Pub Date : 2025-01-23DOI: 10.1186/s13054-025-05262-5
Simon A. Amacher, Tobias Zimmermann, Pimrapat Gebert, Pascale Grzonka, Sebastian Berger, Martin Lohri, Valentina Tröster, Ketina Arslani, Hamid Merdji, Catherine Gebhard, Sabina Hunziker, Raoul Sutter, Martin Siegemund, Caroline E. Gebhard
Conflicting data exist regarding sex-specific outcomes after cardiac arrest. This study investigates sex disparities in the provision of critical care and outcomes of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. Analysis of adult cardiac arrest patients admitted to certified Swiss intensive care units (ICUs) (01/2008–12/2022) using the nationwide prospective ICU registry. The primary outcome was ICU mortality, with secondary outcomes including ICU admission probability and advanced treatment provision. Among 41,733 individuals (34.9% women), 21,692 patients (30.6% women) were admitted to ICUs (16,571 OHCA patients/5121 IHCA patients). Women were less likely to be admitted to the ICU than men (incidence rate ratio 0.82 [95% CI 0.80–0.85] and had a higher ICU mortality (41.8% vs 36.2%; p < 0.001). Mortality differences were more pronounced in OHCA patients (unadjusted HR: 1.35 [95% CI 1.28–1.43]; adjusted HR: 1.19 [95% CI 1.12–1.25]). In IHCA patients, mortality differences were less pronounced (unadjusted HR: 1.14 [95% CI 1.04–1.25]) and vanished after adjustment for confounders: adjusted HR: 1.03 [95% CI 0.94–1.13]). Women after cardiac arrest were older, more severely ill, and received fewer interventions before (44.7% vs 54.0%; p < 0.001) and during ICU stay. A subgroup analysis of 11,202 patients revealed that treatment limitations were more frequent in women (46.7% vs 38.7%; p < 0.001). However, these limitations were associated with an increased risk of death in both sexes. This study highlights sex disparities in short-term mortality and ICU resource allocation among cardiac arrest patients, with women potentially facing disadvantages, in particular after OHCA. The limitations of ICU registry data, particularly the lack of detailed cardiac arrest-specific and comorbidity information, restrict definitive conclusions. Future research should prioritize prospective studies with more granular data to better understand and address these disparities.
关于心脏骤停后性别差异的结果存在矛盾的数据。本研究调查了住院（IHCA）和院外心脏骤停（OHCA）患者提供重症监护和结果的性别差异。2008年1月至2022年12月期间瑞士重症监护病房（ICU）住院的成人心脏骤停患者分析，使用全国前瞻性ICU登记。主要结局是ICU死亡率，次要结局包括ICU入院概率和晚期治疗提供。在41,733例患者中（34.9%为女性），21,692例患者（30.6%为女性）入住icu（16,571例OHCA患者/5121例IHCA患者）。女性入住ICU的可能性低于男性（发病率比0.82 [95% CI 0.80-0.85]），且ICU死亡率较高(41.8% vs 36.2%；p < 0.001)。OHCA患者的死亡率差异更明显(未调整的HR: 1.35 [95% CI 1.28-1.43]；调整后的HR: 1.19 [95% CI 1.12-1.25])。在IHCA患者中，死亡率差异不太明显（未校正的风险比：1.14 [95% CI 1.04-1.25]），校正混杂因素后死亡率差异消失：校正风险比：1.03 [95% CI 0.94-1.13])。心脏骤停后的女性年龄更大，病情更严重，之前接受的干预更少(44.7% vs 54.0%；p < 0.001)和ICU住院期间。11202例患者的亚组分析显示，治疗限制在女性中更为常见(46.7% vs 38.7%；p < 0.001)。然而，这些限制与两性死亡风险增加有关。这项研究强调了在心脏骤停患者中短期死亡率和ICU资源分配的性别差异，女性可能面临劣势，特别是在OHCA之后。ICU注册数据的局限性，特别是缺乏详细的心脏骤停特异性和合并症信息，限制了明确的结论。未来的研究应优先考虑具有更细粒度数据的前瞻性研究，以更好地理解和解决这些差异。
{"title":"Sex disparities in ICU care and outcomes after cardiac arrest: a Swiss nationwide analysis","authors":"Simon A. Amacher, Tobias Zimmermann, Pimrapat Gebert, Pascale Grzonka, Sebastian Berger, Martin Lohri, Valentina Tröster, Ketina Arslani, Hamid Merdji, Catherine Gebhard, Sabina Hunziker, Raoul Sutter, Martin Siegemund, Caroline E. Gebhard","doi":"10.1186/s13054-025-05262-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05262-5","url":null,"abstract":"Conflicting data exist regarding sex-specific outcomes after cardiac arrest. This study investigates sex disparities in the provision of critical care and outcomes of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. Analysis of adult cardiac arrest patients admitted to certified Swiss intensive care units (ICUs) (01/2008–12/2022) using the nationwide prospective ICU registry. The primary outcome was ICU mortality, with secondary outcomes including ICU admission probability and advanced treatment provision. Among 41,733 individuals (34.9% women), 21,692 patients (30.6% women) were admitted to ICUs (16,571 OHCA patients/5121 IHCA patients). Women were less likely to be admitted to the ICU than men (incidence rate ratio 0.82 [95% CI 0.80–0.85] and had a higher ICU mortality (41.8% vs 36.2%; p < 0.001). Mortality differences were more pronounced in OHCA patients (unadjusted HR: 1.35 [95% CI 1.28–1.43]; adjusted HR: 1.19 [95% CI 1.12–1.25]). In IHCA patients, mortality differences were less pronounced (unadjusted HR: 1.14 [95% CI 1.04–1.25]) and vanished after adjustment for confounders: adjusted HR: 1.03 [95% CI 0.94–1.13]). Women after cardiac arrest were older, more severely ill, and received fewer interventions before (44.7% vs 54.0%; p < 0.001) and during ICU stay. A subgroup analysis of 11,202 patients revealed that treatment limitations were more frequent in women (46.7% vs 38.7%; p < 0.001). However, these limitations were associated with an increased risk of death in both sexes. This study highlights sex disparities in short-term mortality and ICU resource allocation among cardiac arrest patients, with women potentially facing disadvantages, in particular after OHCA. The limitations of ICU registry data, particularly the lack of detailed cardiac arrest-specific and comorbidity information, restrict definitive conclusions. Future research should prioritize prospective studies with more granular data to better understand and address these disparities. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"43 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143020366","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}
