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The INTOXICATE study: methodology and preliminary results of a prospective observational study INTOXICATE 研究:前瞻性观察研究的方法和初步结果
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-27 DOI: 10.1186/s13054-024-05096-7
Samanta M. Zwaag, Irma S. van den Hengel-Koot, Stuart Baker, Patrick Druwé, Muhammed Elhadi, Ana Ferrer Dufol, Sune Forsberg, Burcin Halacli, Christian Jung, Gabija Laubner Sakalauskienė, Elin Lindqvist, Rui Moreno, Christian Rabe, Nanna Reiter, Richard Rezar, Radu Țincu, Arzu Topeli, David M. Wood, Dylan W. de Lange, Claudine C. Hunault
There is currently no practice-based, multicenter database of poisoned patients admitted to intensive care units (ICUs). The INTOXICATE study, endorsed by the ESICM and EAPCCT, aimed to determine the rate of eventful admissions among acutely intoxicated adult ICU patients. Ethical approval was obtained for this multicenter, prospective observational study, and data-sharing agreements were signed with each participating center. An electronic case report form was used to collect data on patient demographics, exposure, clinical characteristics, investigations, treatment, and in-hospital mortality data. The primary outcome, ‘eventful admission’, was a composite outcome defined as the rate of patients who received any of the following treatments in the first 24 h after the ICU admission: oxygen supplementation with a FiO2 > 40%, mechanical ventilation, vasopressors, renal replacement therapy (RRT), cardiopulmonary resuscitation, antidotes, active cooling, fluid resuscitation (> 1.5 L of intravenous fluid of any kind), sedation, or who died in the hospital. Seventy-eight ICUs, mainly from Europe, but also from Australia and the Eastern Mediterranean, participated. A total of 2,273 patients were enrolled between November 2020 and June 2023. The median age of the patients was 41 years, 72% were exposed to intoxicating drugs. The observed rate of patients with an eventful ICU admission was 68% (n = 1546/2273 patients). The hospital mortality was 4.5% (n = 103/2273). The vast majority of patients survive, and approximately one third of patients do not receive any ICU-specific interventions after admission in an intensive care unit for acute intoxication. High-quality detailed clinical data have been collected from a large cohort of acutely intoxicated ICU patients, providing information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of these patients. Trial registration: OSF registration ID: osf.io/7e5uy.
目前,重症监护病房(ICU)尚未建立以实践为基础的中毒患者多中心数据库。INTOXICATE 研究得到了 ESICM 和 EAPCCT 的支持,旨在确定急性中毒成人重症监护病房患者的事件性入院率。这项多中心、前瞻性观察研究已获得伦理批准,并与各参与中心签署了数据共享协议。研究采用电子病例报告表收集患者的人口统计学数据、接触情况、临床特征、检查、治疗和院内死亡率数据。主要研究结果 "入院事件 "是一项综合研究结果,其定义为患者在入住重症监护病房后的 24 小时内接受以下任何一种治疗的比例:FiO2 > 40% 的氧气补充、机械通气、血管加压、肾脏替代疗法(RRT)、心肺复苏、解毒剂、主动降温、液体复苏(> 1.5 L 的各种静脉注射液)、镇静或在医院内死亡。共有 78 家重症监护室参与了这项研究,其中主要来自欧洲,也有来自澳大利亚和地中海东部的重症监护室。在 2020 年 11 月至 2023 年 6 月期间,共有 2273 名患者参与了这项研究。患者的年龄中位数为 41 岁,72% 的患者接触过麻醉药物。观察到的重症监护室入院患者事件发生率为 68%(n = 1546/2273)。住院死亡率为 4.5%(n = 103/2273)。绝大多数患者都能存活,约三分之一的患者在因急性中毒入住重症监护室后没有接受任何重症监护室特定的干预措施。该研究从一大批急性中毒重症监护室患者中收集到了高质量的详细临床数据,为需要入住重症监护室的严重急性中毒模式以及这些患者的预后提供了信息。试验注册:OSF 注册编号:osf.io/7e5uy。
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引用次数: 0
Prognostic role of early blood gas variables in critically ill patients with Pneumocystis jirovecii pneumonia: a retrospective analysis 肺孢子虫肺炎重症患者早期血气变量的预后作用:回顾性分析
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-27 DOI: 10.1186/s13054-024-05087-8
Anouk Voutaz, Jean Bonnemain, Zied Ltaief, Oriol Manuel, Lucas Liaudet
<p><i>Pneumocystis jirovecii</i> pneumonia (PJP) is a severe fungal opportunistic infection occurring in immunocompromised patients, commonly associated with Human Immunodeficiency Virus (HIV) in the past and nowadays increasingly diagnosed in non-HIV patients with immune suppression. Severe PJP requiring admission to the intensive care unit is associated with mortality rates > 50%, and several factors have been associated with reduced survival including age, a non-HIV status, invasive mechanical ventilation and the admission SOFA score [1, 2]. Whether additional prognostic factors might help identify high-risk patients at an early stage of ICU stay remains undefined. To address this issue, we retrospectively analyzed (study protocol approved by our ethical committee, CER-VD Nr 2020-00201) the clinical and early (admission—day 0- and day 1) arterial blood gas (ABG) variables, including values of methemoglobin (MetHb) and carboxyhemoglobin (HbCO), in a cohort of PJP patients admitted to our multidisciplinary ICU between 2006 and 2019. The primary outcome was mortality at day 60. Data were compared between survivors and non survivors using the Wilcoxon’s rank sum test and the Pearson’s chi-squared test, and univariate logistic regression analyses were done to evaluate associations between variables and 60-day mortality. We also performed a multivariable analysis incorporating invasive mechanical ventilation at day 1 as a possible confounder, with blood gas data at day 1 (PaCO<sub>2</sub>, HbCO and MetHb) as explanatory co-variables. The impact of blood gas variables on 60-day survival was further assessed using Kaplan–Meier plots and log-rank test analysis.