Pub Date : 2024-11-22DOI: 10.1186/s13054-024-05158-w
Thibault Martinez, Anatole Harrois, Anaïs Codorniu, Nicolas Mongardon, Matthieu Pissot, Benjamin Popoff, Marc Leone, Nathalie Delhaye, Eric Vicaut, Quentin Mathais, Vincent Legros, Jean-Luc Hanouz, Nicolas Gatulle, Véronique Ramonda, Benjamin Cohen, Mathieu Boutonnet, Julien Pottecher, Nicolas Libert
Traumatic rhabdomyolysis (RM) is common and associated with the development of acute kidney injury and potentially with other organ dysfunctions. Thus, RM may increase the risk of death. The primary objective was to assess the effect of severe RM (Creatine Kinase [CK] > 5000 U/L) on 30-day mortality in trauma patients using a causal inference approach. In this multicenter cohort study conducted in France using a national major trauma registry (Traumabase) between January 1, 2012, and July 1, 2023, all patients admitted to a participating major trauma center hospitalized in intensive care unit (ICU) and with CK measurement were included. Confounding variables for both 30-day mortality and exposure were used to establish a propensity score. A doubly robust approach with inverse treatment weighting enabled the calculation of the average treatment effect on the treated (ATT). Analyses were performed in the overall cohort as well as in two subgroups: hemorrhagic shock subgroup (HS) and traumatic brain injury subgroup (TBI). Sensitivity analyses were conducted. Among the 8592 patients included, 1544 (18.0%) had severe RM. They were predominantly males (78.6%) with median [IQR] age of 41 [27–58] years and severely injured (ISS 20 [13 – 29]) mainly from blunt trauma (90.8%). In the entire cohort, the ATT, expressed as a risk difference, was 0.073 [-0.054 to 0.200]. Considering the 1311 patients in the HS subgroup, the ATT was 0.039 [0.014 to 0.063]. As in the overall cohort, there was no effect on mortality in the TBI subgroup. Severe RM was associated with greater severity of trauma and more complications (whether related to renal function or not) during the ICU stay. Mortality due to multiorgan failure (39.9% vs 12.4%) or septic shock (2.6% vs 0.8%) was more frequent among patients with severe RM. Severe RM was not associated with 30-day mortality considering the overall cohort. However, it was associated with a 4.0% increase in 30-day mortality among patients with concurrent hemorrhagic shock. Severe RM plays a significant role in ICU morbidity.
{"title":"Evaluation of severe rhabdomyolysis on day 30 mortality in trauma patients admitted to intensive care: a propensity score analysis of the Traumabase registry","authors":"Thibault Martinez, Anatole Harrois, Anaïs Codorniu, Nicolas Mongardon, Matthieu Pissot, Benjamin Popoff, Marc Leone, Nathalie Delhaye, Eric Vicaut, Quentin Mathais, Vincent Legros, Jean-Luc Hanouz, Nicolas Gatulle, Véronique Ramonda, Benjamin Cohen, Mathieu Boutonnet, Julien Pottecher, Nicolas Libert","doi":"10.1186/s13054-024-05158-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05158-w","url":null,"abstract":"Traumatic rhabdomyolysis (RM) is common and associated with the development of acute kidney injury and potentially with other organ dysfunctions. Thus, RM may increase the risk of death. The primary objective was to assess the effect of severe RM (Creatine Kinase [CK] > 5000 U/L) on 30-day mortality in trauma patients using a causal inference approach. In this multicenter cohort study conducted in France using a national major trauma registry (Traumabase) between January 1, 2012, and July 1, 2023, all patients admitted to a participating major trauma center hospitalized in intensive care unit (ICU) and with CK measurement were included. Confounding variables for both 30-day mortality and exposure were used to establish a propensity score. A doubly robust approach with inverse treatment weighting enabled the calculation of the average treatment effect on the treated (ATT). Analyses were performed in the overall cohort as well as in two subgroups: hemorrhagic shock subgroup (HS) and traumatic brain injury subgroup (TBI). Sensitivity analyses were conducted. Among the 8592 patients included, 1544 (18.0%) had severe RM. They were predominantly males (78.6%) with median [IQR] age of 41 [27–58] years and severely injured (ISS 20 [13 – 29]) mainly from blunt trauma (90.8%). In the entire cohort, the ATT, expressed as a risk difference, was 0.073 [-0.054 to 0.200]. Considering the 1311 patients in the HS subgroup, the ATT was 0.039 [0.014 to 0.063]. As in the overall cohort, there was no effect on mortality in the TBI subgroup. Severe RM was associated with greater severity of trauma and more complications (whether related to renal function or not) during the ICU stay. Mortality due to multiorgan failure (39.9% vs 12.4%) or septic shock (2.6% vs 0.8%) was more frequent among patients with severe RM. Severe RM was not associated with 30-day mortality considering the overall cohort. However, it was associated with a 4.0% increase in 30-day mortality among patients with concurrent hemorrhagic shock. Severe RM plays a significant role in ICU morbidity.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"20 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142690946","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-22DOI: 10.1186/s13054-024-05180-y
Luis Felipe Reyes, Cristian C. Serrano-Mayorga, Zhongheng Zhang, Isabela Tsuji, Gennaro De Pascale, Valeria Enciso Prieto, Mervyn Mer, Elyce Sheehan, Prashant Nasa, Goran Zangana, Kostoula Avanti, Alexis Tabah, Gentle Sunder Shrestha, Hendrik Bracht, Arie Zainul Fatoni, Khalid Abidi, Helmi bin Sulaiman, Vandana Kalwaje Eshwara, Liesbet De Bus, Yoshiro Hayashi, Pervin Korkmaz, Ali Ait Hssain, Niccolò Buetti, Qing Yuan Goh, Arthur Kwizera, Despoina Koulenti, Nathan D. Nielsen, Pedro Povoa, Otavio Ranzani, Jordi Rello, Andrew Conway Morris
Pneumonia remains a significant global health concern, particularly among those requiring admission to the intensive care unit (ICU). Despite the availability of international guidelines, there remains heterogeneity in clinical management. The D-PRISM study aimed to develop a global overview of how pneumonias (i.e., community-acquired (CAP), hospital-acquired (HAP), and Ventilator-associated pneumonia (VAP)) are diagnosed and treated in the ICU and compare differences in clinical practice worldwide. The D-PRISM study was a multinational, survey-based investigation to assess the diagnosis and treatment of pneumonia in the ICU. A self-administered online questionnaire was distributed to intensive care clinicians from 72 countries between September to November 2022. The questionnaire included sections on professional profiles, current clinical practice in diagnosing and managing CAP, HAP, and VAP, and the availability of microbiology diagnostic tests. Multivariable analysis using multiple regression analysis was used to assess the relationship between reported antibiotic duration and organisational variables collected in the study. A total of 1296 valid responses were collected from ICU clinicians, spread between low-and-middle income (LMIC) and high-income countries (HIC), with LMIC respondents comprising 51% of respondents. There is heterogeneity across the diagnostic processes, including clinical assessment, where 30% (389) did not consider radiological evidence essential to diagnose pneumonia, variable collection of microbiological samples, and use and practice in bronchoscopy. Microbiological diagnostics were least frequently available in low and lower-middle-income nation settings. Modal intended antibiotic treatment duration was 5–7 days for all types of pneumonia. Shorter durations of antibiotic treatment were associated with antimicrobial stewardship (AMS) programs, high national income status, and formal intensive care training. This study highlighted variations in clinical practice and diagnostic capabilities for pneumonia, particularly issues with access to diagnostic tools in LMICs were identified. There is a clear need for improved adherence to existing guidelines and standardized approaches to diagnosing and treating pneumonia in the ICU. Trial registration As a survey of current practice, this study was not registered. It was reviewed and endorsed by the European Society of Intensive Care Medicine.