In-hospital cardiac arrest (IHCA) poses a considerable threat to hospitalized patients, leading to high mortality rates and severe neurological deficits among survivors. Despite the advancements in resuscitation practices, the prognosis of IHCA remains poor, and comprehensive studies exploring nationwide trends and long-term survival are scarce, particularly in the Asian populations. Utilizing data from the Taiwan National Health Insurance Research Database, we conducted a nationwide cohort study to analyze the IHCA events among adult patients between 2003 and 2020. The outcomes of interest in this study included the temporal trend in the IHCA incidence, in-hospital mortality, and median survival after discharge for overall hospitalizations. Over the 18-year period, the IHCA incidence in Taiwan declined by 70%, from an annual incidence of 7.1 per 1,000 admissions to a lower rate in 2020, accompanied by a 14% reduction in the in-hospital mortality rate, with an average of 86.5%. The overall long-term survival rate for discharged survivors was 63.9%. We observed a substantial 125% increase in the median survival duration of discharged survivors, rising from 1.56 years in 2003 to 3.51 years in 2015. Favorable in-hospital survival rates and extended life expectancy were notably seen in the patients with shockable rhythms, those with a cardiac primary diagnosis, women, and younger patients. Our study data revealed significant declines in the IHCA incidence and in-hospital mortality in Taiwan, along with improved long-term survival among survivors, particularly among specific subgroups. Women exhibited significantly better long-term survival as compared to men, underscoring the need to avoid sex-based treatment biases. Improvements in discharge survival rates and life expectancy were less pronounced in older survivors, indicating that age alone may not be sufficient to guide IHCA management decisions. Proactive resuscitation should be carefully considered for older patients, particularly those with mild frailty and potentially reversible conditions. Trial registration the institutional review board of Chang Gung Memorial Hospital approved all data usage and the study protocol (Registration number: 202301625B0, Registered 7 November 2023)
{"title":"Longitudinal analysis of in-hospital cardiac arrest: trends in the incidence, mortality, and long-term survival of a nationwide cohort","authors":"Feng-Cheng Chang, Ming-Jer Hsieh, Jih-Kai Yeh, Victor Chien-Chia Wu, Yu-Ting Cheng, An-Hsun Chou, Chia-Pin Lin, Chip‐Jin Ng, Shao-Wei Chen, Chun-Yu Chen","doi":"10.1186/s13054-025-05274-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05274-1","url":null,"abstract":"In-hospital cardiac arrest (IHCA) poses a considerable threat to hospitalized patients, leading to high mortality rates and severe neurological deficits among survivors. Despite the advancements in resuscitation practices, the prognosis of IHCA remains poor, and comprehensive studies exploring nationwide trends and long-term survival are scarce, particularly in the Asian populations. Utilizing data from the Taiwan National Health Insurance Research Database, we conducted a nationwide cohort study to analyze the IHCA events among adult patients between 2003 and 2020. The outcomes of interest in this study included the temporal trend in the IHCA incidence, in-hospital mortality, and median survival after discharge for overall hospitalizations. Over the 18-year period, the IHCA incidence in Taiwan declined by 70%, from an annual incidence of 7.1 per 1,000 admissions to a lower rate in 2020, accompanied by a 14% reduction in the in-hospital mortality rate, with an average of 86.5%. The overall long-term survival rate for discharged survivors was 63.9%. We observed a substantial 125% increase in the median survival duration of discharged survivors, rising from 1.56 years in 2003 to 3.51 years in 2015. Favorable in-hospital survival rates and extended life expectancy were notably seen in the patients with shockable rhythms, those with a cardiac primary diagnosis, women, and younger patients. Our study data revealed significant declines in the IHCA incidence and in-hospital mortality in Taiwan, along with improved long-term survival among survivors, particularly among specific subgroups. Women exhibited significantly better long-term survival as compared to men, underscoring the need to avoid sex-based treatment biases. Improvements in discharge survival rates and life expectancy were less pronounced in older survivors, indicating that age alone may not be sufficient to guide IHCA management decisions. Proactive resuscitation should be carefully considered for older patients, particularly those with mild frailty and potentially reversible conditions. Trial registration the institutional review board of Chang Gung Memorial Hospital approved all data usage and the study protocol (Registration number: 202301625B0, Registered 7 November 2023)","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"15 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143020367","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 : 2025-01-22DOI: 10.1186/s13054-025-05271-4
Khalil Chaïbi, Didier Dreyfuss, Stéphane Gaudry
<p>Renal replacement therapy (RRT) is a cornerstone of the management of severe acute kidney injury (AKI) in critically ill patients. Despite being life-saving in several instances, RRT may be associated with significant complications, including bleeding, hemodynamic instability, infections, thrombosis, and possibly delayed renal recovery. Large randomized controlled trials (RCTs) have demonstrated that delaying RRT initiation, in the absence of life-threatening complications (conservative RRT strategy) allows 38% to 49% of patients to avoid RRT. In addition to reducing unnecessary treatment, this conservative approach may help protect kidney function [1,2,3]. Once RRT is initiated, intensivists usually prescribe a recommended (or standard) dose of RRT (a KT/V of 3.9 per week when using intermittent hemodialysis or extended RRT; an effluent volume of 20–25 ml/kg/h for continuous RRT) [4]. This ensures the efficacy of metabolic control but there remains significant uncertainty about how long RRT should be continued. In daily clinical practice, empirical criteria (i.e. increased urine output or decreased blood urea nitrogen) are used to guide RRT weaning. Current guidelines offer indeed little guidance on how to manage this process.</p><p>Given the safety of a conservative RRT initiation strategy, we suggest extending this concept to a new approach (called restrictive RRT strategy) that could potentially solve the hot topic questions of RRT dosing and RRT weaning. This approach would consist in the suspension of RRT after 3 days. At this moment, metabolic abnormalities that mandated RRT initiation would no longer be present and the cause of AKI would be, in most cases, treated (for instance by controlling sepsis or hemorrhage). Then the question would be the same as before the initiation of the first RRT session i.e., does the situation require starting RRT or can it be delayed until a conservative RRT initiation criterion is observed again? If RRT is resumed, the patient will receive a new RRT session, after which RRT will again be suspended. This targeted approach applied until renal recovery-would ensure the use of RRT only when truly necessary rather than its prolongation for vague reasons. The restrictive strategy differs from ongoing studies that investigate the intensity of each RRT session (only for continuous RRT modality) (NCT06446739, NCT06014801, NCT06021288). Indeed, a restrictive approach would not diminish the intensity of each session, well the contrary, but the number of sessions by suspending pending a new indication for resumption occurs. Although this approach presents methodological challenges, we believe it is essential to evaluate it regardless of the initial RRT modality—intermittent (IHD) or continuous (CRRT)—since neither has shown definitive superiority.</p><p>The potential benefits of a restrictive RRT strategy for patients are numerous. By reducing unnecessary RRT exposure, patients could experience fewer episodes of he
