,465) of IHCAs, with the highest prevalence in monitored locations. Adjusted for confounding factors, a survival rate of 21.2% (95% CI, 20.6-21.9%) was found in the ICU, 22.2% (95% CI, 21.4-23.1%) in the ED, 23.0% (95% CI, 22.3-23.7%) on telemetry wards, and 19.2% (95% CI, 18.4-20.0%) on nontelemetry wards.

Conclusions: Survival after IHCA is low and varies based on the hospital location of the IHCA. Patients with IHCA on nontelemetry wards have the lowest probability of in-hospital survival after IHCA.

Objective: Extracorporeal membrane oxygenation (ECMO) has been used to provide pulmonary and circulatory support in patients with ongoing critical illness. Studies investigating whether an association exists between ECMO center-volume and complications are lacking. Our main aim was to investigate whether an association between ECMO center-volume and the rate of ECMO-related complications for adult patients exists.

Design: Retrospective observational study.

Setting: Patients from the Extracorporeal Life Support Organization Registry were collected from 2018 to 2021.

Subjects: Adult patients (18 yr old or older) were grouped according to ECMO first mode and support modality: venovenous (VV), venoarterial (VA) or extracorporeal cardiopulmonary resuscitation (ECPR).

Interventions: None.

Measurements and main results: The association of support type-specific hospital center-volume on rates of complications was investigated using multivariate, clustered mixed-effects logistic regression. From 2018 to 2021, a total of 9,427 patients underwent VV ECMO across 281 centers, 10,794 patients underwent VA across 275 centers, and 3,595 patients underwent ECPR across 224 centers. Average annual center-volume was 74 (± 55), 80 (± 55), and 89 (± 58) for VV, VA, and ECPR, respectively. Complication rates varied widely across subgroups. Increased annual center-volume was associated with increased mechanical complications (VA: adjusted odds ratio (aOR) = 1.004 [1.001-1.008]), and decreased hemorrhagic complications (VV: aOR = 0.997 [0.994-0.999]; VA: aOR = 0.997 [0.994-0.999]) and pulmonary complications (VV: aOR = 0.997 [0.994-1.000]). Metabolic complications were not significantly associated with center volume.

Conclusions: Higher annual center-volumes of ECMO were associated with decreased pulmonary complications for VV, decreased hemorrhagic complications for VA and VV cohorts and an increase in mechanical complications for VA cohort but not ECPR alone. These associations were small, with a 0.3% increase or decrease in odds per complication category, but are attributable entirely to the center volume and known at the moment of ECMO cannulation.

Objective: The cholinergic anti-inflammatory pathway (ChAP) is the key regulator of the dysregulated cytokine storm in sepsis, with acetylcholine acting on alpha-7 nicotinic acetylcholine receptors (α7nAChRs) to suppress excessive inflammation. The objective of this study was to evaluate whether neostigmine administration modulates the inflammatory response in sepsis by enhancing cholinergic anti-inflammatory activity.

Design: A single-center, prospective, randomized, double-blinded, placebo-controlled study.

Setting: One adult ICU at a tertiary academic medical institution.

Intervention: Patients were randomized to receive neostigmine at a fixed rate of 0.2 mg/hr (2 mL/hr) or placebo. Study drug was administered for 5 days.

Measurements and results: The primary outcome measure was decrease in tumor necrosis factor-alpha levels, in patients treated with neostigmine adjuvant therapy vs. the standard therapy. The secondary outcomes were hemodynamic parameters, septic shock reversal, changes in procalcitonin levels, and organ failure scores. The mean tumor necrosis factor-alpha levels were significantly lower in the neostigmine group (40 ± 36 pg/mL, mean ± sd) on day 5 as compared with the control group (67 ± 43 pg/mL; p = 0.002). There was a significant reduction in Sequential Organ Failure Assessment scores from day 1 to day 5 (p < 0.001) and 28-day mortality was also lower in the neostigmine group (26%) as compared with control group (54%, p = 0.02).

Conclusions: The neostigmine infusion modulates the ChAP by potentiating the acetylcholine release leading to reduced systemic inflammation and decreased cytokine levels in septic shock patients. (Clinical Trial Registry of India number: CTRI/2023/07/ 055054).