{"title":"D-PRISM: a global survey-based study to assess diagnostic and treatment approaches in pneumonia managed in intensive care","authors":"Luis Felipe Reyes, Cristian C. Serrano-Mayorga, Zhongheng Zhang, Isabela Tsuji, Gennaro De Pascale, Valeria Enciso Prieto, Mervyn Mer, Elyce Sheehan, Prashant Nasa, Goran Zangana, Kostoula Avanti, Alexis Tabah, Gentle Sunder Shrestha, Hendrik Bracht, Arie Zainul Fatoni, Khalid Abidi, Helmi bin Sulaiman, Vandana Kalwaje Eshwara, Liesbet De Bus, Yoshiro Hayashi, Pervin Korkmaz, Ali Ait Hssain, Niccolò Buetti, Qing Yuan Goh, Arthur Kwizera, Despoina Koulenti, Nathan D. Nielsen, Pedro Povoa, Otavio Ranzani, Jordi Rello, Andrew Conway Morris","doi":"10.1186/s13054-024-05180-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05180-y","url":null,"abstract":"Pneumonia remains a significant global health concern, particularly among those requiring admission to the intensive care unit (ICU). Despite the availability of international guidelines, there remains heterogeneity in clinical management. The D-PRISM study aimed to develop a global overview of how pneumonias (i.e., community-acquired (CAP), hospital-acquired (HAP), and Ventilator-associated pneumonia (VAP)) are diagnosed and treated in the ICU and compare differences in clinical practice worldwide. The D-PRISM study was a multinational, survey-based investigation to assess the diagnosis and treatment of pneumonia in the ICU. A self-administered online questionnaire was distributed to intensive care clinicians from 72 countries between September to November 2022. The questionnaire included sections on professional profiles, current clinical practice in diagnosing and managing CAP, HAP, and VAP, and the availability of microbiology diagnostic tests. Multivariable analysis using multiple regression analysis was used to assess the relationship between reported antibiotic duration and organisational variables collected in the study. A total of 1296 valid responses were collected from ICU clinicians, spread between low-and-middle income (LMIC) and high-income countries (HIC), with LMIC respondents comprising 51% of respondents. There is heterogeneity across the diagnostic processes, including clinical assessment, where 30% (389) did not consider radiological evidence essential to diagnose pneumonia, variable collection of microbiological samples, and use and practice in bronchoscopy. Microbiological diagnostics were least frequently available in low and lower-middle-income nation settings. Modal intended antibiotic treatment duration was 5–7 days for all types of pneumonia. Shorter durations of antibiotic treatment were associated with antimicrobial stewardship (AMS) programs, high national income status, and formal intensive care training. This study highlighted variations in clinical practice and diagnostic capabilities for pneumonia, particularly issues with access to diagnostic tools in LMICs were identified. There is a clear need for improved adherence to existing guidelines and standardized approaches to diagnosing and treating pneumonia in the ICU. Trial registration As a survey of current practice, this study was not registered. It was reviewed and endorsed by the European Society of Intensive Care Medicine. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"428 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142684432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-21DOI: 10.1186/s13054-024-05139-z
Xiaoming Li, Zhengying Jiang
<p>Sepsis remains an important global health problem and a leading cause of death in critically ill patients worldwide [1]. The β-lactam antibiotics are widely used as an important component of antibiotic therapy for patients with sepsis. The bactericidal activity of β-lactam antibiotics is typically time-dependent, and their clinical effectiveness is affected by the duration of the free drug concentration remains above the minimum inhibitory concentration (MIC) of the target pathogen. Therefore, the prolonged (Extended or continuous) infusion of β-lactam antibiotics has been an attractive strategy, because it provides a more stable free drug concentration and a longer duration of free drug concentration above the MIC [2]. Many previous studies have shown pharmacological rationale and potential clinical advantages in favor of prolonged infusion of β-lactam antibiotics in critically ill patients with sepsis [3]. Therefore, many recent international consensus and guidelines recommend the use of prolonged infusion strategies for β-lactam antibiotics in critically ill patients [4,5,6]. And based on “moderate-quality” evidence, the Surviving Sepsis Campaign guidelines suggest a “weak” recommendation for prolonged infusion of β-lactam antibiotics for patients with sepsis or septic shock, rather than conventional intermittent infusion [7].</p><p>However, two well-conducted studies on this topic published in JAMA showed negative results. In the MERCY trial, a total of 607 patients were enrolled, and unfortunately there was no significant difference in the primary composite outcome or any secondary outcome between the two groups [8]. It may have been underpowered to detect small but still clinically meaningful results. Recently, the BLING III randomized clinical trial (RCT), the largest RCT on this topic to date, has been published [9]. Although only clinical cure was positive result in the continuous vs intermittent infusion group (55.7% vs 50.0%, respectively; <i>P</i> < 0.001), the absolute 90-days mortality (24.9% vs 26.8%, respectively), hospital mortality (23.3% vs 25.0%, respectively) and ICU mortality (17.1% vs 18.4%, respectively) were lower in the continuous infusion group than that in the intermittent infusion group. Thus, adding those data from the BLING III trial to previous meta-analysis would support rather than refute the previously reported benefits.</p><p>Abdul-Aziz and colleagues performed a systematic review and meta-analysis on this topic, including 18 RCTs with 9108 critically ill adults with sepsis or septic shock. And the results showed that prolonged infusion of β-lactam antibiotics was associated with lower 90-days mortality, ICU mortality and an increase in clinical cure [10]. To further verify the reliability of the conclusions and avoid false positive or false negative results, we conducted trial sequential analysis (TSA) based on the work of Abdul-Aziz et al. We used a random effects model to construct the cumulative Z cur
为脓毒症患者延长静脉输注β-内酰胺类抗生素与间歇性静脉输注：随机临床试验的系统回顾、荟萃分析和试验序列分析。Ann Intensive Care.2023; 13(1):121.Article PubMed PubMed Central Google Scholar Hong LT, Downes KJ, FakhriRavari A, et al.使用长期输注β-内酰胺类抗生素的国际共识建议：美国临床药学院、英国抗菌化疗学会、囊性纤维化基金会、欧洲临床微生物学和传染病学会、美国传染病学会、重症医学学会和传染病药剂师学会认可。药物疗法》。2023; 43(8):740-77.Article CAS PubMed Google Scholar Abdul-Aziz MH, Alffenaar JC, Bassetti M, et al. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a position paper().Intensive Care Med.2020;46(6):1127-53.Article PubMed PubMed Central Google Scholar Guilhaumou R, Benaboud S, Bennis Y, et al. 重症患者β-内酰胺类抗生素治疗的优化--法国药理学与治疗学协会（Societe Francaise de Pharmacologie et Therapeutique-SFPT）和法国麻醉与重症医学协会（Societe Francaise d'Anesthesie et Reanimation-SFAR）指南。Crit Care.2019;23(1):104.Article PubMed PubMed Central Google Scholar Evans L, Rhodes A, Alhazzani W, et al. 败血症生存运动：2021 年败血症和脓毒性休克管理国际指南。Intensive Care Med.2021;47(11):1181-247.Article PubMed PubMed Central Google Scholar Monti G, Bradic N, Marzaroli M, et al. Continuous vs intermittent meropenem administration in critically ill patients with sepsis: the MERCY randomized clinical trial.JAMA.2023;330(2):141-51.Article CAS PubMed PubMed Central Google Scholar Dulhunty JM, Brett SJ, De Waele JJ, et al. Continuous vs Intermittent beta-Lactam Antibiotic Infusions in Critically Ill Patients With Sepsis: The BLING III Randomized Clinical Trial.美国医学会杂志》。2024.Abdul-Aziz MH，Hammond NE，Brett SJ，et al.脓毒症或脓毒性休克成人患者持续输注与间断输注β-内酰胺类抗生素：系统综述与荟萃分析。美国医学会杂志》。2024.Dulhunty JM，Roberts JA，Davis JS，et al.严重脓毒症中连续输注与间歇输注β-内酰胺类药物的多中心随机试验。Am J Respir Crit Care Med.2015;192(11):1298-305.Article CAS PubMed Google Scholar 下载参考文献无。作者和单位重庆市汉渝路181号重庆大学附属肿瘤医院重症医学科，重庆，400030李晓明& 蒋正英作者简介李晓明查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者蒋正英查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者贡献李晓明构思了该研究，进行了统计分析，并起草了手稿。伦理批准和参与同意书不适用.发表同意书不适用.利益冲突作者声明无利益冲突.出版者注释Springer Nature对出版地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出许可使用范围，则您需要直接从版权所有者处获得许可。如需查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleLi, X., Jiang, Z. Do prolonged infusions of β-lactam antibiotics improve outcomes in critically ill patients with sepsis?是时候说 "是 "了Crit Care 28, 380 (2024). https://doi.org/10.1186/s13054-024-05139-zDownload citationReceived：2024 年 10 月 17 日接受：18 October 2024Published: 21 November 2024DOI: https://doi.org/10.
