Pub Date : 2025-01-13DOI: 10.1186/s13054-024-05232-3
Heekuk Park, Elissa Lynch, Alice Tillman, Kristen Lewis, Zhezhen Jin, Anne-Catrin Uhlemann, Julian A. Abrams, Daniel E. Freedberg
Patients admitted to the intensive care unit (ICU) often have gut colonization with pathogenic bacteria and such colonization is associated with increased risk for death and infection. We conducted a trial to determine whether a prebiotic would improve the gut microbiome to decrease gut pathogen colonization and decrease downstream risk for infection among newly admitted medical ICU patients with sepsis. This was a randomized, double-blind, placebo-controlled trial of adults who were admitted to the medical ICU for sepsis and were receiving broad-spectrum antibiotics. Participants were randomized 1:1:1 to placebo, inulin 16 g/day, or inulin 32 g/day which were given for seven days. The trial primary outcome was a surrogate measure for gut colonization resistance, namely the within-individual change from ICU admission to Day 3 in the relative abundance of short chain fatty acid (SCFA)-producing bacteria based on rectal swabs. Additional outcomes sought to evaluate the impact of inulin on the gut microbiome and downstream clinical effects. Ninety participants were analyzed including 30 in each study group. There was no difference between study groups in the within-individual change in the relative abundance of SCFA-producing bacteria from ICU admission to ICU Day 3 (placebo: 0.0% change, IQR − 8·0% to + 7·4% vs. combined inulin: 0·0% change, IQR − 10·1% to + 4·8%; p = 0·91). At end-of-treatment on ICU Day 7, inulin did not affect SCFA-producer levels, microbiome diversity, or rates of gut colonization with pathogenic bacteria. After 30 days of clinical follow-up, inulin did not affect rates of death or clinical, culture-proven infection. Patients who died or developed culture-proven infections had lower relative abundance of SCFA-producing bacteria at ICU admission compared to those who did not (p = 0·03). Prebiotic fiber had minimal impact on the gut microbiome in the ICU and did not improve clinical outcomes. Clinicaltrials.gov: NCT03865706. Does prebiotic fiber alter the gut microbiome in the medical ICU to decrease gut pathogen colonization and decrease downstream risk for infection? This randomized controlled trial found that prebiotic inulin at doses up to 32 grams/day did not alter the gut microbiome among adults admitted to the ICU with sepsis. Even at these high doses, inulin was well tolerated. The taxonomic composition of the gut microbiome, assessed using longitudinal rectal swabs and stool samples for up to thirty days of follow-up, was not substantively altered by inulin; also unchanged by inulin were fecal levels of short chain fatty acids, gut colonization with pathogenic bacteria including vancomycin-resistant Enterococcus and multidrug-resistant Gram-negative bacteria, and clinical outcomes including culture-proven infection or death. Pre- and probiotics may face significant challenges in the ICU. Improved understanding of the dynamic changes within the gut microbiome in the ICU may lead to more targeted therapies.
{"title":"A phase 2 randomized, placebo-controlled trial of inulin for the prevention of gut pathogen colonization and infection among patients admitted to the intensive care unit for sepsis","authors":"Heekuk Park, Elissa Lynch, Alice Tillman, Kristen Lewis, Zhezhen Jin, Anne-Catrin Uhlemann, Julian A. Abrams, Daniel E. Freedberg","doi":"10.1186/s13054-024-05232-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05232-3","url":null,"abstract":"Patients admitted to the intensive care unit (ICU) often have gut colonization with pathogenic bacteria and such colonization is associated with increased risk for death and infection. We conducted a trial to determine whether a prebiotic would improve the gut microbiome to decrease gut pathogen colonization and decrease downstream risk for infection among newly admitted medical ICU patients with sepsis. This was a randomized, double-blind, placebo-controlled trial of adults who were admitted to the medical ICU for sepsis and were receiving broad-spectrum antibiotics. Participants were randomized 1:1:1 to placebo, inulin 16 g/day, or inulin 32 g/day which were given for seven days. The trial primary outcome was a surrogate measure for gut colonization resistance, namely the within-individual change from ICU admission to Day 3 in the relative abundance of short chain fatty acid (SCFA)-producing bacteria based on rectal swabs. Additional outcomes sought to evaluate the impact of inulin on the gut microbiome and downstream clinical effects. Ninety participants were analyzed including 30 in each study group. There was no difference between study groups in the within-individual change in the relative abundance of SCFA-producing bacteria from ICU admission to ICU Day 3 (placebo: 0.0% change, IQR − 8·0% to + 7·4% vs. combined inulin: 0·0% change, IQR − 10·1% to + 4·8%; p = 0·91). At end-of-treatment on ICU Day 7, inulin did not affect SCFA-producer levels, microbiome diversity, or rates of gut colonization with pathogenic bacteria. After 30 days of clinical follow-up, inulin did not affect rates of death or clinical, culture-proven infection. Patients who died or developed culture-proven infections had lower relative abundance of SCFA-producing bacteria at ICU admission compared to those who did not (p = 0·03). Prebiotic fiber had minimal impact on the gut microbiome in the ICU and did not improve clinical outcomes. Clinicaltrials.gov: NCT03865706. Does prebiotic fiber alter the gut microbiome in the medical ICU to decrease gut pathogen colonization and decrease downstream risk for infection? This randomized controlled trial found that prebiotic inulin at doses up to 32 grams/day did not alter the gut microbiome among adults admitted to the ICU with sepsis. Even at these high doses, inulin was well tolerated. The taxonomic composition of the gut microbiome, assessed using longitudinal rectal swabs and stool samples for up to thirty days of follow-up, was not substantively altered by inulin; also unchanged by inulin were fecal levels of short chain fatty acids, gut colonization with pathogenic bacteria including vancomycin-resistant Enterococcus and multidrug-resistant Gram-negative bacteria, and clinical outcomes including culture-proven infection or death. Pre- and probiotics may face significant challenges in the ICU. Improved understanding of the dynamic changes within the gut microbiome in the ICU may lead to more targeted therapies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"38 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142974825","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 : 2025-01-13DOI: 10.1186/s13054-024-05244-z
Victoria Metaxa, Flavio E. Nacul, Anna Conway Morris
Conflicts between ICU staff and patient/relatives are common and are a source of additional stress in an already tense environment. These conflicts vary from disagreements to serious controversies, which may lead to legal process or even violence. Unsuccessful communication is recognised as a common denominator for such disagreements. Both conflict prevention and conflict management/resolution rely on understanding and addressing the main reasons behind it. Using a case-example, we propose a ‘mentalisation-based’ approach to family meetings may improve communication and decrease conflict.