</p><p>A total of 37 patients with confirmed <i>Pneumocystis jirovecii</i> infection (except in one patient in whom no sample could be obtained, but with typical clinical/radiological presentation and a positive beta-glucan test) were included. Underlying diagnoses were malignancy (n = 21), chronic immune-mediated inflammatory disease (n = 8), HIV (n = 5), solid organ (n = 4) or bone marrow transplantation (n = 5), with more than 1 condition present in 6 patients. Most patients had been treated prior to admission with one or more immune suppressive therapies. The 60-day mortality was 51% (19/37 patients). Non-survivors were significantly older but did not differ from survivors with respect to gender and underlying diagnoses. All patients received non-invasive and/or invasive respiratory support, and non-survivors required significantly more often invasive mechanical ventilation (79 vs. 39%, <i>p</i> < 0.05). ABG analyses showed that non-survivors had higher PaCO<sub>2</sub> (day 1), lower pHa and higher MetHb as well as a trend for higher HbCO (day 0 and day 1). In contrast, P/F O<sub>2</sub> was comparable in survivors and non-survivors at the two time-points. In univariate analyses, day 0 HbCO and MetHb, and day 1 PaCO<sub>2</sub>, pHa and MetHb were significantly associated with 60-day m
吉罗韦氏肺孢子菌肺炎(PJP)是一种严重的真菌机会性感染,多发于免疫力低下的患者,过去通常与人类免疫缺陷病毒(HIV)有关,如今越来越多的非 HIV 患者因免疫抑制而被诊断为 PJP。需要入住重症监护室的重症 PJP 死亡率高达 50%,有几个因素与存活率降低有关,包括年龄、非 HIV 感染状况、有创机械通气和入院 SOFA 评分[1, 2]。其他预后因素是否有助于在入住 ICU 的早期阶段识别高危患者,目前仍未确定。为了解决这个问题,我们回顾性分析了 2006 年至 2019 年期间入住我们多学科 ICU 的一组 PJP 患者的临床和早期(入院第 0 天和第 1 天)动脉血气(ABG)变量(研究方案已获伦理委员会批准,CER-VD Nr 2020-00201),包括高铁血红蛋白(MetHb)和碳氧血红蛋白(HbCO)的值。主要结果是第 60 天的死亡率。我们使用 Wilcoxon 秩和检验和皮尔逊卡方检验比较了存活者和非存活者之间的数据,并进行了单变量逻辑回归分析,以评估变量与 60 天死亡率之间的关联。我们还进行了多变量分析,将第 1 天的有创机械通气作为可能的混杂因素,并将第 1 天的血气数据(PaCO2、HbCO 和 MetHb)作为解释性共变因素。共纳入 37 名确诊为肺孢子虫感染的患者(除一名患者无法获得样本,但具有典型的临床/放射学表现和β-葡聚糖检测呈阳性外)。基础诊断包括恶性肿瘤(21 例)、慢性免疫介导的炎症性疾病(8 例)、艾滋病(5 例)、实体器官移植(4 例)或骨髓移植(5 例),其中 6 例患者患有一种以上的疾病。大多数患者在入院前曾接受过一种或多种免疫抑制疗法。60天死亡率为51%(19/37名患者)。非幸存者的年龄明显偏大,但在性别和基础诊断方面与幸存者没有差异。所有患者都接受了非侵入性和/或侵入性呼吸支持,非存活者需要侵入性机械通气的比例明显更高(79 比 39%,P &lt;0.05)。ABG 分析显示,非存活者的 PaCO2(第 1 天)较高,pHa 较低,MetHb 较高,HbCO(第 0 天和第 1 天)也呈上升趋势。相比之下,幸存者和非幸存者在两个时间点的 P/F O2 值相当。在单变量分析中,第 0 天的 HbCO 和 MetHb 以及第 1 天的 PaCO2、pHa 和 MetHb 与 60 天死亡率显著相关(图 1A)。在多变量分析中,第 1 天的 PaCO2 和 MetHb 仍与 60 天死亡率显著相关(图 1B)。Kaplan-Meier 分析显示,第 0 天 MetHb 较高和 pHa 较低的患者(图中未显示),以及第 1 天 HbCO、PaCO2 和 MetHb 较高和 pHa 较低的患者(图 1C)生存期明显较短。A 存活者和非存活者在第 0 天和第 1 天的 P/FO2、PaCO2、pHa、HbCO 和 MetHb(中位数,四分位数间差)及其与 60 天死亡率的单变量关系。B 与 60 天死亡率相关因素的多变量分析。C Kaplan-Meier 图显示 60 天观察期内存活者的比例与第 1 天的 PaCO2(单位:mmHg)、pHa、MetHb 和 HbCO 的函数关系,并根据其在整个队列中的中位值进行二分。对于连续变量,计算了每单位变化的几率比(OR)和 95% 置信区间(CI)(P/FO2:10 mmHg;PaCO2:1 mmHg;pHa:0.01 pH 单位;HbCO:0.1%;MetHb:0.1%)。注:第 0 天,1 名患者(存活者)的 P/FO2 缺失,3 名患者(2 名存活者,1 名非存活者)未测量 HbCO 和 MetHB。第 1 天:3 名患者(1 名非存活者,2 名存活者)未获得 ABG,其中 HbCO 和 MetHb 是通过中心静脉血气分析获得的。IMV 有创机械通气全尺寸图片我们的研究发现,在入住 ICU 的头 24 小时内获得的几个 ABG 变量可为 PJP 患者提供重要的早期预后信息。非存活患者较高的 PaCO2 和较低的 pHa 可能反映了呼吸疲劳的发展或死腔通气的增加,这与其他形式的急性呼吸衰竭中较高的死腔分数的负面影响是一致的[3]。非存活者的 MetHb 水平也较高,其第 0 天和第 1 天的值与 60 天死亡率显著相关。
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引用次数: 0
Lymphopenia in sepsis: a narrative review 败血症中的淋巴细胞减少症:叙述性综述
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-20 DOI: 10.1186/s13054-024-05099-4
Zhibin Wang, Wenzhao Zhang, Linlin Chen, Xin Lu, Ye Tu
This narrative review provides an overview of the evolving significance of lymphopenia in sepsis, emphasizing its critical function in this complex and heterogeneous disease. We describe the causal relationship of lymphopenia with clinical outcomes, sustained immunosuppression, and its correlation with sepsis prediction markers and therapeutic targets. The primary mechanisms of septic lymphopenia are highlighted. In addition, the paper summarizes various attempts to treat lymphopenia and highlights the practical significance of promoting lymphocyte proliferation as the next research direction.