{"title":"Do prolonged infusions of β-lactam antibiotics improve outcomes in critically ill patients with sepsis? It is time to say yes","authors":"Xiaoming Li, Zhengying Jiang","doi":"10.1186/s13054-024-05139-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05139-z","url":null,"abstract":"<p>Sepsis remains an important global health problem and a leading cause of death in critically ill patients worldwide [1]. The β-lactam antibiotics are widely used as an important component of antibiotic therapy for patients with sepsis. The bactericidal activity of β-lactam antibiotics is typically time-dependent, and their clinical effectiveness is affected by the duration of the free drug concentration remains above the minimum inhibitory concentration (MIC) of the target pathogen. Therefore, the prolonged (Extended or continuous) infusion of β-lactam antibiotics has been an attractive strategy, because it provides a more stable free drug concentration and a longer duration of free drug concentration above the MIC [2]. Many previous studies have shown pharmacological rationale and potential clinical advantages in favor of prolonged infusion of β-lactam antibiotics in critically ill patients with sepsis [3]. Therefore, many recent international consensus and guidelines recommend the use of prolonged infusion strategies for β-lactam antibiotics in critically ill patients [4,5,6]. And based on “moderate-quality” evidence, the Surviving Sepsis Campaign guidelines suggest a “weak” recommendation for prolonged infusion of β-lactam antibiotics for patients with sepsis or septic shock, rather than conventional intermittent infusion [7].</p><p>However, two well-conducted studies on this topic published in JAMA showed negative results. In the MERCY trial, a total of 607 patients were enrolled, and unfortunately there was no significant difference in the primary composite outcome or any secondary outcome between the two groups [8]. It may have been underpowered to detect small but still clinically meaningful results. Recently, the BLING III randomized clinical trial (RCT), the largest RCT on this topic to date, has been published [9]. Although only clinical cure was positive result in the continuous vs intermittent infusion group (55.7% vs 50.0%, respectively; <i>P</i> < 0.001), the absolute 90-days mortality (24.9% vs 26.8%, respectively), hospital mortality (23.3% vs 25.0%, respectively) and ICU mortality (17.1% vs 18.4%, respectively) were lower in the continuous infusion group than that in the intermittent infusion group. Thus, adding those data from the BLING III trial to previous meta-analysis would support rather than refute the previously reported benefits.</p><p>Abdul-Aziz and colleagues performed a systematic review and meta-analysis on this topic, including 18 RCTs with 9108 critically ill adults with sepsis or septic shock. And the results showed that prolonged infusion of β-lactam antibiotics was associated with lower 90-days mortality, ICU mortality and an increase in clinical cure [10]. To further verify the reliability of the conclusions and avoid false positive or false negative results, we conducted trial sequential analysis (TSA) based on the work of Abdul-Aziz et al. We used a random effects model to construct the cumulative Z cur","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"2 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142678170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-20DOI: 10.1186/s13054-024-05170-0
Lihong Zhu, Juan Lin
<p>To the editor,</p><p>We read with great interest the recent study [1] by Dr. Machado et al., which proposed a new definition for acute kidney injury (AKI) in critically Ill patients, based on varied urine output thresholds and time frames. This study uses in-hospital mortality as an outcome-oriented approach to compose the proposed UO-AKI classification, applying different time frames (3 h, 6 h, 12 h, and 24 h) and distinct cutoff points. Ultimately, the average UO over 6-h frame was used for the new classification, and AKI was redefined as follows: stage 1 (0.2–0.3 mL/kg/h), stage 2 (0.1–0.2 mL/kg/h), and stage 3 (< 0.1 mL/kg/h) over 6 h. this proposed classification demonstrated superior predictive accuracy over the KDIGO criteria, with improved NRI and IDI for mortality. However, some details need to be considered carefully when interpreting and applying the findings.</p><p>First, in the current study, the ability to predict death was used as a criterion to evaluate the quality of AKI criteria. However, the essence of the AKI definition is to reflect impaired excretion of metabolic waste due to damage to the renal tubules and/or renal interstitium. Moreover, not all AKI stages are associated with increased mortality. For instance, in a prospective study [2] including 4683 patients, Kaddourah et al. reported that severe AKI (stage 2–3) conferred an increased risk of death by day 28 after adjustment for 16 covariates while mild AKI stage 1 was not. Similarly, an analysis [3] of two large trials (COVID-19 Critical Care Consortium and LUNG-SAFE studies) showed that both 28-day and 90-day mortality risk was increased for patients with stage 2 (HR 2.00, <i>p</i> < 0.001) and stage 3 AKI (HR 1.95, <i>p</i> < 0.001), but not for stage 1. Therefore, using a mortality-oriented approach to define AKI may overlook the significance of mild AKI (stage 1) and may explain why the proposed classification's urine volume threshold for AKI stage 1 (0.2–0.3 mL/kg/h) is similar to the stage 3 threshold (0.3 mL/kg/h) in the KDIGO guidelines, albeit with different time frames. Also, this approach could introduce bias into the understanding of AKI’s clinical significance, as it focuses solely on the risk of death while neglecting the kidney dysfunction and injury that are essential to the definition of AKI. In addition, we are also somewhat unclear about the time frame definition. Were all time frames measured as the corresponding hours after ICU admission, or were they sliding windows? This distinction may be important for accurately defining AKI.</p><p>Finally, we commend Dr. Machado et al. for their significant work, and we hope our perspectives will help in the interpretation of these findings.</p><p>No datasets were generated or analysed during the current study.</p><ol data-track-component="outbound reference" data-track-context="references section"><li data-counter="1."><p>Machado GD, Santos LL, Liborio AB. Redefining urine output thresholds for acu
致编辑：我们饶有兴趣地阅读了马查多博士等人最近的研究[1]，他们根据不同的尿量阈值和时间框架，提出了重症患者急性肾损伤（AKI）的新定义。本研究将院内死亡率作为结果导向的方法，应用不同的时间框架（3 小时、6 小时、12 小时和 24 小时）和不同的截断点来组成所提出的 UO-AKI 分类。最终，新的分类采用了 6 小时内的平均 UO 值，AKI 被重新定义为：6 小时内的 1 期（0.2-0.3 mL/kg/h）、2 期（0.1-0.2 mL/kg/h）和 3 期（< 0.1 mL/kg/h）。与 KDIGO 标准相比，所提出的分类显示出更高的预测准确性，死亡率的 NRI 和 IDI 也有所提高。然而，在解释和应用研究结果时，需要仔细考虑一些细节。首先，在当前的研究中，预测死亡的能力被用作评估 AKI 标准质量的标准。然而，AKI 定义的本质是反映肾小管和/或肾间质受损导致的代谢废物排泄障碍。此外，并非所有的 AKI 阶段都与死亡率增加有关。例如，在一项包括 4683 名患者的前瞻性研究[2]中，Kaddourah 等人报告称，在对 16 个协变量进行调整后，重度 AKI（2-3 期）会增加第 28 天的死亡风险，而轻度 AKI 1 期则不会。同样，对两项大型试验（COVID-19 重症监护联盟和 LUNG-SAFE 研究）的分析[3]显示，AKI 第 2 期（HR 2.00，p < 0.001）和第 3 期（HR 1.95，p < 0.001）患者的 28 天和 90 天死亡风险均增加，而第 1 期患者则没有增加。因此，使用以死亡率为导向的方法来定义 AKI 可能会忽略轻度 AKI（1 期）的重要性，这也可以解释为什么拟议分类中 AKI 1 期的尿量阈值（0.2-0.3 mL/kg/h）与 KDIGO 指南中的 3 期阈值（0.3 mL/kg/h）相似，尽管时间范围不同。而且，这种方法可能会使人们对 AKI 临床意义的理解出现偏差，因为它只关注死亡风险，而忽视了对 AKI 定义至关重要的肾功能障碍和损伤。此外，我们对时间框架的定义也有些不清楚。所有的时间框架都是以 ICU 入院后的相应小时来衡量的，还是以滑动窗口来衡量的？这一区别对于准确定义 AKI 可能非常重要。最后，我们对 Machado 博士等人所做的重要工作表示赞赏，希望我们的观点有助于对这些研究结果的解释。重新定义重症患者急性肾损伤标准的尿量阈值：推导与验证研究》。Crit Care.2024; 28(1):272.Article PubMed PubMed Central Google Scholar Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically Ill children and young adults.N Engl J Med.2017;376(1):11-20.Article PubMed Google Scholar McNicholas BA, Rezoagli E, Simpkin AJ, Khanna S, Suen JY, Yeung P, Brodie D, Li Bassi G, Pham T, Bellani G, et al. Epidemiology and outcomes of early-onset AKI in COVID-19-related ARDS in comparison with non-COVID-19-related ARDS: insights from two prospective global cohort studies.Crit Care.2023;27(1):3.Article PubMed PubMed Central Google Scholar Download referencesNot applicable.作者及单位浙江医院重症医学科，浙江省杭州市古墩路1229号林荫路12#。作者朱丽红查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者林娟查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者供稿朱丽红提出问题，林娟撰写信函。伦理批准和参与同意书不适用.发表同意书不适用.利益冲突作者声明无利益冲突.出版者注释施普林格-自然（Springer Nature）对发表的地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享从本文或其中部分内容衍生的改编材料。
{"title":"New definition of AKI: shifting the focus beyond mortality","authors":"Lihong Zhu, Juan Lin","doi":"10.1186/s13054-024-05170-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05170-0","url":null,"abstract":"<p>To the editor,</p><p>We read with great interest the recent study [1] by Dr. Machado et al., which proposed a new definition for acute kidney injury (AKI) in critically Ill patients, based on varied urine output thresholds and time frames. This study uses in-hospital mortality as an outcome-oriented approach to compose the proposed UO-AKI classification, applying different time frames (3 h, 6 h, 12 h, and 24 h) and distinct cutoff points. Ultimately, the average UO over 6-h frame was used for the new classification, and AKI was redefined as follows: stage 1 (0.2–0.3 mL/kg/h), stage 2 (0.1–0.2 mL/kg/h), and stage 3 (< 0.1 mL/kg/h) over 6 h. this proposed classification demonstrated superior predictive accuracy over the KDIGO criteria, with improved NRI and IDI for mortality. However, some details need to be considered carefully when interpreting and applying the findings.