{"title":"Understanding and addressing a ‘difficult’ family in ICU","authors":"Victoria Metaxa, Flavio E. Nacul, Anna Conway Morris","doi":"10.1186/s13054-024-05244-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05244-z","url":null,"abstract":"Conflicts between ICU staff and patient/relatives are common and are a source of additional stress in an already tense environment. These conflicts vary from disagreements to serious controversies, which may lead to legal process or even violence. Unsuccessful communication is recognised as a common denominator for such disagreements. Both conflict prevention and conflict management/resolution rely on understanding and addressing the main reasons behind it. Using a case-example, we propose a ‘mentalisation-based’ approach to family meetings may improve communication and decrease conflict.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"22 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142974809","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 : 2025-01-12DOI: 10.1186/s13054-025-05261-6
Teodor Svedung Wettervik, Erta Beqiri, Anders Hånell, Stefan Yu Bögli, Ihsane Olakorede, Xuhang Chen, Adel Helmy, Andrea Lavinio, Peter J. Hutchinson, Peter Smielewski
The oxygen reactivity index (ORx) reflects the correlation between focal brain tissue oxygen (pbtO2) and the cerebral perfusion pressure (CPP). Previous, small cohort studies were conflicting on whether ORx conveys cerebral autoregulatory information and if it is related to outcome in traumatic brain injury (TBI). Thus, we aimed to investigate these issues in a larger TBI cohort. 425 TBI patients with intracranial pressure (ICP)- and pbtO2-monitoring for at least 12 h, who had been treated at Addenbrooke’s Hospital, Cambridge, UK, were included. Association between ORx and ICP, pressure reactivity index (PRx), CPP, ΔCPPopt (actual CPP-CPPopt [PRx based optimal CPP]), and pbtO2 were evaluated with generalized additive models (GAMs). Association between ORx and outcome (Glasgow Outcome Scale [GOS]) was investigated with logistic regressions and heatmaps for those 239 patients with GOS data. GAMs showed that ORx increased with higher ICP, PRx above + 0.30, CPP below 60–70 mmHg, and negative ΔCPPopt. In contrast to PRx, ORx did not increase at higher CPP. In outcome heatmaps, there was a transition towards unfavourable outcome when ORx exceeded + 0.50, particularly for longer durations, and in combination with high ICP, high PRx, low CPP, negative ΔCPPopt, and low pbtO2. In multivariable logistic regressions, higher ORx was associated with increased mortality. ORx seemed to be sensitive to the lower, but not the upper, limit of autoregulation, in contrast to PRx which was sensitive to both. The combination of high values for both ORx and PRx was particularly associated with worse outcome and, thus, ORx may provide a complementary value to the global index PRx. ORx could also be useful to determine the safe and dangerous perfusion target intervals.
{"title":"Revisiting the oxygen reactivity index in traumatic brain injury: the complementary value of combined focal and global autoregulation monitoring","authors":"Teodor Svedung Wettervik, Erta Beqiri, Anders Hånell, Stefan Yu Bögli, Ihsane Olakorede, Xuhang Chen, Adel Helmy, Andrea Lavinio, Peter J. Hutchinson, Peter Smielewski","doi":"10.1186/s13054-025-05261-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05261-6","url":null,"abstract":"The oxygen reactivity index (ORx) reflects the correlation between focal brain tissue oxygen (pbtO2) and the cerebral perfusion pressure (CPP). Previous, small cohort studies were conflicting on whether ORx conveys cerebral autoregulatory information and if it is related to outcome in traumatic brain injury (TBI). Thus, we aimed to investigate these issues in a larger TBI cohort. 425 TBI patients with intracranial pressure (ICP)- and pbtO2-monitoring for at least 12 h, who had been treated at Addenbrooke’s Hospital, Cambridge, UK, were included. Association between ORx and ICP, pressure reactivity index (PRx), CPP, ΔCPPopt (actual CPP-CPPopt [PRx based optimal CPP]), and pbtO2 were evaluated with generalized additive models (GAMs). Association between ORx and outcome (Glasgow Outcome Scale [GOS]) was investigated with logistic regressions and heatmaps for those 239 patients with GOS data. GAMs showed that ORx increased with higher ICP, PRx above + 0.30, CPP below 60–70 mmHg, and negative ΔCPPopt. In contrast to PRx, ORx did not increase at higher CPP. In outcome heatmaps, there was a transition towards unfavourable outcome when ORx exceeded + 0.50, particularly for longer durations, and in combination with high ICP, high PRx, low CPP, negative ΔCPPopt, and low pbtO2. In multivariable logistic regressions, higher ORx was associated with increased mortality. ORx seemed to be sensitive to the lower, but not the upper, limit of autoregulation, in contrast to PRx which was sensitive to both. The combination of high values for both ORx and PRx was particularly associated with worse outcome and, thus, ORx may provide a complementary value to the global index PRx. ORx could also be useful to determine the safe and dangerous perfusion target intervals.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"36 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142967757","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 : 2025-01-10DOI: 10.1186/s13054-025-05260-7
Roberto Brito, Caio C. A. Morais, Daniel H. Arellano, Abraham I. J. Gajardo, Alejandro Bruhn, Laurent J. Brochard, Marcelo B. P. Amato, Rodrigo A. Cornejo
Double cycling with breath-stacking (DC/BS) during controlled mechanical ventilation is considered potentially injurious, reflecting a high respiratory drive. During partial ventilatory support, its occurrence might be attributable to physiological variability of breathing patterns, reflecting the response of the mode without carrying specific risks. This secondary analysis of a crossover study evaluated DC/BS events in hypoxemic patients resuming spontaneous breathing in cross-over under neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV +), and pressure support ventilation (PSV). DC/BS was defined as two inspiratory cycles with incomplete exhalation. Measurements included electrical impedance signal, airway pressure, esophageal and gastric pressures, and flow. Breathing variability, dynamic compliance (CLdyn), and end-expiratory lung impedance (EELI) were analyzed. Twenty patients under assisted breathing, with a median of 9 [5–14] days on mechanical ventilation, were included. DC/BS was attributed to either a single (42%) or two apparent consecutive inspiratory efforts (58%). The median [IQR] incidence of DC/BS was low: 0.6 [0.1–2.6] % in NAVA, 0.0 [0.0–0.4] % in PAV + , and 0.1 [0.0–0.4] % in PSV (p = 0.06). DC/BS events were associated with patient’s coefficient of variability for tidal volume (p = 0.014) and respiratory rate (p = 0.011). DC/BS breaths exhibited higher tidal volume, muscular pressure and regional stretch compared to regular breaths. Post-DC/BS cycles frequently exhibited improved EELI and CLdyn, with no evidence of expiratory muscle activation in 63% of cases. DC/BS events during partial ventilatory support were infrequent and linked to breathing variability. Their frequency and physiological effects on lung compliance and EELI resemble spontaneous sighs and may not be considered a priori as harmful.