这篇叙述性综述概述了淋巴细胞减少症在脓毒症中不断演变的意义,强调了淋巴细胞减少症在这种复杂而多变的疾病中的关键作用。我们描述了淋巴细胞减少症与临床结果、持续免疫抑制的因果关系,以及它与脓毒症预测指标和治疗目标的相关性。文章还强调了脓毒症淋巴细胞减少症的主要机制。此外,本文还总结了治疗淋巴细胞减少症的各种尝试,并强调了促进淋巴细胞增殖作为下一个研究方向的现实意义。
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引用次数: 0
Infusion of sodium DL-3-ß-hydroxybutyrate decreases cerebral injury biomarkers after resuscitation in experimental cardiac arrest 输注 DL-3-ß-hydroxybutyrate 钠可减少实验性心脏骤停患者复苏后的脑损伤生物标志物
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-20 DOI: 10.1186/s13054-024-05106-8
Filippo Annoni, Fuhong Su, Lorenzo Peluso, Ilaria Lisi, Enrico Caruso, Francesca Pischiutta, Elisa Gouvea Bogossian, Bruno Garcia, Hassane Njimi, Jean-Louis Vincent, Nicolas Gaspard, Lorenzo Ferlini, Jacques Creteur, Elisa R. Zanier, Fabio Silvio Taccone
Cerebral complications after cardiac arrest (CA) remain a major problem worldwide. The aim was to test the effects of sodium-ß-hydroxybutyrate (SBHB) infusion on brain injury in a clinically relevant swine model of CA. CA was electrically induced in 20 adult swine. After 10 min, cardiopulmonary resuscitation was performed for 5 min. After return of spontaneous circulation (ROSC), the animals were randomly assigned to receive an infusion of balanced crystalloid (controls, n = 11) or SBHB (theoretical osmolarity 1189 mOsm/l, n = 8) for 12 h. Multimodal neurological and cardiovascular monitoring were implemented in all animals. Nineteen of the 20 animals achieved ROSC. Blood sodium concentrations, osmolarity and circulating KBs were higher in the treated animals than in the controls. SBHB infusion was associated with significantly lower plasma biomarkers of brain injury at 6 (glial fibrillary acid protein, GFAP and neuron specific enolase, NSE) and 12 h (neurofilament light chain, NFL, GFAP and NSE) compared to controls. The amplitude of the stereoelectroencephalograph (sEEG) increased in treated animals after ROSC compared to controls. Cerebral glucose uptake was lower in treated animals. In this experimental model, SBHB infusion after resuscitated CA was associated with reduced circulating markers of cerebral injury and increased sEEG amplitude.
心脏骤停(CA)后的脑部并发症仍然是世界范围内的一个主要问题。本研究旨在测试输注ß-羟基丁酸钠(SBHB)对临床相关的 CA 猪模型脑损伤的影响。对 20 头成年猪进行电诱导 CA。10 分钟后,进行心肺复苏 5 分钟。自发性循环恢复(ROSC)后,动物被随机分配接受平衡晶体液(对照组,n = 11)或 SBHB(理论渗透压 1189 mOsm/l,n = 8)输注 12 小时。20 只动物中有 19 只实现了 ROSC。接受治疗的动物的血钠浓度、渗透压和循环中的 KBs 均高于对照组。与对照组相比,输注 SBHB 在 6 小时(胶质纤维酸蛋白、GFAP 和神经元特异性烯醇化酶、NSE)和 12 小时(神经丝轻链、NFL、GFAP 和 NSE)脑损伤血浆生物标志物明显降低。与对照组相比,ROSC 后接受治疗的动物立体脑电图(sEEG)振幅增大。治疗动物的脑葡萄糖摄取量较低。在该实验模型中,CA复苏后输注SBHB与脑损伤循环标志物减少和sEEG振幅增加有关。
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引用次数: 0
High flow nasal cannula versus non-invasive ventilation in the treatment of acute exacerbations of COPD with acute-moderate hypercapnic respiratory failure 高流量鼻插管与无创通气在治疗慢性阻塞性肺疾病急性加重伴急性-中度高碳酸血症呼吸衰竭中的比较
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-19 DOI: 10.1186/s13054-024-05094-9
Rongpeng Xu, Ziqiang Shao
<p>Dear Editor,</p><p>Recently, we read with great interest the article by Tan et al. [1], in which the authors demonstrated that compared to high-flow nasal cannula oxygen (HFNC), non-invasive ventilation (NIV) is a better choice for initial respiratory support in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) complicated by acute-moderate hypercapnic respiratory failure. Although this result highlights the efficacy of NIV in the treatment of AECOPD patients, we believe that there are still certain issues that need to be clarified in the study conducted by Tan et al.