Critical Care Medicine最新文献

Objectives: To develop an electronic descriptor of clinical deterioration for hospitalized patients that predicts short-term mortality and identifies patient deterioration earlier than current standard definitions.

Design: A retrospective study using exploratory record review, quantitative analysis, and regression analyses.

Setting: Twelve-hospital community-academic health system.

Patients: All adult patients with an acute hospital encounter between January 1, 2018, and December 31, 2022.

Interventions: Not applicable.

Measurements and main results: Clinical trigger events were selected and used to create a revised electronic definition of deterioration, encompassing signals of respiratory failure, bleeding, and hypotension occurring in proximity to ICU transfer. Patients meeting the revised definition were 12.5 times more likely to die within 7 days (adjusted odds ratio 12.5; 95% CI, 8.9-17.4) and had a 95.3% longer length of stay (95% CI, 88.6-102.3%) compared with those who were transferred to the ICU or died regardless of meeting the revised definition. Among the 1812 patients who met the revised definition of deterioration before ICU transfer (52.4%), the median detection time was 157.0 min earlier (interquartile range 64.0-363.5 min).

Conclusions: The revised definition of deterioration establishes an electronic descriptor of clinical deterioration that is strongly associated with short-term mortality and length of stay and identifies deterioration over 2.5 hours earlier than ICU transfer. Incorporating the revised definition of deterioration into the training and validation of early warning system algorithms may enhance their timeliness and clinical accuracy.

Objectives: Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA.

Design: Prospective observational cohort study.

Setting: Single center.

Patients: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings.

Interventions: None.

Measurements and main results: The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups.

Conclusions: Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Objectives: Despite its importance, detailed national estimates of ICU utilization and outcomes remain lacking. We aimed to characterize trends in ICU utilization and outcomes over a recent 12-year period in the United States.

Design/setting: In this longitudinal study, we examined hospitalizations involving ICU care ("ICU hospitalizations") alongside hospitalizations not involving ICU care ("non-ICU hospitalizations") among traditional Medicare beneficiaries using 100% Medicare part A claims data and commercial claims data for the under 65 adult population from 2008 to 2019.

Patients/interventions: There were 18,313,637 ICU hospitalizations and 78,501,532 non-ICU hospitalizations in Medicare, and 1,989,222 ICU hospitalizations and 16,732,960 non-ICU hospitalizations in the commercially insured population.

Measurements and main results: From 2008 to 2019, about 20% of Medicare hospitalizations and 10% of commercial hospitalizations involved ICU care. Among these ICU hospitalizations, length of stay and ICU length of stay decreased on average. Mortality and hospital readmissions on average also decreased, and they decreased more among ICU hospitalizations than among non-ICU hospitalizations, for both Medicare and commercially insured patients. Both Medicare and commercial populations experienced a growth in shorter ICU hospitalizations (between 2 and 7 d in length), which were characterized by shorter ICU stays and lower mortality. Among these short hospitalizations in the Medicare population, for common clinical diagnoses cared for in both ICU and non-ICU settings, patients were increasingly triaged into an ICU during the study period, despite being younger and having shorter hospital stays.

Conclusions: ICUs are used in a sizeable share of hospitalizations. From 2008 to 2019, ICU length of stay and mortality have declined, while short ICU hospitalizations have increased. In particular, for clinical conditions often managed both within and outside of an ICU, shorter ICU hospitalizations involving younger patients have increased. Our findings motivate opportunities to better understand ICU utilization and to improve the value of ICU care for patients and payers.