</p><p>First, in the current study, the ability to predict death was used as a criterion to evaluate the quality of AKI criteria. However, the essence of the AKI definition is to reflect impaired excretion of metabolic waste due to damage to the renal tubules and/or renal interstitium. Moreover, not all AKI stages are associated with increased mortality. For instance, in a prospective study [2] including 4683 patients, Kaddourah et al. reported that severe AKI (stage 2–3) conferred an increased risk of death by day 28 after adjustment for 16 covariates while mild AKI stage 1 was not. Similarly, an analysis [3] of two large trials (COVID-19 Critical Care Consortium and LUNG-SAFE studies) showed that both 28-day and 90-day mortality risk was increased for patients with stage 2 (HR 2.00, <i>p</i> < 0.001) and stage 3 AKI (HR 1.95, <i>p</i> < 0.001), but not for stage 1. Therefore, using a mortality-oriented approach to define AKI may overlook the significance of mild AKI (stage 1) and may explain why the proposed classification's urine volume threshold for AKI stage 1 (0.2–0.3 mL/kg/h) is similar to the stage 3 threshold (0.3 mL/kg/h) in the KDIGO guidelines, albeit with different time frames. Also, this approach could introduce bias into the understanding of AKI’s clinical significance, as it focuses solely on the risk of death while neglecting the kidney dysfunction and injury that are essential to the definition of AKI. In addition, we are also somewhat unclear about the time frame definition. Were all time frames measured as the corresponding hours after ICU admission, or were they sliding windows? This distinction may be important for accurately defining AKI.</p><p>Finally, we commend Dr. Machado et al. for their significant work, and we hope our perspectives will help in the interpretation of these findings.</p><p>No datasets were generated or analysed during the current study.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Machado GD, Santos LL, Liborio AB. Redefining urine output thresholds for acu","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"74 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142673904","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-19DOI: 10.1186/s13054-024-05165-x
Sesmu M. Arbous, Fabian Termorshuizen, Sylvia Brinkman, Dylan W. de Lange, Rob J. Bosman, Olaf M. Dekkers, Nicolette F. de Keizer
Sepsis is a frequent reason for ICU admission and a leading cause of death. Its incidence has been increasing over the past decades. While hospital mortality is decreasing, it is recognized that the sequelae of sepsis extend well beyond hospitalization and are associated with a high mortality rate that persists years after hospitalization. The aim of this study was to disentangle the relative contribution of sepsis (infection with multi-organ failure), of infection and of inflammation, as reasons for ICU admission to long-term survival. This was done as infection and inflammation are both cardinal features of sepsis. We assessed the 3-year mortality of ICU patients admitted with sepsis, with individually matched ICU patients with an infection but not sepsis, and with an inflammatory illness not caused by infection, discharged alive from hospital. A multicenter cohort study of adult ICU survivors admitted between January 1st 2007 and January 1st 2019, with sepsis, an infection or an inflammatory illness. Patients were classified within the first 24 h of ICU admission according to APACHE IV admission diagnoses. Dutch ICUs (n = 78) prospectively recorded demographic and clinical data of all admissions in the NICE registry. These data were linked to a health care insurance claims database to obtain 3-year mortality data. To better understand and distinct the sepsis cohort from the non-sepsis infection and inflammatory condition cohorts, we performed several sensitivity analyses with varying definitions of the infection and inflammatory illness cohort. Three-year mortality after discharge was 32.7% in the sepsis (N = 10,000), 33.6% in the infectious (N = 10,000), and 23.8% in the inflammatory illness cohort (N = 9997). Compared with sepsis patients, the adjusted HR for death within 3 years after hospital discharge was 1.00 (95% CI 0.95–1.05) for patients with an infection and 0.88 (95% CI 0.83–0.94) for patients with an inflammatory illness. Both sepsis and non-sepsis infection patients had a significantly increased hazard rate of death in the 3 years after hospital discharge compared with patients with an inflammatory illness. Among sepsis and infection patients, one third died in the next 3 years, approximately 10% more than patients with an inflammatory illness. The fact that we did not find a difference between patients with sepsis or an infection suggests that the necessity for an ICU admission with an infection increases the risk of long-term mortality. This result emphasizes the need for greater attention to the post-ICU management of sepsis, infection, and severe inflammatory illness survivors.
{"title":"Three-year mortality of ICU survivors with sepsis, an infection or an inflammatory illness: an individually matched cohort study of ICU patients in the Netherlands from 2007 to 2019","authors":"Sesmu M. Arbous, Fabian Termorshuizen, Sylvia Brinkman, Dylan W. de Lange, Rob J. Bosman, Olaf M. Dekkers, Nicolette F. de Keizer","doi":"10.1186/s13054-024-05165-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05165-x","url":null,"abstract":"Sepsis is a frequent reason for ICU admission and a leading cause of death. Its incidence has been increasing over the past decades. While hospital mortality is decreasing, it is recognized that the sequelae of sepsis extend well beyond hospitalization and are associated with a high mortality rate that persists years after hospitalization. The aim of this study was to disentangle the relative contribution of sepsis (infection with multi-organ failure), of infection and of inflammation, as reasons for ICU admission to long-term survival. This was done as infection and inflammation are both cardinal features of sepsis. We assessed the 3-year mortality of ICU patients admitted with sepsis, with individually matched ICU patients with an infection but not sepsis, and with an inflammatory illness not caused by infection, discharged alive from hospital. A multicenter cohort study of adult ICU survivors admitted between January 1st 2007 and January 1st 2019, with sepsis, an infection or an inflammatory illness. Patients were classified within the first 24 h of ICU admission according to APACHE IV admission diagnoses. Dutch ICUs (n = 78) prospectively recorded demographic and clinical data of all admissions in the NICE registry. These data were linked to a health care insurance claims database to obtain 3-year mortality data. To better understand and distinct the sepsis cohort from the non-sepsis infection and inflammatory condition cohorts, we performed several sensitivity analyses with varying definitions of the infection and inflammatory illness cohort. Three-year mortality after discharge was 32.7% in the sepsis (N = 10,000), 33.6% in the infectious (N = 10,000), and 23.8% in the inflammatory illness cohort (N = 9997). Compared with sepsis patients, the adjusted HR for death within 3 years after hospital discharge was 1.00 (95% CI 0.95–1.05) for patients with an infection and 0.88 (95% CI 0.83–0.94) for patients with an inflammatory illness. Both sepsis and non-sepsis infection patients had a significantly increased hazard rate of death in the 3 years after hospital discharge compared with patients with an inflammatory illness. Among sepsis and infection patients, one third died in the next 3 years, approximately 10% more than patients with an inflammatory illness. The fact that we did not find a difference between patients with sepsis or an infection suggests that the necessity for an ICU admission with an infection increases the risk of long-term mortality. This result emphasizes the need for greater attention to the post-ICU management of sepsis, infection, and severe inflammatory illness survivors.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"55 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142670816","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-19DOI: 10.1186/s13054-024-05162-0
Nicolas Boulet, Joris Pensier, Bob-Valéry Occean, Pascale Fabbro Peray, Olivier Mimoz, Claire M. Rickard, Niccolò Buetti, Jean-Yves Lefrant, Laurent Muller, Claire Roger
During central venous catheterization (CVC), ultrasound (US) guidance has been shown to reduce mechanical complications and increase success rates compared to the anatomical landmark (AL) technique. However, the impact of US guidance on catheter-related infections remains controversial. This systematic review and meta-analysis aimed to compare the risk of catheter-related infection with US-guided CVC versus AL technique. A systematic search on MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases was conducted until July 31, 2024. Randomized controlled trials (RCTs) and non-randomized studies of intervention (NRSI) comparing US-guided versus AL-guided CVC placement were included. The primary outcome was a composite outcome including all types of catheter-related infection: catheter-related bloodstream infections (CRBSIs), central line-associated bloodstream infections (CLABSIs), catheter colonization, or any other type of reported infection. The secondary outcomes included individual infection types and mortality at day-28. Subgroup analyses based on study type and operator experience were also performed. Pooling twelve studies (8 RCTs and 4 NRSI), with a total of 5,092 CVC procedures (2072 US-guided and 3020 AL-guided), US-guided CVC was associated with a significant reduction in catheter-related infections compared with the AL technique (risk ratio (RR) = 0.68, 95% confidence interval (CI) 0.53–0.88). In the RCT subgroup, the pooled RR was 0.65 (95% CI 0.49–0.87). This effect was more pronounced in procedures performed by experienced operators (RR = 0.60, 95% CI 0.41–0.89). In inexperienced operators, the infection risk reduction was not statistically significant. The pooled analysis of CRBSIs and CLABSIs also favored US guidance (RR = 0.65, 95% CI 0.48–0.87). US-guided CVC placement significantly reduces the risk of catheter-related infections compared to the AL technique, particularly when performed by experienced operators. Trial registration PROSPERO CRD42022350884. Registered 13 August 2022.