</p><p>First, the gas flow rate of HFNC during treatment needs to be noticed. Mechanically, the high gas flow rate of HFNC can wash out the dead space of chronic obstructive pulmonary disease (COPD) patients, and effectively decreases pressure of arterial carbon dioxide (PaCO<sub>2</sub>). Studies have shown that HFNC as initial respiratory support is non-inferior to NIV in decreasing PaCO<sub>2</sub> after 2 h of treatment in patients with mild-to-moderate AECOPD [2]. However, carbon dioxide retention was the most common reason for treatment failure in the HFNC group in this study. Therefore, whether raising the initial gas flow rate from 40 L/min to 60 L/min could improve the treatment success rate of HFNC. It is worth noting that study has shown that higher gas flow rate than 30 L/min not only fails to lower PaCO<sub>2</sub> but also increases inspiratory effort [3]. In short, the initial gas flow rate of 40 L/min does not seem to be an optimal setting. In addition, HFNC has the advantage of comfort and is usually used continuously after obtaining the optimal gas flow rate required by the patient. In this study, intermittent downregulation of gas flow rate or even discontinuation of HFNC was adopted in the HFNC group, which may be a key factor leading to the failure of HFNC treatment.</p><p>Additionally, the baseline data lacks of information on the frequency of acute exacerbations in patients. The 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD report noted that that the frequency of previous hospitalizations for acute exacerbations of COPD and concurrent cardiovascular disease comorbidities are associated with poor outcomes in patients [4]. Therefore, it is necessary to list the frequency of acute exacerbations and to describe the cardiovascular comorbidities such as heart failure, hypertension, and arrhythmia in the baseline data, which may significantly affect the success of respiratory therapy in each group of patients.</p><p>Furthermore, Oxygen therapy and ventilatory support are only one part of AECOPD treatment [4]. It is well known that the use of bronchodilators is critical in the treatment of AECOPD. Through dilating the bronchi and bronchioles, bronchodilators not only improve the exchange of oxygen and carbon dioxide, but also facilitate the expulsion of sputum, which is closely related to the success of o
高流量鼻插管氧疗与无创通气治疗慢性阻塞性肺病急性加重伴急性-中度高碳酸血症呼吸衰竭:随机对照非劣效性试验。Crit Care.2024;28:250.Article PubMed PubMed Central Google Scholar Cortegiani A, Longhini F, Madotto F, Groff P, Scala R, Crimi C, et al. High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial.Crit Care.2020;24:692.Article PubMed PubMed Central Google Scholar Rittayamai N, Phuangchoei P, Tscheikuna J, Praphruetkit N, Brochard L. Effects of high-flow nasal cannula and non-invasive ventilation on inspiratory effort in hypercapnic patients with chronic obstructive pulmonary disease: a preliminary study.Ann Intensive Care.2019;9:122.Article PubMed PubMed Central Google Scholar Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. 诊断、管理和预防慢性阻塞性肺病全球战略 2017 年报告:GOLD执行摘要。Eur Respir J. 2017;49:1700214.Article PubMed Google Scholar Wang M, Zhao F, Sun L, Liang Y, Yan W, Sun X, et al. High-flow nasal cannula versus noninvasive ventilation in AECOPD patients with respiratory acidosis: a retrospective propensity score-matched study.Can Respir J. 2023;2023:6377441.Article PubMed PubMed Central Google Scholar Longhini F, Pisani L, Lungu R, Comellini V, Bruni A, Garofalo E, et al. 从高碳酸血症急性呼吸衰竭恢复的患者无创通气中断后的高流量氧疗:生理交叉试验。Crit Care Med.2019;47:e506-11.文章 CAS PubMed Google Scholar 下载参考文献无.作者在本研究中未获得任何资助。作者及单位浙江省杭州市上塘路158号浙江省人民医院(杭州医学院附属人民医院)急危重症医学中心重症医学科徐荣鹏&amp;邵自强作者简介徐荣鹏查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者邵自强查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者供稿RPX和ZQS参与了讨论并撰写了手稿。通讯作者邵自强.伦理批准和参与同意书不适用.发表同意书不适用.利益冲突作者声明他们没有利益冲突.出版者注释Springer Nature对出版地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可,该协议允许以任何媒介或格式进行非商业性使用、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 articleXu, R., Shao, Z. High flow nasal cannula versus non-invasive ventilation in the treatment of acute exacerbations of COPD with acute-moderate hypercapnic respiratory failure.https://doi.org/10.1186/s13054-024-05094-9Download citationReceived:接受:2024 年 8 月 31 日10 September 2024Published: 19 September 2024DOI: https://doi.org/10.1186/s13054-024-05094-9Share 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.