{"title":"Renal replacement therapy in ICU: from conservative to restrictive strategy","authors":"Khalil Chaïbi, Didier Dreyfuss, Stéphane Gaudry","doi":"10.1186/s13054-025-05271-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05271-4","url":null,"abstract":"<p>Renal replacement therapy (RRT) is a cornerstone of the management of severe acute kidney injury (AKI) in critically ill patients. Despite being life-saving in several instances, RRT may be associated with significant complications, including bleeding, hemodynamic instability, infections, thrombosis, and possibly delayed renal recovery. Large randomized controlled trials (RCTs) have demonstrated that delaying RRT initiation, in the absence of life-threatening complications (conservative RRT strategy) allows 38% to 49% of patients to avoid RRT. In addition to reducing unnecessary treatment, this conservative approach may help protect kidney function [1,2,3]. Once RRT is initiated, intensivists usually prescribe a recommended (or standard) dose of RRT (a KT/V of 3.9 per week when using intermittent hemodialysis or extended RRT; an effluent volume of 20–25 ml/kg/h for continuous RRT) [4]. This ensures the efficacy of metabolic control but there remains significant uncertainty about how long RRT should be continued. In daily clinical practice, empirical criteria (i.e. increased urine output or decreased blood urea nitrogen) are used to guide RRT weaning. Current guidelines offer indeed little guidance on how to manage this process.</p><p>Given the safety of a conservative RRT initiation strategy, we suggest extending this concept to a new approach (called restrictive RRT strategy) that could potentially solve the hot topic questions of RRT dosing and RRT weaning. This approach would consist in the suspension of RRT after 3 days. At this moment, metabolic abnormalities that mandated RRT initiation would no longer be present and the cause of AKI would be, in most cases, treated (for instance by controlling sepsis or hemorrhage). Then the question would be the same as before the initiation of the first RRT session i.e., does the situation require starting RRT or can it be delayed until a conservative RRT initiation criterion is observed again? If RRT is resumed, the patient will receive a new RRT session, after which RRT will again be suspended. This targeted approach applied until renal recovery-would ensure the use of RRT only when truly necessary rather than its prolongation for vague reasons. The restrictive strategy differs from ongoing studies that investigate the intensity of each RRT session (only for continuous RRT modality) (NCT06446739, NCT06014801, NCT06021288). Indeed, a restrictive approach would not diminish the intensity of each session, well the contrary, but the number of sessions by suspending pending a new indication for resumption occurs. Although this approach presents methodological challenges, we believe it is essential to evaluate it regardless of the initial RRT modality—intermittent (IHD) or continuous (CRRT)—since neither has shown definitive superiority.</p><p>The potential benefits of a restrictive RRT strategy for patients are numerous. By reducing unnecessary RRT exposure, patients could experience fewer episodes of he","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"74 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142992748","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 : 2025-01-21DOI: 10.1186/s13054-025-05255-4
Matthias Mueller, Michael Holzer, Heidrun Losert, Daniel Grassmann, Florian Ettl, Mathias Gatterbauer, Ingrid Magnet, Alexander Nuernberger, Calvin Lukas Kienbacher, Georg Gelbenegger, Michael Girsa, Harald Herkner, Mario Krammel
Microcirculatory alterations are predictive of poor outcomes in patients with shock and after cardiac arrest in animal models. However, microcirculatory alterations during human cardiac arrest have not yet been studied. We prospectively included adult patients receiving resuscitation after witnessed out-of-hospital cardiac arrest. Exclusion criteria were hypovolemia, hypo- or hyperthermia (< 34.0 °C, > 37.5 °C), peripheral arterial disease, Raynaud’s disease, and logistical issues (e.g., shortage of space). Capillary refill time was measured on the finger (CRT-F) and the earlobe (CRT-E) every other minute until return of spontaneous circulation (any ROSC) or termination of resuscitation. The primary endpoint was any ROSC, secondary endpoints were 30-day-mortality and good neurological outcome (defined as cerebral performance category 1–2). Based on the data structure, CRT-F and CRT-E values were grouped post-hoc into quartiles and tertiles. A cluster-robust standard error logistic regression was performed for the primary outcome. Trend analyses were made for each individual. After screening of 141 patients, 50 were included in the analysis (median age 75 years, 28% female, any ROSC 32%). The median CRT-F was > 10 [7–> 10] seconds; the median CRT-E was 3 [3–4] seconds. The any ROSC rate for patients in CRT-F quartile 1 (3–5 s) was 71.4%, 31.7% in quartile 2 (6–8 s), 23.1% in quartile 3 (9–10 s), and 10% in quartile 4 (> 10 s). The odds ratio of 0.39 (95% CI 0.20–0.73, p = 0.004) indicated, that with an increase of CRT-F by a quartile, the chance of achieving any ROSC decreased by 61%. Patients with a decreasing CRT-F achieved any ROSC in 70%, whereas patients with constant or increasing CRT-F had any ROSC in only 21% (p = 0.008). In contrast, CRT-E showed no association with any ROSC (T1 [1–2 s.]: 16.7%, T2 [3 s.]: 27.5%, T3 [4—> 10 s.]: 22.4%, OR by tertiles: 1.18, 95% CI 0.58–2.44, p = 0.646). During out-of-hospital cardiac arrest, shorter CRT-F, but not CRT-E, is associated with a higher chance of any ROSC. Trial registration: This trial was pre-registered on clinicaltrials.gov with the number: NCT04791995 on March 2nd, 2021.
