Critical Care最新文献

Background: Sleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients.

Objectives: We hypothesized that sleep disturbances may be associated with poor outcomes in ICUs.

Methods: Post-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes.

Results: Whereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03).

Conclusion: Complete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

Objective: To report the outcomes of patients with severe tuberculosis (TB)-related acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO), including predictors of 90-day mortality and associated complications.

Methods: An international multicenter retrospective study was conducted in 20 ECMO centers across 13 countries between 2002 and 2022.

Results: We collected demographic data, clinical details, ECMO-related complications, and 90-day survival status for 79 patients (median APACHE II score of 20 [25th to 75th percentile, 16 to 28], median age 39 [28 to 48] years, PaO₂/FiO₂ ratio of 69 [55 to 82] mmHg before ECMO) who met the inclusion criteria. Thoracic computed tomography showed that 61 patients (77%) had cavitary TB, while 18 patients (23%) had miliary TB. ECMO-related complications included major bleeding (23%), ventilator-associated pneumonia (41%), and bloodstream infections (32%). The overall 90-day survival rate was 51%, with a median ECMO duration of 20 days [10 to 34] and a median ICU stay of 42 days [24 to 65]. Among patients on VV ECMO, those with miliary TB had a higher 90-day survival rate than those with cavitary TB (90-day survival rates of 81% vs. 46%, respectively; log-rank P = 0.02). Multivariable analyses identified older age, drug-resistant TB, and pre-ECMO SOFA scores as independent predictors of 90-day mortality.

Conclusion: The use of ECMO for TB-related ARDS appears to be justifiable. Patients with miliary TB have a much better prognosis compared to those with cavitary TB on VV ECMO.

Background: Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆P_ES) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆P_ES in children. We sought to identify risk factors for P0.1 over or underestimating ∆P_ES in ventilated children.

Methods: Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆P_ES (∆P_ES-REAL), P0.1 and predicted ∆P_ES (∆P_ES-PRED = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆P_ES-REAL and ∆P_ES-PRED were aligned (low, normal, and high effort and drive), two where ∆P_ES-REAL and ∆P_ES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes.

Results: We analyzed 953 patient days (222 patients). ∆P_ES-REAL and ∆P_ES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017).

Conclusions: In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome.

Trial registration: NCT03266016; August 23, 2017.

The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.