{"title":"High flow nasal cannula versus non-invasive ventilation in the treatment of acute exacerbations of COPD with acute-moderate hypercapnic respiratory failure","authors":"Rongpeng Xu, Ziqiang Shao","doi":"10.1186/s13054-024-05094-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05094-9","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;Recently, we read with great interest the article by Tan et al. [1], in which the authors demonstrated that compared to high-flow nasal cannula oxygen (HFNC), non-invasive ventilation (NIV) is a better choice for initial respiratory support in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) complicated by acute-moderate hypercapnic respiratory failure. Although this result highlights the efficacy of NIV in the treatment of AECOPD patients, we believe that there are still certain issues that need to be clarified in the study conducted by Tan et al.&lt;/p&gt;&lt;p&gt;First, the gas flow rate of HFNC during treatment needs to be noticed. Mechanically, the high gas flow rate of HFNC can wash out the dead space of chronic obstructive pulmonary disease (COPD) patients, and effectively decreases pressure of arterial carbon dioxide (PaCO&lt;sub&gt;2&lt;/sub&gt;). Studies have shown that HFNC as initial respiratory support is non-inferior to NIV in decreasing PaCO&lt;sub&gt;2&lt;/sub&gt; after 2 h of treatment in patients with mild-to-moderate AECOPD [2]. However, carbon dioxide retention was the most common reason for treatment failure in the HFNC group in this study. Therefore, whether raising the initial gas flow rate from 40 L/min to 60 L/min could improve the treatment success rate of HFNC. It is worth noting that study has shown that higher gas flow rate than 30 L/min not only fails to lower PaCO&lt;sub&gt;2&lt;/sub&gt; but also increases inspiratory effort [3]. In short, the initial gas flow rate of 40 L/min does not seem to be an optimal setting. In addition, HFNC has the advantage of comfort and is usually used continuously after obtaining the optimal gas flow rate required by the patient. In this study, intermittent downregulation of gas flow rate or even discontinuation of HFNC was adopted in the HFNC group, which may be a key factor leading to the failure of HFNC treatment.&lt;/p&gt;&lt;p&gt;Additionally, the baseline data lacks of information on the frequency of acute exacerbations in patients. The 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD report noted that that the frequency of previous hospitalizations for acute exacerbations of COPD and concurrent cardiovascular disease comorbidities are associated with poor outcomes in patients [4]. Therefore, it is necessary to list the frequency of acute exacerbations and to describe the cardiovascular comorbidities such as heart failure, hypertension, and arrhythmia in the baseline data, which may significantly affect the success of respiratory therapy in each group of patients.&lt;/p&gt;&lt;p&gt;Furthermore, Oxygen therapy and ventilatory support are only one part of AECOPD treatment [4]. It is well known that the use of bronchodilators is critical in the treatment of AECOPD. Through dilating the bronchi and bronchioles, bronchodilators not only improve the exchange of oxygen and carbon dioxide, but also facilitate the expulsion of sputum, which is closely related to the success of o","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245195","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}
引用次数: 0
The procalcitonin trajectory as an effective tool for identifying sepsis patients at high risk of mortality 降钙素原轨迹是识别脓毒症高危患者的有效工具
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-19 DOI: 10.1186/s13054-024-05100-0
Xu Wang, Shilong Lin, Ming Zhong, Jieqiong Song
<p>Sepsis is a critical condition that significantly burdens healthcare systems globally. Given the heterogeneity among sepsis patients, identifying high-risk mortality groups is crucial [1]. Procalcitonin (PCT) is a well-established biomarker for evaluating sepsis severity and guiding antibiotic therapy [2]. In practice, PCT is usually measured repeatedly during the hospital stay. While single PCT values are helpful, dynamic trends through repeated measurements offer deeper insights into patient prognosis. Traditional analysis methods often fail to fully capture the complexity of these data [3]. By employing a hierarchical linear mixed-effects (HLME) model [4], this study aims to explore distinct PCT trajectories in sepsis patients and their association with mortality, providing a refined approach to risk stratification.</p><p>We here report our main findings in this study. The medical ethics committee of Zhongshan Hospital Fudan University reviewed and approved this study (B2021-501R). Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data. Between Jan 2019 and March 2024, 537 patients (167 females, 370 males; median age 69 years old [IQR 59–77]) were included. The proportion of patients with septic shock is 47.5%. Abdomen (274/51.0%) and respiratory (202/37.6%) were the two main sites of infection. The median length of stay (LOS) was 10 days [IQR 4–20] in ICU and 15 days [IQR 10–25] in hospital. One hundred sixty-five in-hospital deaths were observed.</p><p>A total of 2492 PCT measurements were available for trajectory modeling analyses. Three classes were identified using the HLME model (Fig. 1A). Class 1, also known as the “high-value-slow-decrease” class, included 43 patients (8%) and was characterized by initially high PCT values that remained stable for the first three days before gradually declining. Class 2, the “consistent-low” class, included 354 patients (66%) and displayed low initial PCT values that remained consistently low over the first 7 days in the ICU. Class 3, the “high-value-fast-decrease” class, included 140 patients (26%) and was marked by high initial PCT values that declined rapidly over time. Baseline characteristics differed significantly between the three PCT classes (Table 1). Patients in Class 1 and Class 3 had higher baseline SOFA scores and required more norepinephrine to maintain blood pressure compared to Class 2. In-hospital mortality was highest in Class 1 (42%) compared to Class 2 (32%) and Class 3 (24%) (<i>P</i> = 0.044). Baseline variables (age, sex, baseline SOFA, baseline lactate, presence of septic shock, surgical intervention, infection sites) and PCT classes were included in the Cox proportional hazards model for in-hospital mortality. With Class 1 as the reference level, Class 2 (HR: 0.507 [95% CI 0.287–0.895], <i>P</i> = 0.020) and Class 3 (HR 0.449 [95% CI 0.244–0.827], <i>P</i> = 0.011) were independent protective factors for in-