{"title":"The association of capillary refill time and return of spontaneous circulation during out-of-hospital cardiac arrest: an observational study","authors":"Matthias Mueller, Michael Holzer, Heidrun Losert, Daniel Grassmann, Florian Ettl, Mathias Gatterbauer, Ingrid Magnet, Alexander Nuernberger, Calvin Lukas Kienbacher, Georg Gelbenegger, Michael Girsa, Harald Herkner, Mario Krammel","doi":"10.1186/s13054-025-05255-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05255-4","url":null,"abstract":"Microcirculatory alterations are predictive of poor outcomes in patients with shock and after cardiac arrest in animal models. However, microcirculatory alterations during human cardiac arrest have not yet been studied. We prospectively included adult patients receiving resuscitation after witnessed out-of-hospital cardiac arrest. Exclusion criteria were hypovolemia, hypo- or hyperthermia (< 34.0 °C, > 37.5 °C), peripheral arterial disease, Raynaud’s disease, and logistical issues (e.g., shortage of space). Capillary refill time was measured on the finger (CRT-F) and the earlobe (CRT-E) every other minute until return of spontaneous circulation (any ROSC) or termination of resuscitation. The primary endpoint was any ROSC, secondary endpoints were 30-day-mortality and good neurological outcome (defined as cerebral performance category 1–2). Based on the data structure, CRT-F and CRT-E values were grouped post-hoc into quartiles and tertiles. A cluster-robust standard error logistic regression was performed for the primary outcome. Trend analyses were made for each individual. After screening of 141 patients, 50 were included in the analysis (median age 75 years, 28% female, any ROSC 32%). The median CRT-F was > 10 [7–> 10] seconds; the median CRT-E was 3 [3–4] seconds. The any ROSC rate for patients in CRT-F quartile 1 (3–5 s) was 71.4%, 31.7% in quartile 2 (6–8 s), 23.1% in quartile 3 (9–10 s), and 10% in quartile 4 (> 10 s). The odds ratio of 0.39 (95% CI 0.20–0.73, p = 0.004) indicated, that with an increase of CRT-F by a quartile, the chance of achieving any ROSC decreased by 61%. Patients with a decreasing CRT-F achieved any ROSC in 70%, whereas patients with constant or increasing CRT-F had any ROSC in only 21% (p = 0.008). In contrast, CRT-E showed no association with any ROSC (T1 [1–2 s.]: 16.7%, T2 [3 s.]: 27.5%, T3 [4—> 10 s.]: 22.4%, OR by tertiles: 1.18, 95% CI 0.58–2.44, p = 0.646). During out-of-hospital cardiac arrest, shorter CRT-F, but not CRT-E, is associated with a higher chance of any ROSC. Trial registration: This trial was pre-registered on clinicaltrials.gov with the number: NCT04791995 on March 2nd, 2021.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"9 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142990860","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 : 2025-01-21DOI: 10.1186/s13054-024-05225-2
Maria Andersson, Karin Fröderberg Schooner, Viktor Karlsson Werther, Thomas Karlsson, Lina De Geer, Daniel B. Wilhelms, Martin Holmbom, Mats Fredrikson, Åse Östholm, Sören Berg, Håkan Hanberger
Rapid, adequate treatment is crucial to reduce mortality in sepsis. Risk stratification scores used at emergency departments (ED) are limited in detecting all septic patients with increased mortality risk. We assessed whether the addition of prehospital lactate analysis to clinical risk stratification tools improves detection of patients with increased risk for rapid deterioration and death in sepsis. A10-month observational study with consecutive, prospective prehospital inclusion of adult patients with suspected sepsis. Prehospital lactate was used as a continuous variable and in intervals. Analyses of patient subgroups with high and lower priorities according to Rapid Emergency Triage and Treatment System (RETTS) and National Early Warning Score 2 (NEWS2) were performed. Primary outcome was 30-day mortality, secondary outcomes were sepsis at the ED and in-hospital mortality. In all, 714 patients were included with a 30-day mortality of 10%. Among the 322 cases (45%) fulfilling Sepsis-3 criteria, the 30-day mortality was 14%. Prehospital lactate was higher among non-survivors (2.6 vs 2.0 mmol/L, p < 0.001). Mortality at different lactate intervals were: 6.7%, at 0–2 mmol/l; 10.0% at > 2–3 mmol/l; 19.2% at > 3–4 mmol/l; and 17.0% at levels > 4 mmol/l. The highest RETTS priority (red) group had higher lactate levels than the lower (non-red) priority group (2.5 vs 1.9 mmol/L, p < 0.001). In the non-red group, prehospital lactate was higher among non-survivors (2.4 vs 1.8 mmol/L, p = 0.002). In the multivariable regression analysis, prehospital lactate > 3 mmol/l was a predictor of 30-day mortality (OR 2.20, p = 0.009) This association was even stronger in the lower priority RETTS non-red group (OR 3.02, p = 0.009). Adding prehospital lactate > 3 mmol/l increased identification of non-survivors from 48 to 68% in the RETTS red group and from 77 to 85% for the NEWS2 ≥ 7 group. The addition of a prehospital lactate level > 3 mmol/l improved early recognition of individuals with increased mortality risk in a cohort with suspected sepsis admitted to the ED. This was particularly evident in patients whose risk stratification scores did not indicate severe illness. We suggest that the addition of prehospital lactate analysis could improve recognition of subjects with suspected sepsis and increased mortality risk.
快速、充分的治疗对于降低败血症的死亡率至关重要。急诊科（ED）使用的风险分层评分在检测所有死亡风险增加的脓毒症患者方面是有限的。我们评估了在临床风险分层工具中加入院前乳酸分析是否可以提高对脓毒症中快速恶化和死亡风险增加的患者的检测。一项为期10个月的观察性研究，对疑似脓毒症的成年患者进行了连续的前瞻性院前纳入研究。院前乳酸作为连续变量，间隔使用。根据快速紧急分类和治疗系统（RETTS）和国家预警评分2 （NEWS2）对优先级高低的患者亚组进行分析。主要结局是30天死亡率，次要结局是急诊科败血症和住院死亡率。总共有714名患者，30天死亡率为10%。在322例（45%）符合脓毒症-3标准的患者中，30天死亡率为14%。非幸存者院前乳酸水平较高(2.6 vs 2.0 mmol/L, p 2 ~ 3 mmol/L；3 ~ 4 mmol/l浓度为19.2%；在4 mmol/l水平下为17.0%。RETTS优先级最高（红色）组的乳酸水平高于较低（非红色）优先组(2.5 vs 1.9 mmol/L， p 3 mmol/L是30天死亡率的预测因子（OR 2.20, p = 0.009），这种关联在较低优先级RETTS非红色组中甚至更强（OR 3.02, p = 0.009）。院前添加乳酸bbbb3 mmol/l可使RETTS红组的非幸存者识别率从48%提高到68%，NEWS2≥7组的非幸存者识别率从77%提高到85%。院前乳酸水平bb0.3 mmol/l的增加提高了对急诊室疑似脓毒症患者死亡风险增加个体的早期识别。这在风险分层评分未显示严重疾病的患者中尤为明显。我们建议增加院前乳酸分析可以提高对疑似脓毒症患者的识别，并增加死亡风险。