在中心静脉导管插入术（CVC）中，与解剖标志（AL）技术相比，超声（US）引导可减少机械并发症并提高成功率。然而，超声引导对导管相关感染的影响仍存在争议。本系统综述和荟萃分析旨在比较 US 引导 CVC 与 AL 技术的导管相关感染风险。截至 2024 年 7 月 31 日，我们在 MEDLINE、Cochrane 对照试验中央注册中心 (CENTRAL) 和 Web of Science 数据库中进行了系统检索。纳入了比较 US 引导与 AL 引导 CVC 置管术的随机对照试验 (RCT) 和非随机干预研究 (NRSI)。主要结果是包括所有导管相关感染类型的综合结果：导管相关血流感染（CRBSIs）、中心静脉相关血流感染（CLABSIs）、导管定植或任何其他类型的报告感染。次要结果包括个别感染类型和第 28 天的死亡率。还根据研究类型和操作者经验进行了分组分析。汇总了 12 项研究（8 项 RCT 和 4 项 NRSI），共进行了 5092 例 CVC 手术（2072 例 US 引导和 3020 例 AL 引导），与 AL 技术相比，US 引导 CVC 可显著减少导管相关感染（风险比 (RR) = 0.68，95% 置信区间 (CI) 0.53-0.88）。在 RCT 分组中，汇总的 RR 为 0.65（95% 置信区间为 0.49-0.87）。这一效应在由经验丰富的操作者实施的手术中更为明显（RR = 0.60，95% CI 0.41-0.89）。对于缺乏经验的操作者，感染风险的降低并无统计学意义。对 CRBSIs 和 CLABSIs 的汇总分析也显示 US 引导更有效（RR = 0.65，95% CI 0.48-0.87）。与AL技术相比，US引导下的CVC置管可显著降低导管相关感染的风险，尤其是由经验丰富的操作者进行置管。试验注册号：PROSPERO CRD42022350884。注册日期：2022 年 8 月 13 日。
{"title":"Central venous catheter-related infections: a systematic review, meta-analysis, trial sequential analysis and meta-regression comparing ultrasound guidance and landmark technique for insertion","authors":"Nicolas Boulet, Joris Pensier, Bob-Valéry Occean, Pascale Fabbro Peray, Olivier Mimoz, Claire M. Rickard, Niccolò Buetti, Jean-Yves Lefrant, Laurent Muller, Claire Roger","doi":"10.1186/s13054-024-05162-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05162-0","url":null,"abstract":"During central venous catheterization (CVC), ultrasound (US) guidance has been shown to reduce mechanical complications and increase success rates compared to the anatomical landmark (AL) technique. However, the impact of US guidance on catheter-related infections remains controversial. This systematic review and meta-analysis aimed to compare the risk of catheter-related infection with US-guided CVC versus AL technique. A systematic search on MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases was conducted until July 31, 2024. Randomized controlled trials (RCTs) and non-randomized studies of intervention (NRSI) comparing US-guided versus AL-guided CVC placement were included. The primary outcome was a composite outcome including all types of catheter-related infection: catheter-related bloodstream infections (CRBSIs), central line-associated bloodstream infections (CLABSIs), catheter colonization, or any other type of reported infection. The secondary outcomes included individual infection types and mortality at day-28. Subgroup analyses based on study type and operator experience were also performed. Pooling twelve studies (8 RCTs and 4 NRSI), with a total of 5,092 CVC procedures (2072 US-guided and 3020 AL-guided), US-guided CVC was associated with a significant reduction in catheter-related infections compared with the AL technique (risk ratio (RR) = 0.68, 95% confidence interval (CI) 0.53–0.88). In the RCT subgroup, the pooled RR was 0.65 (95% CI 0.49–0.87). This effect was more pronounced in procedures performed by experienced operators (RR = 0.60, 95% CI 0.41–0.89). In inexperienced operators, the infection risk reduction was not statistically significant. The pooled analysis of CRBSIs and CLABSIs also favored US guidance (RR = 0.65, 95% CI 0.48–0.87). US-guided CVC placement significantly reduces the risk of catheter-related infections compared to the AL technique, particularly when performed by experienced operators. Trial registration PROSPERO CRD42022350884. Registered 13 August 2022.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"65 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142673905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-19DOI: 10.1186/s13054-024-05150-4
Letao Li, Julia Zinger, Sebastiaan D. T. Sassen, Nicole P. Juffermans, Birgit C. P. Koch, Henrik Endeman
The level of inflammation alters drug pharmacokinetics (PK) in critically ill patients. This might compromise treatment efficacy. Understanding the specific effects of inflammation, measured by biomarkers, on drug absorption, distribution, metabolism, and excretion is might help in optimizing dosing strategies. This review investigates the relationship between inflammatory biomarkers and PK parameters absorption, distribution, metabolism and excretion (ADME) in critically ill patients, providing insight in the complexity of dosing drugs in critically ill patients. Following PRISMA guidelines, we conducted a comprehensive search of Medline, Embase, Web of Science, and Cochrane databases (January 1946–November 2023). Studies examining inflammatory biomarkers, PK parameters, or drug exposure in critically ill patients were included. Records were screened by title, abstract, and full text, with any discrepancies resolved through discussion or consultation with a third reviewer. Of the 4479 records screened, 31 met our inclusion criteria: 2 on absorption, 7 on distribution, 17 on metabolism, and 6 on excretion. In general, results are only available for a limited number of drugs, and most studies are done only looking at one of the components of ADME. Higher levels of inflammatory biomarkers may increase or decrease drug absorption depending on whether the drug undergoes hepatic first-pass elimination. For drug distribution, inflammation is negatively correlated with drug protein binding capacity, positively correlated with cerebrospinal fluid penetration, and negatively correlated with peritoneal penetration. Metabolizing capacity of most drugs was inversely correlated with inflammatory biomarkers. Regarding excretion, inflammation can lead to reduced drug clearance, except in the neonatal population. Inflammatory biomarkers can offer valuable information regarding altered PK in critically ill patients. Our findings emphasize the need to consider inflammation-driven PK variability when individualizing drug therapy in this setting, at the same time research is limited to certain drugs and needs further research, also including pharmacodynamics.