{"title":"Double cycling with breath-stacking during partial support ventilation in ARDS: Just a feature of natural variability?","authors":"Roberto Brito, Caio C. A. Morais, Daniel H. Arellano, Abraham I. J. Gajardo, Alejandro Bruhn, Laurent J. Brochard, Marcelo B. P. Amato, Rodrigo A. Cornejo","doi":"10.1186/s13054-025-05260-7","DOIUrl":"https://doi.org/10.1186/s13054-025-05260-7","url":null,"abstract":"Double cycling with breath-stacking (DC/BS) during controlled mechanical ventilation is considered potentially injurious, reflecting a high respiratory drive. During partial ventilatory support, its occurrence might be attributable to physiological variability of breathing patterns, reflecting the response of the mode without carrying specific risks. This secondary analysis of a crossover study evaluated DC/BS events in hypoxemic patients resuming spontaneous breathing in cross-over under neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV +), and pressure support ventilation (PSV). DC/BS was defined as two inspiratory cycles with incomplete exhalation. Measurements included electrical impedance signal, airway pressure, esophageal and gastric pressures, and flow. Breathing variability, dynamic compliance (CLdyn), and end-expiratory lung impedance (EELI) were analyzed. Twenty patients under assisted breathing, with a median of 9 [5–14] days on mechanical ventilation, were included. DC/BS was attributed to either a single (42%) or two apparent consecutive inspiratory efforts (58%). The median [IQR] incidence of DC/BS was low: 0.6 [0.1–2.6] % in NAVA, 0.0 [0.0–0.4] % in PAV + , and 0.1 [0.0–0.4] % in PSV (p = 0.06). DC/BS events were associated with patient’s coefficient of variability for tidal volume (p = 0.014) and respiratory rate (p = 0.011). DC/BS breaths exhibited higher tidal volume, muscular pressure and regional stretch compared to regular breaths. Post-DC/BS cycles frequently exhibited improved EELI and CLdyn, with no evidence of expiratory muscle activation in 63% of cases. DC/BS events during partial ventilatory support were infrequent and linked to breathing variability. Their frequency and physiological effects on lung compliance and EELI resemble spontaneous sighs and may not be considered a priori as harmful.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"57 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142940361","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 : 2025-01-09DOI: 10.1186/s13054-024-05248-9
Bixin Deng, Zhe Zhao, Tiechao Ruan, Ruixi Zhou, Chang’e Liu, Qiuping Li, Wenzhe Cheng, Jie Wang, Feng Wang, Haixiu Xie, Chenglong Li, Zhongtao Du, Wenting Lu, Xiaohong Li, Junjie Ying, Tao Xiong, Xiaotong Hou, Xiaoyang Hong, Dezhi Mu
Patients supported by extracorporeal membrane oxygenation (ECMO) are at a high risk of brain injury, contributing to significant morbidity and mortality. This study aimed to employ machine learning (ML) techniques to predict brain injury in pediatric patients ECMO and identify key variables for future research. Data from pediatric patients undergoing ECMO were collected from the Chinese Society of Extracorporeal Life Support (CSECLS) registry database and local hospitals. Ten ML methods, including random forest, support vector machine, decision tree classifier, gradient boosting machine, extreme gradient boosting, light gradient boosting machine, Naive Bayes, neural networks, a generalized linear model, and AdaBoost, were employed to develop and validate the optimal predictive model based on accuracy and area under the curve (AUC). Patients were divided into retrospective cohort for model development and internal validation, and one cohort for external validation. A total of 1,633 patients supported by ECMO were included in the model development, of whom 181 experienced brain injury. In the external validation cohort, 30 of the 154 patients experienced brain injury. Fifteen features were selected for the model construction. Among the ML models tested, the random forest model achieved the best performance, with an AUC of 0.912 for internal validation and 0.807 for external validation. The Random Forest model based on machine learning demonstrates high accuracy and robustness in predicting brain injury in pediatric patients supported by ECMO, with strong generalization capabilities and promising clinical applicability.