Objective: Postoperative pneumonia (POP) is a frequent complication after cardiac surgery, which significantly worsens prognosis. This study aimed to identify preoperative and intraoperative factors independently associated with POP in a cardiac surgery cohort, perform a systematic review (SR) and meta-analysis of risk factors, outcomes, and predictive models, and validate these models in the cohort.

Design: This is an ancillary study of the STERNOCAT (Catheter Outcomes With Sternotomy Cardiac Operated) trial completed by an SR and meta-analysis. PubMed, Embase, and Cochrane Library were searched (January 2000 to March 31, 2025). Two reviewers independently screened references to identify studies on adult cardiac surgery patients assessing POP risk factors or predictive models, extracted data, and assessed methodological quality. Predictive models identified through the SR were externally validated using the STERNOCAT cohort.

Setting: Cardiac surgery units in France (STERNOCAT cohort) and international hospital settings (SR studies).

Patients: A total of 1,470 patients from the STERNOCAT cohort and 172,079 from 24 studies overall were included in the SR.

Interventions: None.

Measurements and main results: In the STERNOCAT ancillary study, 78 of 1470 patients developed POP (5.3%). Independent risk factors included ischemic cardiomyopathy (odds ratio [OR] 1.89, 95% CI [1.13-3.16]), cardiopulmonary bypass (CPB) duration (OR 1.10, 95% CI [1.02-1.18]), and catecholamine use (OR 4.07, 95% CI [2.45-6.76]). POP was associated with higher 30-day mortality (14.1% vs. 1.5%, p < 0.0001). The meta-analysis identified 14 significant risk factors for POP. Of these, 10 were non-modifiable (e.g., age, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal disease, previous cardiac surgery, emergency surgery). Four were partially modifiable: active smoking, CPB duration, intraoperative transfusions (presence and amount). Only one model, limited to preoperative variables, could be externally validated and showed poor accuracy.

Conclusions: This study highlights the difficulty of predicting and preventing POP, as most identified risk factors are non-modifiable or require long-term preventive strategies. Perioperative optimization, particularly regarding CPB management and transfusion practices, therefore, remains essential to improving patient outcomes.

Registration: PROSPERO (CRD42024555519).

Objectives: To evaluate the efficacy and safety of conservative (oxygen saturation [Spo2] 88-94% or Pao2 < 80 mm Hg) vs. liberal oxygen targets (Spo2 ≥ 94% or Pao2 ≥ 90 mm Hg) in mechanically ventilated critically ill adults.

Data sources: PubMed, Cochrane CENTRAL, Embase, and ClinicalTrials.gov.

Study selection: We conducted the OXY-BREATHES, a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing conservative vs. liberal oxygen targets in mechanically ventilated ICU patients. Primary outcomes were 90-day mortality and ICU length of stay. Secondary outcomes included ventilator- and vasopressor-free days, renal replacement therapy, nosocomial pneumonia, and cardiac or cerebral ischemic events. Subgroup analyses included patients with sepsis/septic shock and post-cardiac arrest.

Data extraction: Data were collected according to study selection criteria. Certainty of evidence was appraised with Grading of Recommendations, Assessment, Development, and Evaluation, and risk of bias with the Cochrane tool. Data were analyzed using a random-effects model.

Data synthesis: Nine RCTs enrolling 20,447 patients were included. Conservative and liberal targets showed no substantial differences in 90-day (risk ratio [RR], 1.01; 95% CI, 0.94-1.09) or ICU length of stay (mean difference [MD], -0.17; 95% CI, -0.41 to 0.06). Secondary outcomes, including organ support-free days and the incidence of adverse events, were comparable between groups. In subgroup analyses, conservative targets yielded more vasopressor-free days in septic patients (MD, 2.0; p = 0.008) and a potential survival benefit in post-cardiac arrest patients (RR, 0.89; p = 0.05). Certainty of evidence was rated moderate for 90-day mortality, ICU length of stay, vasopressor-free days, and ventilator-free days; low for renal replacement therapy and nosocomial pneumonia; and very low for cerebral and cardiac ischemia due to imprecision and open-label trial designs.

Conclusions: Conservative oxygenation is comparable to liberal oxygen targets in mechanically ventilated critically ill patients, with possible advantages in sepsis and post-cardiac arrest. Future condition-specific RCTs are warranted to define optimal ICU oxygen strategies.