{"title":"The relation between inflammatory biomarkers and drug pharmacokinetics in the critically ill patients: a scoping review","authors":"Letao Li, Julia Zinger, Sebastiaan D. T. Sassen, Nicole P. Juffermans, Birgit C. P. Koch, Henrik Endeman","doi":"10.1186/s13054-024-05150-4","DOIUrl":"https://doi.org/10.1186/s13054-024-05150-4","url":null,"abstract":"The level of inflammation alters drug pharmacokinetics (PK) in critically ill patients. This might compromise treatment efficacy. Understanding the specific effects of inflammation, measured by biomarkers, on drug absorption, distribution, metabolism, and excretion is might help in optimizing dosing strategies. This review investigates the relationship between inflammatory biomarkers and PK parameters absorption, distribution, metabolism and excretion (ADME) in critically ill patients, providing insight in the complexity of dosing drugs in critically ill patients. Following PRISMA guidelines, we conducted a comprehensive search of Medline, Embase, Web of Science, and Cochrane databases (January 1946–November 2023). Studies examining inflammatory biomarkers, PK parameters, or drug exposure in critically ill patients were included. Records were screened by title, abstract, and full text, with any discrepancies resolved through discussion or consultation with a third reviewer. Of the 4479 records screened, 31 met our inclusion criteria: 2 on absorption, 7 on distribution, 17 on metabolism, and 6 on excretion. In general, results are only available for a limited number of drugs, and most studies are done only looking at one of the components of ADME. Higher levels of inflammatory biomarkers may increase or decrease drug absorption depending on whether the drug undergoes hepatic first-pass elimination. For drug distribution, inflammation is negatively correlated with drug protein binding capacity, positively correlated with cerebrospinal fluid penetration, and negatively correlated with peritoneal penetration. Metabolizing capacity of most drugs was inversely correlated with inflammatory biomarkers. Regarding excretion, inflammation can lead to reduced drug clearance, except in the neonatal population. Inflammatory biomarkers can offer valuable information regarding altered PK in critically ill patients. Our findings emphasize the need to consider inflammation-driven PK variability when individualizing drug therapy in this setting, at the same time research is limited to certain drugs and needs further research, also including pharmacodynamics.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"23 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142673907","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-19DOI: 10.1186/s13054-024-05153-1
Annika Reintam Blaser, Antonella Cotoia, Mette M. Berger, Martin Padar, Yaseen M. Arabi, Michael P. Casaer, Jan Gunst, Imre W. K. Kouw, Manu L. N. G. Malbrain, Stefan J. Schaller, Joel Starkopf, Martin Sundström Rehal, Arthur R. H. van Zanten, Kaspar F. Bachmann
<p>In the context of an international, multicentre observational study—the GUTPHOS study [1]—the investigators documented the use of parenteral nutrition (PN), including daily energy intake via this route. A secondary outcome, “days free of PN," was planned to validate a gastrointestinal dysfunction score. During data quality check, we observed that the definition of PN varied among the participating sites. This observation was further confirmed in a subsequent survey, in which the sites were asked to report the approach they used to document PN. All 28 GUTPHOS study sites (21 from Europe, four from Asia, one from North America, one from South America and one from Oceania) responded and reported their approach (Fig. 1A). In addition to some expectable differences in practice (e.g., using multi-chamber bags vs. separate components), relevant conceptual variability was observed, leading the steering committee to develop a consensus definition for PN in GUTPHOS: “The administration of intravenous amino acids or lipids alone, or any combination of at least two macronutrient components is considered as being PN, whereas administration of only glucose in any concentration is not.” Sites adjusted their data accordingly.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><source srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05153-1/MediaObjects/13054_2024_5153_Fig1_HTML.png?as=webp" type="image/webp"/><img alt="figure 1" aria-describedby="Fig1" height="615" loading="lazy" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05153-1/MediaObjects/13054_2024_5153_Fig1_HTML.png" width="685"/></picture><p>Results of the survey among 28 sites participating in the GUTPHOS study. <b>A</b> Frequency of Positive Responses for PN Options. Bubble chart representing the frequency of responses for different Parenteral Nutrition (PN) options in the survey with 28 sites. Each bubble represents a PN option. Each bubble's size and colour intensity correspond to the number of positive responses for that option, with larger and brighter bubbles indicating more frequent selection. The number inside each bubble indicates the exact count of positive responses. PN options are labelled beneath each bubble. <i>AA</i> amino acids. <b>B</b> Summary of minimum requirements to label a solution as PN. Bar chart illustrating the diversity in defining Parenteral Nutrition (PN) among survey respondents. The x-axis shows five categories of increasing complexity in PN definition, from "Any single component" to "Only commercial preparations." The y-axis and bar heights represent the number of responses in each category. The sites were categorised according to the minimal definition (left-to-right on the x-axis)</p><span>Full size image</span><svg aria-hidden="true" focusable="false" height="16" role="img" width="16"><use xlink:href="#icon-eds-i-chevron-right-small" xmlns:xlin
阿根廷布宜诺斯艾利斯拉普拉塔圣马丁：Cecilia Loudet；希腊雅典 KAT Atikki 综合医院：Maria Theodorakopoulou；罗马涅 USL：Azienda USL della Romagna, Cesena, Italy：Giuliano Bolondi；捷克共和国布拉格 Královské Vinohrady 大学医院：František Duška；西班牙巴塞罗那 Clínic de Barcelona 医院：西班牙巴塞罗那 Clínic de Barcelona 医院：Juan Carlos Lopez-Delgado；新西兰奥克兰市奥克兰市医院：Varsha Asrani：Varsha Asrani；Univerity Cinical Center Niš，Niš，Serbia：Natalija Vukovic；North Estonia Medical Centre，Tallinn，Estonia：Oskar Appelberg；美国休斯顿卫理公会医院研究所：Raul Sanchez Leon；爱沙尼亚塔林北爱沙尼亚医疗中心：Oskar Appelberg；美国休斯顿卫理公会医院研究所：Raul Sanchez Leon；爱沙尼亚塔林北爱沙尼亚医疗中心：Oskar Appelberg：Raul Sanchez Leon；法国贝桑松 CHU de Besançon：Guillaume Besch；莱比锡大学，德国莱比锡：Sirak Petros；瑞典斯德哥尔摩 Södersjukhuset AB：Rebecka Rubenson Wahlin；中国成都华西医院：Qin Wu；塞尔维亚贝尔格莱德塞尔维亚大学临床中心：Jovana Stanisavljevic；吉林大学第一医院，中国吉林：GUTPHOS研究由ESICM费森尤斯卡比临床营养奖2023和爱沙尼亚研究理事会（PRG1255）资助。作者和单位爱沙尼亚塔尔图，塔尔图大学临床医学研究所麻醉学和重症监护系Annika Reintam Blaser, Martin Padar, Joel Starkopf & Kaspar F.Bachmann 卢塞恩州立医院，瑞士卢塞恩Annika Reintam Blaser & Benjamin Hess意大利福贾大学医院麻醉和重症监护部Antonella Cotoia洛桑大学医学和生物学系，瑞士洛桑Mette M. Berger塔尔图大学医院，瑞士塔尔图M.Berger爱沙尼亚塔尔图，塔尔图大学医院Martin Padar, Joel Starkopf & Anna-Liisa Voomets沙特阿拉伯利雅得，沙特本阿卜杜勒阿齐兹国王健康科学大学医学院，阿卜杜拉国王国际医学研究中心，阿卜杜勒阿齐兹国王医疗城重症监护部，国民卫队-卫生事务部Yaseen M. ArabiClinical Division and Laboratory。ArabiClinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, BelgiumMichael P.Casaer & Jan GunstGelderse Vallei 医院，荷兰埃德Imre W. K. Kouw, Arthur R. H. van Zanten & Yvonnen Swaen-DekkersDivision of Human Nutrition and Health, Nutritional Biology, Wageningen University and Research, Wageningen, The NetherlandsImre W. K. Kouw & Arthur R. H. van ZantenFirst Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, PolandManu L. N. G. MalbrainD.N. G. MalbrainDepartment of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, AustriaStefan J. SchallerDepartment of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, Berlin, GermanyStefan J. Schaller & Linus J. Schaller & Linus J. Schaller & Linus J. Schaller & Linus J. Schaller &.Schaller & Linus O. Warner瑞典斯德哥尔摩卡罗林斯卡大学医院围手术期医学和重症监护马丁-桑德斯特罗姆-雷哈尔瑞典斯德哥尔摩卡罗林斯卡研究所临床科学、干预和技术部（CLINTEC）麻醉和重症监护科马丁-桑德斯特罗姆-雷哈尔瑞士伯尔尼伯尔尼大学 Inselspital 医院重症监护医学部卡斯帕-巴赫曼（Kaspar F. Bachmann）瑞典斯德哥尔摩卡罗林斯卡大学医院围手术期医学和重症监护科卡斯帕-巴赫曼（Kaspar F. Bachmann）瑞典斯德哥尔摩卡罗林斯卡研究所临床科学、干预和技术部（CLINTEC）麻醉和重症监护科卡斯帕-巴赫曼（Kaspar F. Bachmann）瑞典斯德哥尔摩卡罗林斯卡大学医院围手术期医学和重症监护科BachmannKarolinska University Hospital Huddinge, Stockholm, SwedenRebecca LindströmKarolinska University Hospital Solna, Solna, SwedenJonas BlixtCHUV, Centre Hospitalier Universitaire Vaudois, Lausanne, SwitzerlandOlivier PantetKing Abdullah International Me