{"title":"Development and external validation of a machine learning model for brain injury in pediatric patients on extracorporeal membrane oxygenation","authors":"Bixin Deng, Zhe Zhao, Tiechao Ruan, Ruixi Zhou, Chang’e Liu, Qiuping Li, Wenzhe Cheng, Jie Wang, Feng Wang, Haixiu Xie, Chenglong Li, Zhongtao Du, Wenting Lu, Xiaohong Li, Junjie Ying, Tao Xiong, Xiaotong Hou, Xiaoyang Hong, Dezhi Mu","doi":"10.1186/s13054-024-05248-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05248-9","url":null,"abstract":"Patients supported by extracorporeal membrane oxygenation (ECMO) are at a high risk of brain injury, contributing to significant morbidity and mortality. This study aimed to employ machine learning (ML) techniques to predict brain injury in pediatric patients ECMO and identify key variables for future research. Data from pediatric patients undergoing ECMO were collected from the Chinese Society of Extracorporeal Life Support (CSECLS) registry database and local hospitals. Ten ML methods, including random forest, support vector machine, decision tree classifier, gradient boosting machine, extreme gradient boosting, light gradient boosting machine, Naive Bayes, neural networks, a generalized linear model, and AdaBoost, were employed to develop and validate the optimal predictive model based on accuracy and area under the curve (AUC). Patients were divided into retrospective cohort for model development and internal validation, and one cohort for external validation. A total of 1,633 patients supported by ECMO were included in the model development, of whom 181 experienced brain injury. In the external validation cohort, 30 of the 154 patients experienced brain injury. Fifteen features were selected for the model construction. Among the ML models tested, the random forest model achieved the best performance, with an AUC of 0.912 for internal validation and 0.807 for external validation. The Random Forest model based on machine learning demonstrates high accuracy and robustness in predicting brain injury in pediatric patients supported by ECMO, with strong generalization capabilities and promising clinical applicability.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"6 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142936829","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 : 2025-01-09DOI: 10.1186/s13054-024-05238-x
Jihad Mallat, Matthew T. Siuba, Osama Abou-Arab, Pedja Kovacevic, Khaled Ismail, Abhijit Duggal, Pierre-Grégoire Guinot
Pulse pressure variation (PPV) is limited in low tidal volume mechanical ventilation. We conducted this systematic review and meta-analysis to evaluate whether passive leg raising (PLR)-induced changes in PPV can reliably predict preload/fluid responsiveness in mechanically ventilated patients with low tidal volume in the intensive care unit. PubMed, Embase, and Cochrane databases were screened for diagnostic research relevant to the predictability of PPV change after PLR in low-tidal volume mechanically ventilated patients. The QUADAS-2 scale was used to assess the risk of bias of the included studies. In-between study heterogeneity was assessed through the I2 indicator. Publication bias was assessed by the Deeks’ funnel plot asymmetry test. Summary receiving operating characteristic curve (SROC), pooled sensitivity, and specificity were calculated. Five studies with a total of 474 patients were included in this meta-analysis. The SROC of the absolute PPV change resulted in an area under the curve of 0.91 (95% CI 0.88–0.93), with overall pooled sensitivity and specificity of 0.88 (95% CI 0.82–0.91) and 0.83 (95% CI 0.76–0.89), respectively. The diagnostic odds ratio was 35 (95% CI 19–67). The mean and median cutoff values of PLR-induced absolute change in absolute PPV were both -2 points and ranged from -2.5 to -1 points. Overall, there was no significant heterogeneity with I2 = 0%. There was no significant publication bias. Fagan's nomogram showed that with a pre-test probability of 50%, the post-test probability reached 84% and 17% for the positive and negative tests, respectively. PLR-induced change in absolute PPV has good diagnostic performance in predicting preload/fluid responsiveness in ICU patients on mechanical ventilation with low tidal volume. Trial registration PROSPERO (CRD42024496901). Registered on 15 January 2024.
脉冲压力变化（PPV）在低潮气量机械通气中是有限的。我们进行了这项系统回顾和荟萃分析，以评估被动抬腿（PLR）引起的PPV变化是否可以可靠地预测重症监护病房低潮气量机械通气患者的预负荷/液体反应性。对PubMed、Embase和Cochrane数据库进行筛选，寻找与低潮气量机械通气患者PLR后PPV变化可预测性相关的诊断研究。采用QUADAS-2量表评估纳入研究的偏倚风险。通过I2指标评估研究间异质性。发表偏倚采用Deeks漏斗图不对称检验。计算总接受工作特征曲线（SROC）、合并敏感性和特异性。这项荟萃分析纳入了5项研究，共474名患者。PPV绝对变化的SROC曲线下面积为0.91 (95% CI 0.88 - 0.93)，总体合并敏感性和特异性分别为0.88 （95% CI 0.82-0.91）和0.83 （95% CI 0.76-0.89）。诊断优势比为35 （95% CI 19-67）。plr诱导的绝对PPV绝对变化的均值和中位截止值均为-2点，范围为-2.5 ~ -1点。总体而言，I2 = 0%无显著异质性。没有显著的发表偏倚。Fagan’s nomogram显示，阳性和阴性检测的前测概率为50%，后测概率分别为84%和17%。plr诱导的绝对PPV变化对预测低潮气量机械通气ICU患者的预负荷/液体反应性有较好的诊断价值。试验注册PROSPERO （CRD42024496901）。于2024年1月15日注册。