{"title":"Prehospital lactate analysis in suspected sepsis improves detection of patients with increased mortality risk: an observational study","authors":"Maria Andersson, Karin Fröderberg Schooner, Viktor Karlsson Werther, Thomas Karlsson, Lina De Geer, Daniel B. Wilhelms, Martin Holmbom, Mats Fredrikson, Åse Östholm, Sören Berg, Håkan Hanberger","doi":"10.1186/s13054-024-05225-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05225-2","url":null,"abstract":"Rapid, adequate treatment is crucial to reduce mortality in sepsis. Risk stratification scores used at emergency departments (ED) are limited in detecting all septic patients with increased mortality risk. We assessed whether the addition of prehospital lactate analysis to clinical risk stratification tools improves detection of patients with increased risk for rapid deterioration and death in sepsis. A10-month observational study with consecutive, prospective prehospital inclusion of adult patients with suspected sepsis. Prehospital lactate was used as a continuous variable and in intervals. Analyses of patient subgroups with high and lower priorities according to Rapid Emergency Triage and Treatment System (RETTS) and National Early Warning Score 2 (NEWS2) were performed. Primary outcome was 30-day mortality, secondary outcomes were sepsis at the ED and in-hospital mortality. In all, 714 patients were included with a 30-day mortality of 10%. Among the 322 cases (45%) fulfilling Sepsis-3 criteria, the 30-day mortality was 14%. Prehospital lactate was higher among non-survivors (2.6 vs 2.0 mmol/L, p < 0.001). Mortality at different lactate intervals were: 6.7%, at 0–2 mmol/l; 10.0% at > 2–3 mmol/l; 19.2% at > 3–4 mmol/l; and 17.0% at levels > 4 mmol/l. The highest RETTS priority (red) group had higher lactate levels than the lower (non-red) priority group (2.5 vs 1.9 mmol/L, p < 0.001). In the non-red group, prehospital lactate was higher among non-survivors (2.4 vs 1.8 mmol/L, p = 0.002). In the multivariable regression analysis, prehospital lactate > 3 mmol/l was a predictor of 30-day mortality (OR 2.20, p = 0.009) This association was even stronger in the lower priority RETTS non-red group (OR 3.02, p = 0.009). Adding prehospital lactate > 3 mmol/l increased identification of non-survivors from 48 to 68% in the RETTS red group and from 77 to 85% for the NEWS2 ≥ 7 group. The addition of a prehospital lactate level > 3 mmol/l improved early recognition of individuals with increased mortality risk in a cohort with suspected sepsis admitted to the ED. This was particularly evident in patients whose risk stratification scores did not indicate severe illness. We suggest that the addition of prehospital lactate analysis could improve recognition of subjects with suspected sepsis and increased mortality risk. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"46 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142990859","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}
Critical care nurses are vulnerable to depression, which not only lead to poor well-being and increased turnover intention, but also affect their working performances and organizational productivity as well. Work related factors are important drivers of depressive symptoms. However, the non-liner and multi-directional relationships between job demands-resources and depressive symptoms in critical care nurses has not been adequately analyzed. Understanding these relationships would be helpful for reducing depression, increasing nurses’ well-being and retain healthcare forces. This was a cross-sectional study using baseline data from the Nurses’ mental health study (NMHS), a prospective cohort study on nurses from 67 tertiary hospitals in 31 province-level administrative regions in China. Only clinical nurses working in the ICU were included (n = 13,745). Data were collected using online questionnaires, and analyzed using network analysis and structural equation model. Job demands (average working hours per week, average number of night shifts per month, paperwork burden and work-life balance), job resources (supervisor support, co-worker support, leader justice, organizational climate satisfaction, work meaning, and career prospect), personal resource (resilience) and depressive symptoms were main variables in the networks, while demographic data and social health (social-emotional support and loneliness) were covariates. The prevalence of severe, moderately severe, moderate, mild, and none or minimum depressive symptoms in critical care nurses of this study were 1.21, 3.42, 9.76, 42.88, and 42.07% respectively. In the final network, 132 of 210 possible edges (62.8%) were not zero. “Fatigue” had the highest expected influence, followed by “Motor”, and “Appetite”. Meanwhile, in terms of job demands-resources and personal resources, the node with the highest expected influence was “Supervisor support”, followed by “Work meaning” and “Co-worker support”. Three bridge variables were identified: “Resilience-adaptation”, “Average working hours per week”, and “Co-worker support”. The final structural equation model basically supported the results of network analysis with an acceptable model-fit (GFI = 0.918, AGFI = 0.896, PCFI = 0.789, PNFI = 0.788, NFI = 0.909, IFI = 0.911, CFI = 0.911, SRMR = 0.040, and RMSEA = 0.064). There was a rather strong interconnectedness between depressive symptoms and job demands-resources. Fatigue, motor, and appetite were core depressive symptoms of critical care nurses. Close attention to those symptoms could help recognize depression in critical care nurses. Supervisor support, work meaning, and co-worker support played vital roles as job resources in reducing depression, while negative impact of long average working hours per week were more contagious. Resilience, as personal resources, could help mediate the associations between job demands-resources and depression. In clinical practice, it’s recommended for nursing man
{"title":"Network of job demands-resources and depressive symptoms in critical care nurses: a nationwide cross-sectional study","authors":"Xuting Li, Yusheng Tian, Jiaxin Yang, Meng Ning, Zengyu Chen, Qiang Yu, Yiting Liu, Chongmei Huang, Yamin Li","doi":"10.1186/s13054-025-05282-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05282-1","url":null,"abstract":"Critical care nurses are vulnerable to depression, which not only lead to poor well-being and increased turnover intention, but also affect their working performances and organizational productivity as well. Work related factors are important drivers of depressive symptoms. However, the non-liner and multi-directional relationships between job demands-resources and depressive symptoms in critical care nurses has not been adequately analyzed. Understanding these relationships would be helpful for reducing depression, increasing nurses’ well-being and retain healthcare forces. This was a cross-sectional study using baseline data from the Nurses’ mental health study (NMHS), a prospective cohort study on nurses from 67 tertiary hospitals in 31 province-level administrative regions in China. Only clinical nurses working in the ICU were included (n = 13,745). Data were collected using online questionnaires, and analyzed using network analysis and structural equation model. Job demands (average working hours per week, average number of night shifts per month, paperwork burden and work-life balance), job resources (supervisor support, co-worker support, leader justice, organizational climate satisfaction, work meaning, and career prospect), personal resource (resilience) and depressive symptoms were main variables in the networks, while demographic data and social health (social-emotional