{"title":"How to define parenteral nutrition","authors":"Annika Reintam Blaser, Antonella Cotoia, Mette M. Berger, Martin Padar, Yaseen M. Arabi, Michael P. Casaer, Jan Gunst, Imre W. K. Kouw, Manu L. N. G. Malbrain, Stefan J. Schaller, Joel Starkopf, Martin Sundström Rehal, Arthur R. H. van Zanten, Kaspar F. Bachmann","doi":"10.1186/s13054-024-05153-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05153-1","url":null,"abstract":"<p>In the context of an international, multicentre observational study—the GUTPHOS study [1]—the investigators documented the use of parenteral nutrition (PN), including daily energy intake via this route. A secondary outcome, “days free of PN,\" was planned to validate a gastrointestinal dysfunction score. During data quality check, we observed that the definition of PN varied among the participating sites. This observation was further confirmed in a subsequent survey, in which the sites were asked to report the approach they used to document PN. All 28 GUTPHOS study sites (21 from Europe, four from Asia, one from North America, one from South America and one from Oceania) responded and reported their approach (Fig. 1A). In addition to some expectable differences in practice (e.g., using multi-chamber bags vs. separate components), relevant conceptual variability was observed, leading the steering committee to develop a consensus definition for PN in GUTPHOS: “The administration of intravenous amino acids or lipids alone, or any combination of at least two macronutrient components is considered as being PN, whereas administration of only glucose in any concentration is not.” Sites adjusted their data accordingly.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05153-1/MediaObjects/13054_2024_5153_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"615\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05153-1/MediaObjects/13054_2024_5153_Fig1_HTML.png\" width=\"685\"/></picture><p>Results of the survey among 28 sites participating in the GUTPHOS study. <b>A</b> Frequency of Positive Responses for PN Options. Bubble chart representing the frequency of responses for different Parenteral Nutrition (PN) options in the survey with 28 sites. Each bubble represents a PN option. Each bubble's size and colour intensity correspond to the number of positive responses for that option, with larger and brighter bubbles indicating more frequent selection. The number inside each bubble indicates the exact count of positive responses. PN options are labelled beneath each bubble. <i>AA</i> amino acids. <b>B</b> Summary of minimum requirements to label a solution as PN. Bar chart illustrating the diversity in defining Parenteral Nutrition (PN) among survey respondents. The x-axis shows five categories of increasing complexity in PN definition, from \"Any single component\" to \"Only commercial preparations.\" The y-axis and bar heights represent the number of responses in each category. The sites were categorised according to the minimal definition (left-to-right on the x-axis)</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlin","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"52 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142670817","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-19DOI: 10.1186/s13054-024-05169-7
Haotian Zhao, Kai Liu, Li Li, Heling Zhao
<p>We read with interest the article by Michael Beshara et al. [1] entitled “Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies”. In this review, the author provides a complete and accurate description of the latest applications of pulmonary ultrasound. For the part of pneumothorax, only the diagnostic methods and ultrasound signs were described. However, the application of pneumothorax in pulmonary imaging tools should include qualitative diagnosis, quantification, and localization.</p><p>Numerous studies have demonstrated the value of lung ultrasound in diagnosing pneumothorax. Lung ultrasound can preliminarily diagnose pneumothorax by identifying four key signs: absence of pleural sliding, lung pulse, B-lines, and lung consolidation [2, 3]. Additionally, scanning for the “lung point” and/or “stratosphere sign” aids in diagnosing and localizing pneumothorax [4]. However, for intensivists, quantitative assessment is crucial for making informed decisions regarding treatment strategies for pneumothorax. This assessment helps determine whether to adopt conservative management, such as watchful waiting, or to proceed with interventional options like chest tube placement. In this context, the diagnostic accuracy of lung ultrasound is superior to that of supine chest X-ray (CXR); however, this evaluation may have significant limitations [5].</p><p>It is suggested that when lung ultrasound shows a complete "stratosphere sign" (absence of the lung point sign) on one side, it indicates that the lung lobe has been fully compressed by intrapleural gas, resulting in a complete loss of pleural apposition, potentially indicating a large pneumothorax. However, the actual volume of pneumothorax in patients with a complete stratosphere sign can vary widely. In three patients with a complete stratosphere sign on one side, chest CT scans revealed varying degrees of lung compression by pneumothorax, resulting in significant differences in pneumothorax volume and subsequent treatment choices (Fig. 1A–C). Thus, the complete stratosphere sign only indicates a large surface area of pneumothorax but cannot quantify its volume.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><source srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05169-7/MediaObjects/13054_2024_5169_Fig1_HTML.png?as=webp" type="image/webp"/><img alt="figure 1" aria-describedby="Fig1" height="694" loading="lazy" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05169-7/MediaObjects/13054_2024_5169_Fig1_HTML.png" width="685"/></picture><p>Three patients with pneumothorax all showed the stratosphere sign on lung ultrasound, but the pneumothorax volume could not be quantified: <b>a</b> Lung compression was approximately 20%. <b>b</b> Lung compression was approximately 50%. <b>c</b> Lung compression was more than 90%</p><span>Full
我们饶有兴趣地阅读了 Michael Beshara 等人[1]撰写的题为 "肺部超声的基本原理：实用性、扫描技术、方案和常见病症的发现 "的文章。在这篇综述中，作者完整而准确地描述了肺部超声的最新应用。对于气胸部分，只介绍了诊断方法和超声征象。然而，肺部成像工具对气胸的应用应包括定性诊断、定量诊断和定位诊断。大量研究证明了肺部超声在诊断气胸方面的价值。肺部超声波可通过识别四个关键征象初步诊断气胸：无胸膜滑动、肺脉搏、B 线和肺实变[2, 3]。此外，扫描 "肺点 "和/或 "平流层征 "有助于气胸的诊断和定位[4]。然而，对于重症监护医生来说，定量评估对于气胸治疗策略的明智决策至关重要。这种评估有助于确定是采取保守治疗（如观察等待），还是进行介入治疗（如放置胸管）。在这种情况下，肺部超声波的诊断准确性优于仰卧位胸部 X 光检查（CXR）；然而，这种评估方法可能有很大的局限性[5]。有学者认为，当肺部超声波显示一侧肺叶完全出现 "平流层征"（无肺点征）时，表明肺叶已被胸膜内气体完全压迫，导致胸膜完全脱落，有可能是大气胸。然而，完全平气层征兆患者的实际气胸量可能差别很大。在三位一侧有完全平流层征的患者中，胸部 CT 扫描显示气胸对肺部的压迫程度各不相同，导致气胸体积和后续治疗方案有显著差异（图 1A-C）。图 1三位气胸患者在肺部超声波检查中均显示平流层征象，但气胸体积无法量化：a 肺压缩约 20%；b 肺压缩约 50%；c 肺压缩超过 90%全尺寸图片肺点征象标志着胸膜层贴合的正常肺与胸膜层分离的气胸之间的界限。有人认为，当肺点征更靠近上肺时，可能表示气胸较小[6]。然而，这种假设并不完全准确。肺点征象只能反映气胸的表面积，与实际体积可能并不相关。例如，在两名在同一解剖位置出现肺点征象的患者中，胸部 CT 扫描显示胸腔内气体深度存在显著差异，导致气胸体积差异很大，治疗方案也不同（图 2A，B）。因此，肺点征只能显示气胸的表面范围，不能用于定量评估气胸的体积。图 2 两名气胸患者在肺部超声检查中均显示肺点征，肺点位置几乎相同（位于左侧胸壁、腋后线和第 7 肋骨的交界处）。a 肺压缩率约为 70%. b 肺压缩率约为 10%Full size image 总之，由于肺部超声波不能评估气胸的深度，因此完全平流层征（无肺点征）和肺点征都只能对气胸进行定性诊断，并显示气胸在患侧的表面位置。但是，它们不能直接评估气胸的体积。考虑到 CT 才是金标准，认识到肺部超声在定量评估气胸方面的局限性至关重要。支持本文结论的数据集包含在文章中。肺部超声的要点与难点：实用性、扫描技术、方案和常见病症的发现。Crit Care.2024; 28(1):328.Article PubMed PubMed Central Google Scholar Volpicelli G. Sonographic diagnosis of pneumothorax.重症监护医学。2011;37(2):224-32.Article PubMed Google Scholar Lichtenstein DA.BLUE协议和FALLS协议：肺部超声在重症患者中的两种应用。Chest.2015;147(6):1659-70.