{"title":"Changes in pulse pressure variation induced by passive leg raising test to predict preload responsiveness in mechanically ventilated patients with low tidal volume in ICU: a systematic review and meta-analysis","authors":"Jihad Mallat, Matthew T. Siuba, Osama Abou-Arab, Pedja Kovacevic, Khaled Ismail, Abhijit Duggal, Pierre-Grégoire Guinot","doi":"10.1186/s13054-024-05238-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05238-x","url":null,"abstract":"Pulse pressure variation (PPV) is limited in low tidal volume mechanical ventilation. We conducted this systematic review and meta-analysis to evaluate whether passive leg raising (PLR)-induced changes in PPV can reliably predict preload/fluid responsiveness in mechanically ventilated patients with low tidal volume in the intensive care unit. PubMed, Embase, and Cochrane databases were screened for diagnostic research relevant to the predictability of PPV change after PLR in low-tidal volume mechanically ventilated patients. The QUADAS-2 scale was used to assess the risk of bias of the included studies. In-between study heterogeneity was assessed through the I2 indicator. Publication bias was assessed by the Deeks’ funnel plot asymmetry test. Summary receiving operating characteristic curve (SROC), pooled sensitivity, and specificity were calculated. Five studies with a total of 474 patients were included in this meta-analysis. The SROC of the absolute PPV change resulted in an area under the curve of 0.91 (95% CI 0.88–0.93), with overall pooled sensitivity and specificity of 0.88 (95% CI 0.82–0.91) and 0.83 (95% CI 0.76–0.89), respectively. The diagnostic odds ratio was 35 (95% CI 19–67). The mean and median cutoff values of PLR-induced absolute change in absolute PPV were both -2 points and ranged from -2.5 to -1 points. Overall, there was no significant heterogeneity with I2 = 0%. There was no significant publication bias. Fagan's nomogram showed that with a pre-test probability of 50%, the post-test probability reached 84% and 17% for the positive and negative tests, respectively. PLR-induced change in absolute PPV has good diagnostic performance in predicting preload/fluid responsiveness in ICU patients on mechanical ventilation with low tidal volume. Trial registration PROSPERO (CRD42024496901). Registered on 15 January 2024.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"28 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142936827","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 : 2025-01-08DOI: 10.1186/s13054-024-05236-z
Patrick M. Honore, Sydney Blackman, Min-Min Wang
<p>We read with interest the RECCAS trial by Hohn et al., investigating intraoperative hemoadsorption (HA) with CytoSorb during cardiopulmonary bypass (CPB) in patients over 65 years undergoing elective on-pump cardiac surgery. In this randomized controlled trial (RCT), patients were assigned to either intraoperative HA or standard care. The primary outcome was the difference in mean interleukin (IL)-6 serum concentrations upon ICU admission, while secondary outcomes included various clinical and biochemical endpoints. The authors reported no significant differences in cytokine levels, organ dysfunction, ICU/hospital lengths of stay, or mortality between groups [1]. As HA is less effective in CPB without significant inflammation [2], we turned to the REMOVE trial, which assessed CytoSorb in patients undergoing cardiac surgery for infective endocarditis (IE). This RCT used the change in SOFA score (ΔSOFA) as the primary outcome, comparing the total postoperative score (up to day 9) with the baseline. REMOVE found no significant reduction in postoperative organ dysfunction with HA [2].</p><p>In contrast, the SIRAKI02 trial evaluated extracorporeal blood purification (BP) with oXiris for cardiac surgery-associated acute kidney injury (CSA-AKI). Among 343 patients (mean age 69 years, 119 female), BP significantly reduced CSA-AKI rates (28.4% vs. 39.7%; <i>P</i> = 0.03) with an adjusted difference of 10.4% (<i>P</i> = 0.01). The benefits were particularly notable in patients with chronic kidney disease, diabetes, hypertension, reduced left ventricular ejection fraction (< 40%), and lower BMI (< 30). However, no significant differences were observed in most secondary or exploratory endpoints [3].</p><p>The divergent results between RECCAS, REMOVE, and SIRAKI02 may be explained by differences in adsorption mechanisms. While CytoSorb targets cytokines, oXiris also removes endotoxins, which play a critical role in the inflammatory cascade [4]. One study found elevated endotoxin levels in 73% of patients with CPB > 90 min, compared to 36% with CPB < 90 min [5]. Both RECCAS and SIRAKI02 included patients with prolonged CPB, but only SIRAKI02 demonstrated efficacy. This suggests that endotoxin removal is crucial in addressing the "endotoxin storm" that precedes the cytokine storm. Without effective endotoxin control, as seen in RECCAS, cytokine levels may continue to rise post-surgery, undermining the potential benefits of CytoSorb. These findings emphasize the need for comprehensive strategies targeting both endotoxins and cytokines to improve outcomes in CPB-associated inflammation.</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>Hohn A, Malewicz-Oeck NM, Buchwald D, Annecke T, Zahn PK, Baumann A. REmoval of cytokines during CArdiac surgery (RECCAS): a randomised controlled trial. Crit Care. 2024;28(1):406. ht