support and loneliness) were covariates. The prevalence of severe, moderately severe, moderate, mild, and none or minimum depressive symptoms in critical care nurses of this study were 1.21, 3.42, 9.76, 42.88, and 42.07% respectively. In the final network, 132 of 210 possible edges (62.8%) were not zero. “Fatigue” had the highest expected influence, followed by “Motor”, and “Appetite”. Meanwhile, in terms of job demands-resources and personal resources, the node with the highest expected influence was “Supervisor support”, followed by “Work meaning” and “Co-worker support”. Three bridge variables were identified: “Resilience-adaptation”, “Average working hours per week”, and “Co-worker support”. The final structural equation model basically supported the results of network analysis with an acceptable model-fit (GFI = 0.918, AGFI = 0.896, PCFI = 0.789, PNFI = 0.788, NFI = 0.909, IFI = 0.911, CFI = 0.911, SRMR = 0.040, and RMSEA = 0.064). There was a rather strong interconnectedness between depressive symptoms and job demands-resources. Fatigue, motor, and appetite were core depressive symptoms of critical care nurses. Close attention to those symptoms could help recognize depression in critical care nurses. Supervisor support, work meaning, and co-worker support played vital roles as job resources in reducing depression, while negative impact of long average working hours per week were more contagious. Resilience, as personal resources, could help mediate the associations between job demands-resources and depression. In clinical practice, it’s recommended for nursing man","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"15 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142992745","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}
Intermediate care units (IMCUs) provide care for patients who need more intensive treatment than general wards but less than intensive care units (ICUs). Although the concept of an IMCU requires co-location with an ICU, some hospitals have IMCUs but no ICUs, which potentially worsens patient outcomes. This study aimed to examine the annual trends and care processes, and compare the outcomes of patients admitted to IMCUs in hospitals with and without ICUs using a nationwide inpatient database in Japan. This retrospective cohort study was conducted from 2016 to 2022 using the Diagnosis Procedure Combination Database and Hospital Bed Function Reports in Japan. The main exposure was admission to the IMCU in hospitals with and without ICUs. The primary outcome was in-hospital mortality rate in hospitals with and without ICUs that were compared using multilevel logistic regression models adjusted for confounders. The number of IMCU beds in hospitals without ICUs increased by 59% from 3,388 in 2016 to 5,403 in 2022, and the IMCU beds in hospitals without ICUs represented 38% (n = 5,403/14,185) of all IMCU beds in Japan in 2022. Among the 3,061,960 eligible patients in the IMCUs, 2,296,939 (75%) and 765,021 (25%) were admitted to hospitals with and without ICUs, respectively. Transfer between IMCUs and ICUs occurred for 10.5% (n = 320,938/3,061,960) of patients, with a large variability between hospitals. After adjusting for potential confounders, patients admitted to IMCUs in hospitals without ICUs had significantly higher in-hospital mortality than those in hospitals with ICUs (adjusted odds ratio: 1.15; 95% confidence interval: 1.10–1.20; p < 0.001). Admission in IMCUs in hospitals without ICUs increased, but was associated with higher in-hospital mortality. These findings suggest that IMCUs should be placed in hospitals with ICUs.
{"title":"In-hospital mortality of patients admitted to the intermediate care unit in hospitals with and without an intensive care unit: a nationwide inpatient database study","authors":"Hiroyuki Ohbe, Daisuke Kudo, Yuya Kimura, Hiroki Matsui, Hideo Yasunaga, Shigeki Kushimoto","doi":"10.1186/s13054-025-05275-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05275-0","url":null,"abstract":"Intermediate care units (IMCUs) provide care for patients who need more intensive treatment than general wards but less than intensive care units (ICUs). Although the concept of an IMCU requires co-location with an ICU, some hospitals have IMCUs but no ICUs, which potentially worsens patient outcomes. This study aimed to examine the annual trends and care processes, and compare the outcomes of patients admitted to IMCUs in hospitals with and without ICUs using a nationwide inpatient database in Japan. This retrospective cohort study was conducted from 2016 to 2022 using the Diagnosis Procedure Combination Database and Hospital Bed Function Reports in Japan. The main exposure was admission to the IMCU in hospitals with and without ICUs. The primary outcome was in-hospital mortality rate in hospitals with and without ICUs that were compared using multilevel logistic regression models adjusted for confounders. The number of IMCU beds in hospitals without ICUs increased by 59% from 3,388 in 2016 to 5,403 in 2022, and the IMCU beds in hospitals without ICUs represented 38% (n = 5,403/14,185) of all IMCU beds in Japan in 2022. Among the 3,061,960 eligible patients in the IMCUs, 2,296,939 (75%) and 765,021 (25%) were admitted to hospitals with and without ICUs, respectively. Transfer between IMCUs and ICUs occurred for 10.5% (n = 320,938/3,061,960) of patients, with a large variability between hospitals. After adjusting for potential confounders, patients admitted to IMCUs in hospitals without ICUs had significantly higher in-hospital mortality than those in hospitals with ICUs (adjusted odds ratio: 1.15; 95% confidence interval: 1.10–1.20; p < 0.001). Admission in IMCUs in hospitals without ICUs increased, but was associated with higher in-hospital mortality. These findings suggest that IMCUs should be placed in hospitals with ICUs.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"18 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142989896","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 : 2025-01-20DOI: 10.1186/s13054-024-05213-6
Matthew E. Cove, Alain Combes, Matthias P. Hilty