{"title":"Pitfall of lung ultrasound in the quantification of pneumothorax","authors":"Haotian Zhao, Kai Liu, Li Li, Heling Zhao","doi":"10.1186/s13054-024-05169-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05169-7","url":null,"abstract":"<p>We read with interest the article by Michael Beshara et al. [1] entitled “Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies”. In this review, the author provides a complete and accurate description of the latest applications of pulmonary ultrasound. For the part of pneumothorax, only the diagnostic methods and ultrasound signs were described. However, the application of pneumothorax in pulmonary imaging tools should include qualitative diagnosis, quantification, and localization.</p><p>Numerous studies have demonstrated the value of lung ultrasound in diagnosing pneumothorax. Lung ultrasound can preliminarily diagnose pneumothorax by identifying four key signs: absence of pleural sliding, lung pulse, B-lines, and lung consolidation [2, 3]. Additionally, scanning for the “lung point” and/or “stratosphere sign” aids in diagnosing and localizing pneumothorax [4]. However, for intensivists, quantitative assessment is crucial for making informed decisions regarding treatment strategies for pneumothorax. This assessment helps determine whether to adopt conservative management, such as watchful waiting, or to proceed with interventional options like chest tube placement. In this context, the diagnostic accuracy of lung ultrasound is superior to that of supine chest X-ray (CXR); however, this evaluation may have significant limitations [5].</p><p>It is suggested that when lung ultrasound shows a complete \"stratosphere sign\" (absence of the lung point sign) on one side, it indicates that the lung lobe has been fully compressed by intrapleural gas, resulting in a complete loss of pleural apposition, potentially indicating a large pneumothorax. However, the actual volume of pneumothorax in patients with a complete stratosphere sign can vary widely. In three patients with a complete stratosphere sign on one side, chest CT scans revealed varying degrees of lung compression by pneumothorax, resulting in significant differences in pneumothorax volume and subsequent treatment choices (Fig. 1A–C). Thus, the complete stratosphere sign only indicates a large surface area of pneumothorax but cannot quantify its volume.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05169-7/MediaObjects/13054_2024_5169_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"694\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05169-7/MediaObjects/13054_2024_5169_Fig1_HTML.png\" width=\"685\"/></picture><p>Three patients with pneumothorax all showed the stratosphere sign on lung ultrasound, but the pneumothorax volume could not be quantified: <b>a</b> Lung compression was approximately 20%. <b>b</b> Lung compression was approximately 50%. <b>c</b> Lung compression was more than 90%</p><span>Full ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"40 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142670821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sepsis is a global health problem with high morbidity and mortality. Low- and middle-income countries have a higher incidence and poorer outcome with sepsis. Large epidemiological studies in sepsis using Sepsis-3 criteria, addressing the process of care and deriving predictors of mortality are scarce in India. A multicentre, prospective sepsis registry was conducted using Sepsis 3 criteria of suspected or confirmed infection and SOFA score of 2 or more in 19 ICUs in India over a period of one year (August 2022–July 2023). All adult patients admitted to the Intensive Care Unit who fulfilled the Sepsis 3 criteria for sepsis and septic shock were included. Patient infected with Covid 19 were excluded. Patients demographics, severity, admission details, initial resuscitation, laboratory and microbiological data and clinical outcome were recorded. Performance improvement programs as recommended by the Surviving Sepsis guideline were noted from the participating centers. Patients were followed till discharge or death while in hospital. Registry Data of 1172 patients with sepsis (including 500 patients with septic shock) were analysed. The average age of the study cohort was 65 years, and 61% were male. The average APACHE II and SOFA score was 21 and 6.7 respectively. The majority of patients had community-acquired infections, and lung infections were the most common source. Of all culture positive results, 65% were gram negative organism. Carbapenem-resistance was identified in 50% of the gram negative blood culture isolates. The predominant gram negative organisms were Klebsiella spp (25%), Escherechia coli (24%) and Acinetobacter Spp (11%). Tropical infections (Dengue, Malaria, Typhus) constituted minority (n = 32, 2.2%) of sepsis patients. The observed hospital mortality for the entire cohort (n = 1172) was 36.3%, for those without shock (n = 672) it was 25.6% and for those with shock (n = 500) it was 50.8%. The average length of ICU and hospital stay for the study cohort was 8.64 and 11.9 respectively. In multivariate analysis adequate source control, correct choice of empiric antibiotic and the use of intravenous thiamine were protective. The general demographics of the sepsis population in the Indian Sepsis Registry is comparable to Western population. The mortality of sepsis cohort was higher (36.3%) but septic shock mortality (50.8%) was comparable to Western reports. Gram negative infection was the predominant cause of sepsis with a high incidence of carbapenem resistance. Eschericia coli, Klebsiella Spp and Acinetobacter Spp were the predominant causative organism. Tropical infection constituted a minority of sepsis population with low hospital mortality. The SOFA score on admission was a comparatively better predictor of poor outcome. Sepsis secondary to nosocomial infections had the worst outcomes, while source control, correct empirical antibiotic selection, and intravenous thiamine were protective. CTRI Registration CTRI:2022/07/044516.
{"title":"A multicentre prospective registry of one thousand sepsis patients admitted in Indian ICUs: (SEPSIS INDIA) study","authors":"Subhash Todi, Yatin Mehta, Kapil Zirpe, Subhal Dixit, Atul P. Kulkarni, Sushma Gurav, Shweta Ram Chandankhede, Deepak Govil, Amitabha Saha, Arpit Kumar Saha, Sumalatha Arunachala, Kapil Borawake, Shilpushp Bhosale, Sumit Ray, Ruchi Gupta, Swarna Deepak Kuragayala, Srinivas Samavedam, Mehul Shah, Ashit Hegde, Palepu Gopal, Abdul Samad Ansari, Ajoy Krishna Sarkar, Rahul Pandit","doi":"10.1186/s13054-024-05176-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05176-8","url":null,"abstract":"Sepsis is a global health problem with high morbidity and mortality. Low- and middle-income countries have a higher incidence and poorer outcome with sepsis. Large epidemiological studies in sepsis using Sepsis-3 criteria, addressing the process of care and deriving predictors of mortality are scarce in India. A multicentre, prospective sepsis registry was conducted using Sepsis 3 criteria of suspected or confirmed infection and SOFA score of 2 or more in 19 ICUs in India over a period of one year (August 2022–July 2023). All adult patients admitted to the Intensive Care Unit who fulfilled the Sepsis 3 criteria for sepsis and septic shock were included. Patient infected with Covid 19 were excluded. Patients demographics, severity, admission details, initial resuscitation, laboratory and microbiological data and clinical outcome were recorded. Performance improvement programs as recommended by the Surviving Sepsis guideline were noted from the participating centers. Patients were followed till discharge or death while in hospital. Registry Data of 1172 patients with sepsis (including 500 patients with septic shock) were analysed. The average age of the study cohort was 65 years, and 61% were male. The average APACHE II and SOFA score was 21 and 6.7 respectively. The majority of patients had community-acquired infections, and lung infections were the most common source. Of all culture positive results, 65% were gram negative organism. Carbapenem-resistance was identified in 50% of the gram negative blood culture isolates. The predominant gram negative organisms were Klebsiella spp (25%), Escherechia coli (24%) and Acinetobacter Spp (11%). Tropical infections (Dengue, Malaria, Typhus) constituted minority (n = 32, 2.2%) of sepsis patients. The observed hospital mortality for the entire cohort (n = 1172) was 36.3%, for those without shock (n = 672) it was 25.6% and for those with shock (n = 500) it was 50.8%. The average length of ICU and hospital stay for the study cohort was 8.64 and 11.9 respectively. In multivariate analysis adequate source control, correct choice of empiric antibiotic and the use of intravenous thiamine were protective. The general demographics of the sepsis population in the Indian Sepsis Registry is comparable to Western population. The mortality of sepsis cohort was higher (36.3%) but septic shock mortality (50.8%) was comparable to Western reports. Gram negative infection was the predominant cause of sepsis with a high incidence of carbapenem resistance. Eschericia coli, Klebsiella Spp and Acinetobacter Spp were the predominant causative organism. Tropical infection constituted a minority of sepsis population with low hospital mortality. The SOFA score on admission was a comparatively better predictor of poor outcome. Sepsis secondary to nosocomial infections had the worst outcomes, while source control, correct empirical antibiotic selection, and intravenous thiamine were protective. CTRI Registration CTRI:2022/07/044516.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"54 47 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142673908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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