我们饶有兴趣地阅读了Hohn等人的RECCAS试验，研究65岁以上接受非泵心脏手术的患者在体外循环（CPB）期间使用CytoSorb进行术中血液吸附（HA）。在这项随机对照试验（RCT）中，患者被分配到术中HA或标准护理组。主要终点是ICU入院时平均白细胞介素(IL)-6血清浓度的差异，次要终点包括各种临床和生化终点。作者报告bb0组在细胞因子水平、器官功能障碍、ICU/住院时间或死亡率方面无显著差异。由于HA在没有明显炎症的CPB中效果较差，我们转向了REMOVE试验，该试验评估了因感染性心内膜炎（IE）接受心脏手术的患者的CytoSorb。该RCT以SOFA评分的变化（ΔSOFA）作为主要结局，将术后总评分（截至第9天）与基线进行比较。REMOVE发现HA[2]术后器官功能障碍无明显减少。相比之下，SIRAKI02试验评估了oXiris体外血液净化（BP）治疗心脏手术相关急性肾损伤（CSA-AKI）的效果。在343例患者（平均年龄69岁，119例女性）中，BP显著降低CSA-AKI发生率(28.4% vs 39.7%；P = 0.03)，校正后差异为10.4% （P = 0.01）。对于慢性肾病、糖尿病、高血压、左心室射血分数降低（40%）和BMI较低（30%）的患者，益处尤其显著。然而，在大多数次要或探索性终点[3]中没有观察到显著差异。recas、REMOVE和SIRAKI02的不同结果可能与吸附机制的差异有关。虽然CytoSorb靶向细胞因子，但oXiris也可以去除内毒素，内毒素在炎症级联反应中起关键作用。一项研究发现，CPB 90分钟患者中有73%的内毒素水平升高，而CPB 90分钟患者中有36%的内毒素水平升高。RECCAS和SIRAKI02都纳入了长期CPB患者，但只有SIRAKI02显示出疗效。这表明去除内毒素对于解决细胞因子风暴之前的“内毒素风暴”至关重要。如RECCAS所见，如果没有有效的内毒素控制，术后细胞因子水平可能继续上升，从而破坏了CytoSorb的潜在益处。这些发现强调需要针对内毒素和细胞因子的综合策略来改善cpb相关炎症的预后。在本研究中没有生成或分析数据集。Hohn A, Malewicz-Oeck NM, Buchwald D, Annecke T, Zahn PK, Baumann A.心脏手术中细胞因子去除（recas）的随机对照试验。危重症护理，2024;28(1):406。https://doi.org/10.1186/s13054-024-05175-9.Article PubMed PubMed Central谷歌学者Diab M， Lehmann T, Bothe W，等。移除试验调查员*。心脏手术期间的细胞因子血液吸附与感染性心内膜炎（REMOVE）的标准手术护理：一项多中心随机对照试验的结果循环。2022;145(13): 959 - 968。https://doi.org/10.1161/CIRCULATIONAHA.121.056940Pérez-Fernández X, Ulsamer A, Cámara-Rosell M，等。SIRAKI02研究组。体外血液净化和心脏手术中的急性肾损伤：SIRAKI02随机临床试验。《美国医学协会杂志》上。2024年;332(17): 1446 - 1454。https://doi.org/10.1001/jama.2024.20630Honore PM, Blackman S, Perriens E，等。脓毒症和炎症的吸附疗法：描述各种吸附技术及其改善结果的失败。中国农业科学学报，2009;35(6):559 - 564。https://doi.org/10.24875/RIC.23000185.Article PubMed bbb Scholar Adamik B, k<e:1> bler A, Gozdzik A, Gozdzik W.延长体外循环是肠缺血损伤和内毒素血症的危险因素。中华心肺杂志，2017;26(7):717-23。https://doi.org/10.1016/j.hlc.2016.10.012.Article PubMed谷歌学者下载参考文献作者与单位UCL UCL Godinne Namur大街G号，比利时Yvoir， thacimassse 1, 5530; patrick M. honrec医院，比利时布鲁塞尔；悉尼布莱克曼急性治疗大中华区，百特国际股份有限公司，上海，200031；ChinaMin-Min wangauthorsppatrick M. HonoreView作者出版物您也可以在PubMed b谷歌ScholarSydney BlackmanView作者出版物您也可以在PubMed谷歌ScholarMin-Min WangView作者出版物您也可以在PubMed谷歌ScholarContributionsPMH &；本文对毫米波进行了设计。EP和效益;MMW参与起草和审查。PMH, EP,,MMW阅读并批准了手稿的最终版本。通讯作者：Patrick M. Honore对参与者的伦理批准和同意不适用。 出版物同意不适用。相互竞争的利益我们宣称有相互竞争的利益。PMH,某人,EP,MMW声明没有竞争利益。出版商声明：对于已出版的地图和机构关系中的管辖权要求，普林格·自然保持中立。开放获取本文遵循知识共享署名-非商业-非衍生品4.0国际许可协议，该协议允许以任何媒介或格式进行非商业用途、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，并注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其部分内容的改编材料。本文中的图像或其他第三方材料包含在文章的知识共享许可协议中，除非在材料的署名中另有说明。如果材料未包含在文章的知识共享许可中，并且您的预期用途不被法律法规允许或超过允许的用途，您将需要直接获得版权所有者的许可。要查看本许可的副本，请访问http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints并访问permissionsCite这篇文章honore， p.m., Blackman， S. &；RECCAS， REMOVE和SIRAKI02：不同的结果和潜在的解释。危重护理29,16（2025）。https://doi.org/10.1186/s13054-024-05236-zDownload citation：收稿日期：2024年12月21日接受日期：2024年12月23日发布日期：2025年1月8日doi: https://doi.org/10.1186/s13054-024-05236-zShare这篇文章任何你分享以下链接的人都可以阅读到这篇文章：获取可共享链接对不起，这篇文章目前没有可共享链接。关键词心脏手术血液吸附脓毒症心内膜延长搭桥时间内毒素oxiris
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Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05227-0
Jason H. T. Bates, David W. Kaczka, Michaela Kollisch‑Singule, Gary F. Nieman, Donald P. Gaver
<p><b>Correction: Crit Care 28, 329 (2024).</b> <b>https://doi.org/10.1186/s13054-024-05112-w</b></p><br/><p>Following publication of the original article [1], the authors identified an error in the Declarations. The Competing Interests section was missing.</p><p><b>Competing interests</b></p><br/><p>DWK is a co-founder and shareholder of OscillaVent, Inc., and a co-inventor on U.S. and international patents involving mechanical ventilation. DWK also receives research support from ZOLL Medical Corporation, unrelated to the present work. JHTB is a shareholder in and advisor for Oscillavent, Inc., and a co-inventor on U.S. patents involving mechanical ventilation. He is also a shareholder in and advisor for Respiratory Sciences, Inc. MKS received a research grant from Dräger Medical Systems, Inc. MKS and GFN have delivered lectures for Dräger Medical Systems, Inc.</p><br/><p>The Competing Interests section has been indicated in this correction and the original article [1] has been corrected.</p><ol data-track-component="outbound reference" data-track-context="references section"><li data-counter="1."><p>Bates JHT, Kaczka DW, Kollisch-Singule M, et al. Atelectrauma can be avoided if expiration is sufficiently brief: evidence from inverse modeling and oscillometry during airway pressure release ventilation. Crit Care. 2024;28:329. https://doi.org/10.1186/s13054-024-05112-w.</p><p>Article PubMed PubMed Central Google Scholar </p></li></ol><p>Download references<svg aria-hidden="true" focusable="false" height="16" role="img" width="16"><use xlink:href="#icon-eds-i-download-medium" xmlns:xlink="http://www.w3.org/1999/xlink"></use></svg></p><h3>Authors and Affiliations</h3><ol><li><p>Department of Medicine, University of Vermont, University of Vermont Larner College of Medicine, 149 Beaumont Avenue, Burlington, VT, 05405, USA</p><p>Jason H. T. Bates</p></li><li><p>Departments of Anesthesia, Biomedical Engineering, and Radiology, University of Iowa, Iowa City, IA, 52242, USA</p><p>David W. Kaczka</p></li><li><p>Department of Surgery, SUNY Upstate Medical Center, Syracuse, NY, 13210, USA</p><p>Michaela Kollisch‑Singule & Gary F. Nieman</p></li><li><p>Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA</p><p>Donald P. Gaver</p></li></ol><span>Authors</span><ol><li><span>Jason H. T. Bates</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>David W. Kaczka</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Michaela Kollisch‑Singule</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Gary F. Nieman</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Donald P. Gaver</span>View author publicati