<p>Extracorporeal carbon dioxide removal (ECCO₂R) was introduced over 40 years ago but still faces scrutiny through feasibility studies, the latest of which was recently published in Critical Care [1]. Perhaps this enduring curiosity highlights a problem with the name because the role of ECCO₂R is not simply to reduce carbon dioxide (CO₂) levels; rather, it enables more protective ventilator settings by decoupling CO₂ elimination from minute ventilation. In short, ECCO₂R is all about reducing the intensity of mechanical ventilation, but which patients and ventilator settings should we select for this?</p><p>ECCO₂R was first clinically applied by the late Professor Luciano Gattinoni in the 1980s to facilitate low-frequency ventilation in acute respiratory distress syndrome (ARDS) patients. [2] This early strategy didn’t show mortality benefits in a randomised control trial (RCT), likely because low-frequency ventilation could not adequately protect against excessive airway pressures and tidal volumes and because of significant complications (mainly severe haemorrhages) related to devices used at that time. [3] Subsequent research, however, showed lower tidal volumes (4–8 mL/kg ideal body weight [IBW]) could improve ARDS outcomes [4] by reducing ventilator-induced lung injury through minimised airway pressures. [5] This sparked interest in ultra-low tidal volume ventilation (≤ 4 mL/kg IBW) supported by ECCO₂R [6], known as “ultra-protective” ventilation, even though the only two RCTs to study these tidal volumes did not conclusively show they are protective. [7, 8]</p><p>The first of these studies, "Lower tidal volume strategy (≈ 3 mL/kg) combined with ECCO<sub>2</sub>R versus 'conventional' protective ventilation (6 mL/kg) in severe ARDS study (Xtravent)," randomised 79 ARDS patients. [7] It fell short of its 120-patient recruitment goal after the Data Safety Monitoring Board (DSMB) advised discontinuation due to low likelihood of achieving a statistically significant difference, partially because mortality rates were low in both groups (17.5% intervention vs 15% control). The intervention used pumpless arteriovenous ECCO<sub>2</sub>R (AV-ECCO<sub>2</sub>R), which is only feasible in haemodynamically stable patients, excluding many critically ill ARDS patients and partly explaining the low mortality rates. Today, few intensivists would use pumpless AV-ECCO<sub>2</sub>R in critically ill patients—even if they were hemodynamically stable—due to concerns about complications associated with femoral artery cannulation and the reluctance of many teams to employ prone positioning in this situation. This intervention improves mortality in moderately-severe ARDS [9], and generally, prone positioning is more easily performed with veno-venous, pump-driven, ECCO<sub>2</sub>R devices. [10]</p><p>The second study, "Effect of lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal vs standard care ventilation on 90-day mortality in pa
{"title":"Forty years on, why are we still publishing extracorporeal carbon dioxide removal feasibility studies?","authors":"Matthew E. Cove, Alain Combes, Matthias P. Hilty","doi":"10.1186/s13054-024-05213-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05213-6","url":null,"abstract":"<p>Extracorporeal carbon dioxide removal (ECCO₂R) was introduced over 40 years ago but still faces scrutiny through feasibility studies, the latest of which was recently published in Critical Care [1]. Perhaps this enduring curiosity highlights a problem with the name because the role of ECCO₂R is not simply to reduce carbon dioxide (CO₂) levels; rather, it enables more protective ventilator settings by decoupling CO₂ elimination from minute ventilation. In short, ECCO₂R is all about reducing the intensity of mechanical ventilation, but which patients and ventilator settings should we select for this?</p><p>ECCO₂R was first clinically applied by the late Professor Luciano Gattinoni in the 1980s to facilitate low-frequency ventilation in acute respiratory distress syndrome (ARDS) patients. [2] This early strategy didn’t show mortality benefits in a randomised control trial (RCT), likely because low-frequency ventilation could not adequately protect against excessive airway pressures and tidal volumes and because of significant complications (mainly severe haemorrhages) related to devices used at that time. [3] Subsequent research, however, showed lower tidal volumes (4–8 mL/kg ideal body weight [IBW]) could improve ARDS outcomes [4] by reducing ventilator-induced lung injury through minimised airway pressures. [5] This sparked interest in ultra-low tidal volume ventilation (≤ 4 mL/kg IBW) supported by ECCO₂R [6], known as “ultra-protective” ventilation, even though the only two RCTs to study these tidal volumes did not conclusively show they are protective. [7, 8]</p><p>The first of these studies, \"Lower tidal volume strategy (≈ 3 mL/kg) combined with ECCO<sub>2</sub>R versus 'conventional' protective ventilation (6 mL/kg) in severe ARDS study (Xtravent),\" randomised 79 ARDS patients. [7] It fell short of its 120-patient recruitment goal after the Data Safety Monitoring Board (DSMB) advised discontinuation due to low likelihood of achieving a statistically significant difference, partially because mortality rates were low in both groups (17.5% intervention vs 15% control). The intervention used pumpless arteriovenous ECCO<sub>2</sub>R (AV-ECCO<sub>2</sub>R), which is only feasible in haemodynamically stable patients, excluding many critically ill ARDS patients and partly explaining the low mortality rates. Today, few intensivists would use pumpless AV-ECCO<sub>2</sub>R in critically ill patients—even if they were hemodynamically stable—due to concerns about complications associated with femoral artery cannulation and the reluctance of many teams to employ prone positioning in this situation. This intervention improves mortality in moderately-severe ARDS [9], and generally, prone positioning is more easily performed with veno-venous, pump-driven, ECCO<sub>2</sub>R devices. [10]</p><p>The second study, \"Effect of lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal vs standard care ventilation on 90-day mortality in pa","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"59 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142990923","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}
Aneurysmatic subarachnoid hemorrhage (aSAH) is a critical condition associated with significant mortality rates and complex rehabilitation challenges. Early prediction of functional outcomes is essential for optimizing treatment strategies. A multicenter study was conducted using data collected from 718 patients with aSAH who were treated at five hospitals in Japan. A deep learning model was developed to predict outcomes based on modified Rankin Scale scores using pretherapy clinical data collected from admission to the initiation of physical therapy. The model’s performance was assessed using the area under the curve, and interpretability was enhanced using SHapley Additive exPlanations (SHAP). Logistic regression analysis was also performed for further validation. The area under the receiver operating characteristic curve of the model was 0.90, with age, World Federation of Neurosurgical Societies grade, and higher brain dysfunction identified as key predictors. SHAP analysis supported the importance of these features in the prediction model, and logistic regression analysis further confirmed the model’s robustness. The novel deep learning model demonstrated strong predictive performance in determining functional outcomes in patients with aSAH, making it a valuable tool for guiding early rehabilitation strategies.