败血症是一种危重病,给全球医疗系统带来沉重负担。鉴于败血症患者的异质性,识别高危死亡人群至关重要[1]。降钙素原(PCT)是评估败血症严重程度和指导抗生素治疗的公认生物标志物[2]。实际上,PCT 通常在住院期间反复测量。虽然单一的 PCT 值很有帮助,但通过重复测量得出的动态趋势能更深入地了解患者的预后。传统的分析方法往往无法完全捕捉到这些数据的复杂性[3]。通过采用分层线性混合效应(HLME)模型[4],本研究旨在探索脓毒症患者不同的 PCT 变化轨迹及其与死亡率的关系,为风险分层提供一种完善的方法。复旦大学附属中山医院医学伦理委员会审查并批准了本研究(B2021-501R)。由于本研究为回顾性研究,且分析使用的是匿名临床数据,因此免除了知情同意。在2019年1月至2024年3月期间,共纳入537例患者(女性167例,男性370例;中位年龄69岁[IQR 59-77])。脓毒性休克患者占 47.5%。腹部(274/51.0%)和呼吸道(202/37.6%)是两个主要感染部位。在重症监护室的中位住院时间(LOS)为 10 天 [IQR 4-20],住院时间为 15 天 [IQR 10-25]。共有 2492 个 PCT 测量值可用于轨迹模型分析。使用 HLME 模型确定了三个等级(图 1A)。第 1 类也称为 "高值-缓慢下降 "类,包括 43 名患者(8%),其特点是最初的 PCT 值较高,在前三天保持稳定,然后逐渐下降。第 2 类是 "持续低值 "类,包括 354 名患者(66%),其初始 PCT 值较低,在重症监护室的前 7 天内持续保持低值。第 3 类是 "高值-快速下降 "类,包括 140 名患者(占 26%),其特点是初始 PCT 值较高,但随着时间的推移迅速下降。三个 PCT 等级的基线特征差异很大(表 1)。与 2 级相比,1 级和 3 级患者的基线 SOFA 评分较高,需要更多去甲肾上腺素来维持血压。与 2 级(32%)和 3 级(24%)相比,1 级患者的院内死亡率最高(42%)(P = 0.044)。基线变量(年龄、性别、基线 SOFA、基线乳酸、是否存在脓毒性休克、手术干预、感染部位)和 PCT 分级被纳入院内死亡率的 Cox 比例危险模型。以 1 级为参考水平,2 级(HR:0.507 [95% CI 0.287-0.895],P = 0.020)和 3 级(HR 0.449 [95% CI 0.244-0.827],P = 0.011)是院内死亡率的独立保护因素。图 1A 显示了 3 个不同的降钙素原等级。B 包含 3 个等级患者的 Kaplan-Meier 曲线。1 级:"高值-缓慢-下降 "级;2 级:"持续-低值 "级;3 级:"高值-快速-下降 "级图片全尺寸表 1 三个 PCT 级之间基线特征的比较表格全尺寸本研究确定了三种不同的 PCT 轨迹。尽管各等级之间存在明显的基线差异,但 "高值-慢减 "PCT轨迹是导致较高院内死亡率的独立风险因素。鉴于 PCT 轨迹与死亡率之间的密切联系,临床医生必须持续监测 PCT 水平,以发现潜在的高危脓毒症患者。这项研究为临床医生提供了优化临床决策的信息,并有助于制定更个性化、更有效的脓毒症管理策略,最终改善患者的预后。Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, McIntyre L, Ostermann M, Prescott HC, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021.Intensive Care Med.2021;47(11):1181-247.Article PubMed PubMed Central Google Scholar Papp M, Kiss N, Baka M, Trásy D, Zubek L, Fehérvári P, Harnos A, Turan C, Hegyi P, Molnár Z. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis.Crit Care.2023;27(1):394.
{"title":"The procalcitonin trajectory as an effective tool for identifying sepsis patients at high risk of mortality","authors":"Xu Wang, Shilong Lin, Ming Zhong, Jieqiong Song","doi":"10.1186/s13054-024-05100-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05100-0","url":null,"abstract":"&lt;p&gt;Sepsis is a critical condition that significantly burdens healthcare systems globally. Given the heterogeneity among sepsis patients, identifying high-risk mortality groups is crucial [1]. Procalcitonin (PCT) is a well-established biomarker for evaluating sepsis severity and guiding antibiotic therapy [2]. In practice, PCT is usually measured repeatedly during the hospital stay. While single PCT values are helpful, dynamic trends through repeated measurements offer deeper insights into patient prognosis. Traditional analysis methods often fail to fully capture the complexity of these data [3]. By employing a hierarchical linear mixed-effects (HLME) model [4], this study aims to explore distinct PCT trajectories in sepsis patients and their association with mortality, providing a refined approach to risk stratification.&lt;/p&gt;&lt;p&gt;We here report our main findings in this study. The medical ethics committee of Zhongshan Hospital Fudan University reviewed and approved this study (B2021-501R). Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data. Between Jan 2019 and March 2024, 537 patients (167 females, 370 males; median age 69 years old [IQR 59–77]) were included. The proportion of patients with septic shock is 47.5%. Abdomen (274/51.0%) and respiratory (202/37.6%) were the two main sites of infection. The median length of stay (LOS) was 10 days [IQR 4–20] in ICU and 15 days [IQR 10–25] in hospital. One hundred sixty-five in-hospital deaths were observed.&lt;/p&gt;&lt;p&gt;A total of 2492 PCT measurements were available for trajectory modeling analyses. Three classes were identified using the HLME model (Fig. 1A). Class 1, also known as the “high-value-slow-decrease” class, included 43 patients (8%) and was characterized by initially high PCT values that remained stable for the first three days before gradually declining. Class 2, the “consistent-low” class, included 354 patients (66%) and displayed low initial PCT values that remained consistently low over the first 7 days in the ICU. Class 3, the “high-value-fast-decrease” class, included 140 patients (26%) and was marked by high initial PCT values that declined rapidly over time. Baseline characteristics differed significantly between the three PCT classes (Table 1). Patients in Class 1 and Class 3 had higher baseline SOFA scores and required more norepinephrine to maintain blood pressure compared to Class 2. In-hospital mortality was highest in Class 1 (42%) compared to Class 2 (32%) and Class 3 (24%) (&lt;i&gt;P&lt;/i&gt; = 0.044). Baseline variables (age, sex, baseline SOFA, baseline lactate, presence of septic shock, surgical intervention, infection sites) and PCT classes were included in the Cox proportional hazards model for in-hospital mortality. With Class 1 as the reference level, Class 2 (HR: 0.507 [95% CI 0.287–0.895], &lt;i&gt;P&lt;/i&gt; = 0.020) and Class 3 (HR 0.449 [95% CI 0.244–0.827], &lt;i&gt;P&lt;/i&gt; = 0.011) were independent protective factors for in-","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245196","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}
引用次数: 0
Post-insufflation diaphragm contractions in patients receiving various modes of mechanical ventilation 接受各种机械通气模式的患者吸气后横膈膜收缩的情况
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-18 DOI: 10.1186/s13054-024-05091-y
Antenor Rodrigues, Fernando Vieira, Michael C. Sklar, L. Felipe Damiani, Thomas Piraino, Irene Telias, Ewan C. Goligher, W. Darlene Reid, Laurent Brochard
During mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients’ characteristics or both. One-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II. Forty-seven patients (median[25%-75%IQR] age: 63[52–77] years, BMI: 24.9[22.9–33.7] kg/m2, 49% male, APACHE II: 21[19–28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05). In critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.