修正：致命护理28,329（2024）。https://doi.org/10.1186/s13054-024-05112-wFollowing发表原始文章b[1]时，作者在声明中发现了一个错误。“利益竞争”一节不见了。竞争利益sdwk是振荡avent， Inc.的联合创始人和股东，也是美国和国际机械通风专利的共同发明人。DWK还获得了ZOLL医疗公司的研究支持，与本工作无关。JHTB是振荡avent， Inc.的股东和顾问，也是涉及机械通风的美国专利的共同发明人。他也是Respiratory Sciences， Inc.的股东和顾问。MKS获得Dräger Medical Systems， Inc.的研究资助。MKS和GFN曾为Dräger Medical Systems， inc .发表过讲座。本文更正了“竞争利益”部分，并对原文b[1]进行了更正。Bates JHT, Kaczka DW, Kollisch-Singule M，等。如果呼气时间足够短，则可以避免无电损伤：来自气道释放通气期间逆模型和振荡测量的证据。危重症护理。2024;28:329。https://doi.org/10.1186/s13054-024-05112-w.Article PubMed PubMed Central b谷歌学者下载参考文献作者和单位佛蒙特大学医学院佛蒙特大学医学院，博蒙特大道149号，佛蒙特州伯灵顿，佛蒙特州，05405，美国jason H. T. bats爱荷华大学麻醉、生物医学工程和放射学系，爱荷华州，爱荷华州，52242，美国大卫W.卡兹卡，纽约州立大学北部医疗中心，锡拉丘兹，NY, 13210，USAMichaela kolisch - single &；Gary F. nieman杜兰大学生物医学工程系，新奥尔良，洛杉矶USADonald p GaverAuthorsJason h . t . BatesView publicationsYou作者也可以搜索PubMed的作者在谷歌ScholarDavid w . KaczkaView publicationsYou作者也可以搜索PubMed的作者在谷歌ScholarMichaela Kollisch - SinguleView publicationsYou作者也可以搜索PubMed的作者在谷歌ScholarGary f . NiemanView publicationsYou作者也可以搜索PubMed的作者在谷歌ScholarDonald p GaverView publicationsYou也可以搜索这个作者通讯作者：Jason H. T. Bates出版商声明：对于已出版的地图和机构关系中的管辖权要求，普林格·自然保持中立。开放获取本文遵循知识共享署名-非商业-非衍生品4.0国际许可协议，该协议允许以任何媒介或格式进行非商业用途、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，并注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其部分内容的改编材料。本文中的图像或其他第三方材料包含在文章的知识共享许可协议中，除非在材料的署名中另有说明。如果材料未包含在文章的知识共享许可中，并且您的预期用途不被法律法规允许或超过允许的用途，您将需要直接获得版权所有者的许可。要查看本许可协议的副本，请访问http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints和permissionsCite这篇文章bates， j.h.t., Kaczka, d.w., Kollisch - Singule， M. et al。纠正：如果呼气时间足够短，可以避免不电损伤：来自气道释放通气期间逆模型和振荡测量的证据。危重护理29,14（2025）。https://doi.org/10.1186/s13054-024-05227-0Download citationpublishing: 07 January 2025DOI: https://doi.org/10.1186/s13054-024-05227-0Share这篇文章任何你分享以下链接的人都可以阅读到这篇文章：获取可共享链接对不起，这篇文章目前没有可共享的链接。复制到剪贴板由施普林格自然共享内容倡议提供
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Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05247-w
Tài Pham, Miklos Lipcsey
<p>Dear Editor,</p><p>The Rolling Stones say “<i>Time is on my side, yes it is!—Now you always say, that you want to be free…</i>”, indeed time is not always on patients' and clinicians’ side in the ICU, and being free, especially from ventilation is of benefit if it can be avoided. However, it is the clinician who imposes ventilator treatment on the patient and chooses the time to do this.</p><p>The ever-recurring decision for every clinician is to act or not to act and when to act. The balance of benefit or harm of an intervention and the optimal timing of treatment is not always clear. Intervening or not and the timing are different questions but related especially in studies of the latter. In intensive care, the issue of timing of life-sustaining treatments such as renal replacement therapy (RRT) [1] and vasopressors in sepsis [2] have been investigated. There is also an ongoing debate regarding ventilation strategy, as early tracheal intubation exposes patients to procedural complications, ventilator-induced lung injury, or ventilator-acquired pneumonia, on the other hand, delayed intubation exposes them to self-induced lung injury [3] or the emergency procedure in the context of more respiratory or hemodynamic instability that is associated with major adverse peri-intubation events can lead to more complications [4]. The timing of intubation has been studied in the general ICU population and COVID-19 patients in observational studies [5,6,7] and varies widely across countries and according to the physician in charge [8]. In sepsis, mechanical ventilation affects not only the lung but also other organs, making early intubation a double-edged sword: it may contribute to sustained oxygen delivery, but it may also contribute to circulatory instability due to sedatives and the effects of positive pressure ventilation.</p><p>In a paper recently published in this <i>Journal</i>, Kim et al<i>.</i> reported a cohort of 2440 patients with sepsis who received invasive mechanical ventilation in one of the 20 hospitals participating in the Korean Sepsis Alliance [9]. They found that the 2119 (87%) patients intubated on the first day of ICU admission had better outcomes, including lower ICU and hospital mortality, than those who received invasive ventilation later during their ICU stay. So, based on these results, should we intubate all patients admitted with sepsis upon arrival in the ICU? We argue that this study does not resolve the uncertainty. Although a valuable contribution to our knowledge on the timing of intubation in sepsis patients, there are some issues to mention that put these data into context.</p><p>To answer the question of timing of intubation Kim et al<i>.</i> used propensity score matching to minimize bias and render the two groups as similar as possible. This is not the first study exploring the timing of intubation using this method. For example, Mellado-Artigas et al. also using propensity score matching have reported that intubat
作者和工作单位法国比歇特尔医院、DMU CORREVE、重症监护室、FHU SEPSIS、Groupe de recherche clinique CARMAS、巴黎萨克雷大学、AP-HP、Le Kremlin-BicêtreTài Pham巴黎南大学、Inserm U1018、Epidémiologie respiratoire intégrative Equipe d'Epidémiologie、Centre de Recherche en Epidémiologie et Santé des Populations。巴黎南大学，Inserm U1018，Epidémiologie respiratoire intégrative，Centre de Recherche en Epidémiologie et Santé des Populations，Université Paris-Saclay，UVSQ，Villejuif，FranceTài PhamAnaesthesiology and Intensive Care，Department of Surgical Sciences，Uppsala University，Uppsala，SwedenMiklos LipcseyHedenstierna Laboratory，Department of Surgical Sciences、Uppsala University, 751 85, Uppsala, SwedenMiklos LipcseyAuthorsTài PhamView author publications您也可以在PubMed Google Scholar中搜索该作者Miklos LipcseyView author publications您也可以在PubMed Google Scholar中搜索该作者ContributionsTP and ML co-wrote the manuscript, reviewed modifications and approved the final version.通讯作者Miklos Lipcsey.Competing interests作者未声明任何利益冲突.Publisher's Note施普林格-自然对出版地图中的管辖权主张和机构隶属关系保持中立.Open Access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，该协议允许以任何媒介或格式进行非商业性使用、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了许可使用范围，则您需要直接获得版权所有者的许可。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 articlePham, T., Lipcsey, M. Intubate patients with sepsis before midnight or do it when the time comes?.Crit Care 29, 10 (2025). https://doi.org/10.1186/s13054-024-05247-wDownload citationReceived：2024 年 12 月 23 日接受：31 December 2024Published: 07 January 2025DOI: https://doi.org/10.1186/s13054-024-05247-wShare this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