{"title":"Interpretable machine learning model for outcome prediction in patients with aneurysmatic subarachnoid hemorrhage","authors":"Masamichi Moriya, Kenji Karako, Shogo Miyazaki, Shin Minakata, Shuhei Satoh, Yoko Abe, Shota Suzuki, Shohei Miyazato, Hikaru Takara","doi":"10.1186/s13054-024-05245-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05245-y","url":null,"abstract":"Aneurysmatic subarachnoid hemorrhage (aSAH) is a critical condition associated with significant mortality rates and complex rehabilitation challenges. Early prediction of functional outcomes is essential for optimizing treatment strategies. A multicenter study was conducted using data collected from 718 patients with aSAH who were treated at five hospitals in Japan. A deep learning model was developed to predict outcomes based on modified Rankin Scale scores using pretherapy clinical data collected from admission to the initiation of physical therapy. The model’s performance was assessed using the area under the curve, and interpretability was enhanced using SHapley Additive exPlanations (SHAP). Logistic regression analysis was also performed for further validation. The area under the receiver operating characteristic curve of the model was 0.90, with age, World Federation of Neurosurgical Societies grade, and higher brain dysfunction identified as key predictors. SHAP analysis supported the importance of these features in the prediction model, and logistic regression analysis further confirmed the model’s robustness. The novel deep learning model demonstrated strong predictive performance in determining functional outcomes in patients with aSAH, making it a valuable tool for guiding early rehabilitation strategies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"45 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142990922","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 : 2025-01-20DOI: 10.1186/s13054-025-05253-6
Wei Jiang, Lin Song, Weilei Gong, Xianghui Li, Keran Shi, Luanluan Li, Chuanqing Zhang, Jing Wang, Xiaolan Xu, Haixia Wang, Xiaoyan Wu, Jun Shao, Yang Yu, Jiangquan Yu, Ruiqiang Zheng
Phospholipid transfer protein (PLTP), a glycoprotein widely expressed in the body, is primarily involved in plasma lipoprotein metabolism. Previous research has demonstrated that PLTP can exert anti-inflammatory effects and improve individual survival in patients with sepsis and endotoxemia by neutralizing LPS and facilitating LPS clearance. However, the role of PLTP in sepsis-associated acute kidney injury (SA-AKI) and the specific mechanism of its protective effects are unclear. This study aimed to assess the potential role of PLTP in SA-AKI. This is a population-based prospective observational study of patients with sepsis admitted to the intensive care unit. Blood samples were collected on days 1, 3, 5, and 7 after admission to the ICU. Plasma PLTP lipotransfer activity was measured to assess outcomes, including the incidence of SA-AKI and 30-day major adverse kidney events (MAKE 30). The correlation between PLTP lipotransfer activity and SA-AKI and MAKE 30 was evaluated through logistic regression modeling. Receiver operating characteristic curves were used to assess the diagnostic value of PLTP lipotransfer activity for SA-AKI and MAKE 30. The PLTP lipotransfer activity was categorized into high and low groups based on the optimal cut-off values. The differences between the high and low PLTP lipotransfer activity groups in terms of MAKE 30 were evaluated using Kaplan–Meier analysis. The SA-AKI mouse model was established via cecum ligation and puncture (CLP) in the animal experimental phase. The impact of PLTP on renal function was then investigated in wild-type and PLTP ± mice. The wild-type mice were given recombinant human PLTP (25 μg, 200 μL each/dose) via the tail vein at 1-, 7-, and 23-h intervals on the day preceding CLP. The control group received an equal volume of solvent. The 10-day survival and kidney function among the treatment groups were then evaluated. A total of 93 patients were enrolled in this clinical trial, of which 52 developed acute kidney injury (AKI). A total of 32 patients died over the course of the 30-day follow-up period, 34 underwent kidney replacement therapy, 37 developed persistent acute kidney injury, and 55 patients met the composite endpoint. The plasma PLTP lipotransfer activity was identified as an independent predictor of SA-AKI (crude OR = 0.96, 95% CI 0.95–0.98, p < 0.001; adjusted OR = 0.92, 95% CI 0.86–0.96, p = 0.001) and MAKE 30 (crude OR = 0.97, 95% CI 0.96–0.98, p < 0.001; adjusted OR = 0.96, 95% CI 0.93–0.98, p = 0.001). The area under the curve (AUC) of plasma PLTP lipotransfer activity within 24 h of ICU admission could predict the occurrence of SA-AKI and MAKE 30 in septic patients (AUC values; 0.87 (95% CI 0.79–0.94) and 0.87 (95% CI 0.80–0.94), respectively). The cumulative incidence of main kidney adverse events was significantly lower in the high group than in the low group (p < 0.001). Compared with the controls, creatinine levels were significantly elevated in the CLP mice, while PLT
磷脂转移蛋白（PLTP）是一种在体内广泛表达的糖蛋白，主要参与血浆脂蛋白代谢。既往研究表明，PLTP可通过中和LPS，促进LPS清除，发挥抗炎作用，提高脓毒症和内毒素血症患者的个体生存率。然而，PLTP在脓毒症相关急性肾损伤（SA-AKI）中的作用及其保护作用的具体机制尚不清楚。本研究旨在评估PLTP在SA-AKI中的潜在作用。这是一项基于人群的前瞻性观察性研究，研究对象是入住重症监护室的脓毒症患者。于入院后第1、3、5、7天采集血样。测量血浆PLTP脂转移活性以评估结果，包括SA-AKI发生率和30天主要肾脏不良事件（MAKE 30）。通过logistic回归模型评估PLTP脂转移活性与SA-AKI和MAKE 30的相关性。采用受试者工作特征曲线评价PLTP脂转移活性对SA-AKI和MAKE 30的诊断价值。根据最佳临界值将PLTP脂转移活性分为高组和低组。利用Kaplan-Meier分析评估高、低PLTP脂转移活性组在MAKE 30方面的差异。动物实验阶段采用盲肠结扎穿刺法（CLP）建立SA-AKI小鼠模型。然后在野生型和PLTP±小鼠中研究PLTP对肾功能的影响。野生型小鼠分别于CLP前一天1、7、23 h通过尾静脉注射重组人PLTP （25 μg， 200 μL /剂）。对照组给予等体积的溶剂。观察各治疗组10天生存率及肾功能。该临床试验共纳入93例患者，其中52例发生急性肾损伤（AKI）。在30天的随访期间，共有32名患者死亡，34名患者接受了肾脏替代治疗，37名患者出现了持续性急性肾损伤，55名患者达到了复合终点。血浆PLTP脂转移活性被确定为SA-AKI的独立预测因子(粗OR = 0.96, 95% CI 0.95-0.98, p < 0.001；调整OR = 0.92, 95% CI 0.86-0.96, p = 0.001)和MAKE 30(粗OR = 0.97, 95% CI 0.96-0.98, p < 0.001；调整或= 0.96,95% CI 0.93 - -0.98, p = 0.001)。入院24 h内血浆PLTP脂转移活性曲线下面积（AUC）可预测脓毒症患者SA-AKI和MAKE 30的发生(AUC值；分别为0.87 （95% CI 0.79-0.94）和0.87 （95% CI 0.80-0.94）。高剂量组主要肾脏不良事件累积发生率显著低于低剂量组（p < 0.001）。与对照组相比，术后24 h CLP小鼠肌酐水平显著升高，而PLTP脂转移活性显著降低。此外，与野生型CLP小鼠相比，PTLP±小鼠表现出明显的肾功能受损和血浆炎症介质水平显著升高。值得注意的是，人重组PTLP显著延长了野生型CLP小鼠的10天生存期，改善了肾功能，减轻了线粒体结构损伤。这些发现表明PLTP是脓毒症相关急性肾损伤的潜在治疗靶点。
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