在机械通气过程中,吸气后横膈膜收缩(PIDC)是非生理现象,可能会造成伤害。在反向触发时,膈肌收缩会跟随呼吸机的节律,因此 PIDCs 可能会频繁发生。不同的辅助通气模式是否会发生 PIDC 尚不清楚。在低氧血症呼吸衰竭的机械通气患者中,我们旨在研究 PIDC 是否与呼吸机设置、患者特征或两者都有关联。从插管到膈肌活动完全恢复或死亡的长达五天的时间里,我们每天收集一次膈肌电图(EAdi)、气道压力和气流的一小时记录。每次呼吸被分为强制性(无反向触发)、反向触发或患者触发。根据相对于呼吸机周期的 EAdi 时间或导致呼吸堆积的反向触发,对反向触发进行了进一步分类。逐次测量 EAdi 时间(起始、偏移)、峰值和神经吸气时间(Tineuro),并与呼吸机呼气时间进行比较。采用多变量逻辑回归模型研究与 PIDCs 独立相关的因素,包括 EAdi 时间、振幅、Tineuro、呼吸机设置和 APACHE II。47名患者(中位数[25%-75%IQR]年龄:63[52-77]岁,体重指数:24.9[22.9-33.7]kg/m2,49%为男性,APACHE II:21[19-28])每人提供了2 ± 1次记录,共计183,962次呼吸。74%的反向触发呼吸、27%的压力支持呼吸、21%的辅助控制呼吸、5%的神经调节通气辅助呼吸发生了 PIDC。PIDC 与更高的 EAdi 峰值(几率比 [OR][95%CI] 1.01[1.01;1.01])、更长的 Tineuro(OR 37.59[34.50;40.98])、更短的呼吸机吸气时间(OR 0.27[0.24;0.30])、高吸气峰值流量(OR 0.22[0.20;0.26])和小潮气量(OR 0.31[0.25;0.37])(所有 P 均≤0.008)。NAVA 与无 PIDCs 相关(OR 0.03[0.02;0.03]; P <0.001)。反向触发的特点是 EAdi 峰值低于在压力支持下触发的呼吸,并且与辅助控制下触发的呼吸相比,潮气量较小,设定吸气时间较短(均 P < 0.05)。与所有其他反向触发表型相比,导致呼吸叠加的反向触发的特点是 EAdi 峰值更高、Tineuro 时间更长,并与潮气量小有关(所有 P < 0.05)。在重症机械通气患者中,PIDC 和反向触发表型与潜在的可调节因素有关,包括呼吸机设置。NAVA 等比例模式是消除 PIDC 的一种解决方案。
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引用次数: 0
Further support for the intracranial compartmental syndrome concept 颅内隔室综合征概念的进一步佐证
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-18 DOI: 10.1186/s13054-024-04974-4
Daniel Agustin Godoy, Sergio Brasil, Andres M. Rubiano
<p>The current approach to severe neuro-injury monitoring, especially traumatic brain injury (TBI), has experienced paradigm shifts that open a broad outlook for the future [1]. On one hand, advances in pathophysiological knowledge have made possible establishing today that intracranial pressure (ICP) control is just one more epiphenomenon within other serious events that occur simultaneously such as tissue hypoxia, metabolic crises and cerebral energy dysfunction [1]. On the other hand, the advent of new monitoring techniques (invasive and noninvasive) have allowed a deeper analysis in real time of what is happening in the injured brain [1]. One of the most important advancements in neuromonitoring was the recent popularization of the analysis of the ICP wave (ICPw) morphology. Current studies pointed the changes in ICPw as reliable markers of cerebrospinal compliance and to be followed in clinical environments. In this regard, ICPw was considered the pillar of the intracranial compartmental syndrome (ICCS) concept [2]. So, <i>“ICCS occurs when the compliance of the intracranial system is compromised as a result of the exhaustion of the compensating mechanisms that try to keep it within normal limits’’</i>. ‘<i>’Perfusion, oxygenation and energy utilization compromise are its consequences’’</i> [2]<i>.</i></p><p>Further enlightenments raised from the recent study of Kazimierska et al., which evaluated a series of 130 patients who were victims of severe TBI from the CENTER-TBI database. Those authors analyzed the relationship between parameters obtained from the neuroimaging Computed Tomography (CT) scan upon admission and variables collected from invasive ICP monitoring [3]. Injury mass volume, degree of midline shift, Marshall’s and Rotterdam classifications were the data provided by the CT scans, while mean ICP values, wave amplitude and indices derived from the analysis of ICP recordings. A neural network model (previously tested with 93% accuracy) was applied in order to automatically group ICP waveforms into 4 classes [3]. As a main finding, the pulse shape index—PSI was strongly correlated with the analyzed tomographic parameters (<i>p</i> = 0.001), while mean ICP was correlated with ICPw amplitude, indicating that the morphology of the ICP pulse wave reflects a decrease in the cerebrospinal compensatory reserve therefore of cerebral compliance [3].</p><p>ICP waveform is a result of complex interaction between volumes (blood, brain and cerebrospinal fluid) restrained by meninges and the bony skull box, interacting with dynamic phenomena as blood viscosity, cardiac and respiratory cycles per example [1]. Therefore, several are the ways of exploring and translating ICPw into parameters readable at the bedside to assess compensatory reserve status. Prior to PSI, the compensatory reserve index (RAP) was described by Czosnyka et al. as the moving correlation between ICP values and ICP pulse amplitude variation [4]. Both the PSI and RAP can be a