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Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05234-1
Xiaoyang Zhou, Bixin Chen, Caibao Hu
<p>Dear Editor,</p><p>In a recent release in the journal Intensive Care Medicine, Saura et al. presented a systematic echo checklist for managing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) [1]. They proposed nine key challenges requiring ultrasound assessment throughout the entire VA-ECMO course. We have read this article with great interest and found the comprehensive insights highly beneficial. However, we would like to add a general comment regarding the assessment of blood flow in a distal perfusion catheter (DPC) during VA-ECMO using ultrasound.</p><p>In the last decades, V-A ECMO has been increasingly used to provide temporary cardiopulmonary support for potentially reversible cardiac diseases or as a bridge therapy to transplantation or ventricular assist device for unrecoverable cardiac illnesses. Peripheral cannulation represents the primary catheterization approach of VA-ECMO, usually accompanied by a high incidence of vascular complications [2]. Lower limb ischemia is a common and clinically important complication of VA-ECMO, often attributed to femoral arterial cannulation and vasospasm. Implanting a DPC into the superficial femoral artery effectively alleviates lower limb ischemia and is increasingly used for prophylactic purposes. According to the Extracorporeal Life Support Organization guidelines, maintaining a blood flow of at least 100 mL/min in the DPC is necessary to ensure adequate limb perfusion [3]. However, monitoring the blood flow in a DPC remains a challenge in the clinical management of VA-ECMO. While ultrasonic flowmeters offer continuous DPC flow assessment, it is typically limited to ¼-inch connecting tubes and is unavailable in many ECMO centers, particularly in resource-limited settings [4]. To address these limitations, we propose a method for quantitatively estimating the DPC flow using conventional ultrasound, without relying on flowmeters or specific tube diameters.</p><p>In our ECMO center, a 6-Fr introducer sheath is routinely used as a DPC to prevent limb ischemia in VA-ECMO patients, with dialysis tubing commonly serving as the connecting tube between the DPC and the arterial return cannula (Fig. 1A). First, a linear array probe (4–12 MHz) is placed on the connecting tube to obtain a long-axis view (Fig. 1B), allowing measurement of the internal diameter of the connecting tube (D<sub>CT</sub>) (Fig. 1C), while tilting the probe to form a certain angle with the connecting tube to reduce the angle between the ultrasound beam and the blood flow (≤ 60°). Next, pulsed-wave Doppler ultrasound is used to measure the blood flow velocity. To accurately measure the time-averaged mean velocity (TAMEAN), the sampling volume size is adjusted to cover the diameter of the tube and a conventional angle correction line is regulated (Fig. 1D). Given the non-pulsatile and laminar nature of ECMO blood flow, the DPC flow can be calculated as: π × (D<sub>CT</sub>/2)<sup>2</sup> × TAMEAN × 60 (mL/min). For examp
VA-ECMO:Veno-arterial extraorporeal membrane oxygenation DPC:Distal perfusion catheterDCT :The internal diameter of the connecting tubeTAMEAN:Time-averaged mean velocitySaura O, Combes A, Hekimian G. My echo checklist in venoarterial ECMO patients.Intensive Care Med.2024; 50(12):2158-61.Article PubMed Google Scholar Bonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Lo Coco V, et al. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment.Crit Care.2019;23(1):266.Article PubMed PubMed Central Google Scholar Lorusso R, Shekar K, MacLaren G, Schmidt M, Pellegrino V, Meyns B, et al. ELSO 关于成人心脏病患者静脉体外膜氧合的临时指南。ASAIO J. 2021; 67(8):827-44.Article PubMed Google Scholar Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, et al. 股动脉插管成人外周静脉体外膜肺氧合远端肢体灌注管理的演变。灌注。2024; 39(1):23S-38S.Article PubMed Google Scholar Holland CK, Brown JM, Scoutt LM, Taylor KJ.正常人的下肢容积动脉血流。1998; 24(8):1079-86.Article PubMed Google Scholar Walker RD, Smith RE, Sherriff SB, Wood RF.容积血流测量的时间平均平均速度：使用生理股动脉血流波形的体外模型验证研究。本文由浙江省医药卫生科技项目（编号：2023KY1084）资助。作者和单位宁波市第二医院重症医学科，宁波，315000周晓阳 &；浙江大学医学院附属浙江医院重症医学科，浙江杭州，310000、中国Caibao Hu作者Xiaoyang Zhou查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者Bixin Chen查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者Caibao Hu查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者ContributionsXZ提出了意见并起草了手稿。BC和CH提出了意见并修改了手稿。伦理批准和参与同意书不适用。同意发表不适用。利益冲突作者声明无利益冲突。出版者注释Springer Nature对已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了许可使用范围，则您需要直接获得版权所有者的许可。要查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleZhou, X., Chen, B. & Hu, C. A tip for assessing blood flow in distal perfusion catheter during veno-arterial extracorporeal membrane oxygenation.https://doi.org/10.1186/s13054-024-05234-1Download citationReceived：11 December 2024Accepted: 22 December 2024Published: 07 January 2025DOI: https://doi.org/10.1186/s13054-024-05234-1Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
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