Article PubMed PubMed Central Google Scholar Czosnyka M, Smielewski P, Timofeev I, Lavinio A, Guazzo E, Hutchinson P, et al. 颅内压:不仅仅是一个数字。神经外科聚焦。https://doi.org/10.3171/foc.2007.22.5.11.Article PubMed Google Scholar Brasil S, Solla DJF, Nogueira RC, Teixeira MJ, Malbouisson LMS, Paiva WDS.重症监护中颅内压波形监测的新型无创技术。J Pers Med.2021;11(12):1302. https://doi.org/10.3390/jpm11121302.Article PubMed PubMed Central Google Scholar Download referencesNone.Not applicable.Authors and AffiliationsNeurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, ArgentinaDaniel Agustin GodoyLIM 62, Department of Neurology, University of Sao Paulo Medical School, Sao Paulo, BrazilSergio Brasil &amp; Andres M. RubianoProfessor of Neurology, University of Sao Paulo.Rubiano哥伦比亚波哥大 El Bosque 大学神经科学和神经外科教授Andres M. Rubiano哥伦比亚卡利 MEDITECH 基金会医学和研究主任Daniel Agustin Godoy, Sergio Brasil &amp; Andres M. RubianoRubianoAuthorsDaniel Agustin GodoyView author publications您也可以在PubMed Google ScholarSergio BrasilView author publications您也可以在PubMed Google ScholarAndres M. RubianoView author publications您也可以在PubMed Google Scholar搜索该作者Rubiano查看作者发表的作品您还可以在PubMed Google Scholar中搜索该作者供稿所有作者的供稿均等通讯作者:Daniel Agustin Godoy伦理批准和参与同意书不适用同意发表所有作者同意发表竞业利益DAG和AMR声称没有竞业利益或利益冲突。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。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 articleGodoy, D.A., Brasil, S. &amp; Rubiano, A.M. Further support for the intracranial compartmental syndrome concept.Crit Care 28, 311 (2024). https://doi.org/10.1186/s13054-024-04974-4Download citationReceived:11 March 2024Accepted: 27 May 2024Published: 18 September 2024DOI: https://doi.org/10.1186/s13054-024-04974-4Share 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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引用次数: 0
Lung ultrasound and ARDS: global collaboration is the way to go 肺部超声和 ARDS:全球合作是必由之路
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-17 DOI: 10.1186/s13054-024-05075-y
Marry R. Smit, Maud Boumans, William Aerts, Pieter R. Tuinman
We would like to extend our gratitude to Dr. da Hora Passos et al. for their interest in our recently published review and meta-analysis in Critical Care. In this response, we will elaborate on the points raised by the authors. We agree with the authors that LUS, like any other diagnostic technique, is valuable and safe only when utilized by trained operators. The authors expressed uncertainty regarding the sensitivity of LUS in detecting mild ARDS or ARDS at an early stage. This variance in sensitivity is more likely due to diversity in diagnostic thresholds. We advocate for global collaboration among LUS experts to align LUS methodologies and strengthen the evidence supporting LUS in the diagnosis of ARDS and its morphological subphenotypes.
我们要感谢 da Hora Passos 博士等人对我们最近在《重症监护》杂志上发表的综述和荟萃分析的关注。在本回复中,我们将详细阐述作者提出的观点。我们同意作者的观点,即 LUS 和其他诊断技术一样,只有由训练有素的操作人员使用才是有价值和安全的。作者对 LUS 检测轻度 ARDS 或早期 ARDS 的灵敏度表示不确定。灵敏度的差异很可能是由于诊断阈值的不同造成的。我们主张 LUS 专家之间开展全球合作,以统一 LUS 方法并加强支持 LUS 诊断 ARDS 及其形态学亚型的证据。
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引用次数: 0
Prevention of ventilator-associated pneumonia by metal-coated endotracheal tubes: a meta-analysis 金属涂层气管导管预防呼吸机相关肺炎:荟萃分析
IF 15.1 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-17 DOI: 10.1186/s13054-024-05095-8
Yuxin Yang, Xuan Xiong, Xiaofei Wang, Qionglan Dong, Lingai Pan
This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54–0.95), P = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86–1.27), P = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (− 0.52, 1.72), P = 0.29, I2 = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (− 1.02, 1.95), P = 0.54, I2 = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.
本研究旨在评估与无涂层气管插管(ETT)相比,有金属涂层的气管插管(ETT)是否能降低呼吸机相关性肺炎(VAP)的发病率。我们进行了广泛的文献综述,在四个数据库中找到了比较金属涂层 ETT 和无涂层 ETT 的研究:PubMed、Embase、Cochrane Library 和 Web of Science。搜索参数设置从每个数据库建立之初到 2024 年 6 月。主要结果指标为 VAP 发生率和住院死亡率。两名独立研究人员进行了文献筛选、数据提取和质量评估。数据分析使用 RevMan 5.4.1 进行。此外,还使用 Deeks 漏斗图评估了纳入研究中潜在的发表偏倚。经过筛选,确定了五项随机对照试验(RCT),共涉及 2157 名患者。在主要结果方面,使用金属涂层 ETT 组的 VAP 发生率低于使用无涂层 ETT 组,差异具有统计学意义[RR = 0.71,95% CI (0.54-0.95),P = 0.02]。两组死亡率无明显差异[RR = 1.05,95% CI (0.86-1.27),P = 0.65]。关于次要结果,对两项研究进行了评估,以比较两组患者的机械通气持续时间(RR = 0.60,95% CI (- 0.52, 1.72),P = 0.29,I2 = 97%)和重症监护室(ICU)停留时间(RR = 0.47,95% CI (- 1.02, 1.95),P = 0.54,I2 = 50%)。由于存在明显的异质性,因此无法对两组患者的机械通气时间进行比较。不过,两项研究均表明,使用金属涂层 ETT 的患者与使用无涂层 ETT 的患者在通气时间上没有明显差异。与无涂层 ETT 相比,金属涂层 ETT 的 VAP 发生率较低。尽管如此,金属涂层 ETT 并没有显著缩短机械通气时间和重症监护病房的住院时间,也没有降低住院死亡率。系统综述注册:https://www.crd.york.ac.uk/prospero/ ,标识符为 CRD42024560618。
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引用次数: 0
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Critical Care
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