Critical Care最新文献

Background: Transesophageal echocardiography during out-of-hospital cardiac arrest can be performed during ongoing chest compressions and may improve resuscitation quality, but its prehospital use has not been systematically evaluated. To assess the feasibility, diagnostic yield, and impact of prehospital TEE on resuscitation metrics and advanced life support (ALS) interventions during OHCA.

Methods: We conducted a randomized controlled trial in a physician-staffed two-tiered emergency medical service (EMS). Adults with ongoing non-traumatic OHCA were randomized 1:1 to standard ALS or ALS plus TEE. The primary endpoints were hands-off time and chest compression fraction (CCF) from EMS arrival to return of spontaneous circulation (ROSC) or resuscitation termination. Secondary endpoints included ROSC at hospital admission, survival to hospital discharge, neurological status at hospital discharge, and TEE findings. Analyses followed the intention-to-treat principle.

Results: Of 249 screened patients, 35 were randomized and 32 analyzed (TEE n = 15; control n = 17). Median hands-off time was 4 s in both groups. Mean CCF was higher in the TEE group (96.2%) than the control group (91.6%), with a mean difference of 4.6% (95% confidence interval 2.5-6.7; p < 0.001). Sustained ROSC occurred in 40% (TEE) versus 71% (control; p = 0.083). The control group had an eCPR rate of 41%, compared to 20% in the TEE group. Using TEE, an incorrect area of maximal compression or inadequate depth was identified in 23% and 14%, respectively.

Conclusion: Prehospital TEE during OHCA was feasible without negatively interfering with CPR metrics, and provided clinically relevant diagnostic information and procedural guidance, warranting further evaluation in larger trials.

Trial registration: German Clinical Trials Register DRKS00028695 registered on 28 April 2022.

Background: The gray-white matter ratio (GWR) on head CT is a well-established marker of hypoxic-ischemic brain injury after cardiac arrest, but its prognostic performance may vary with the timing of imaging. We aimed (i) to evaluate the prognostic value of GWR across serial CT scans within the same comatose patients, and (ii) to determine whether the longitudinal changes of GWR provide additional prognostic information beyond single time-point measurements.

Methods: We prospectively recruited 123 comatose patients with cardiac arrest admitted to three intensive care units. All patients underwent serial non-contrast head CT at three predefined time windows (< 24 h, 24-96 h, and 96-168 h after cardiac arrest). GWR values were automatically calculated using an atlas-based approach. Neurological outcome at 3 months was assessed with the Cerebral Performance Category score (CPC) and dichotomized into good (CPC 1-2) or poor (CPC 3-5). GWR values and their progression were compared between outcome groups. Prognostic accuracy of GWR at each time window was assessed using receiver operating characteristic (ROC) analysis.

Results: GWR was consistently lower in patients with poor outcomes compared to those with good outcomes across all time windows (for all p < 0.001). In poor-outcome patients, GWR declined after the first 24 h, whereas it was stable in good-outcome patients. The prognostic performance of GWR improved with later imaging, with an AUC of 0.72 (95% CI 0.62-0.81) at < 24 h, 0.78 (95% CI 0.69-0.86) at 24-96 h, and 0.81 (95% CI 0.72-0.88) at 96-168 h after cardiac arrest. Incorporating longitudinal changes in GWR slightly improved prediction, with the AUC increasing from 0.81 to 0.83 at 96-168 h.

Conclusions: Automated GWR is a useful predictor of outcome after cardiac arrest, with higher accuracy on delayed CT (> 24 h). The different GWR progression trajectories between patients with poor and good outcomes suggest that longitudinal CT assessments may provide additional prognostic information.

Introduction: Haemodynamic adverse events related to renal replacement therapy are a complication of all RRT modalities used in the ICU, including intermittent haemodialysis (IHD), sustained low efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT). At present it is unclear which risk factors predispose to HAE and whether these contribute to adverse patient outcomes.

Methods: We performed a secondary analysis of the multinational STARRT-AKI trial to assess factors associated with the occurrence of haemodynamic adverse events (HAE) in patients receiving RRT and whether these HAE were associated with less favourable clinical outcomes. The primary analysis was a multivariable Cox proportional hazards model based on the least absolute shrinkage and selection operator (LASSO), which included time to HAE as the dependent variable.

Results: Factors significantly associated with an increased hazard ratio (HR) for HAE during RRT were a higher SOFA score at RRT initiation (HR 1.05; 95% 1.00-1.10), use of IHD as the initial RRT modality in comparison to CRRT (HR 1.74; 95% CI 1.28-2.37) and use of SLED as the initial RRT modality in comparison to CRRT (HR 2.73; 95% CI 1.65-4.51). In a multivariable analysis, adjusted for baseline patient characteristics and RRT initiation covariates, there was no significant association between the occurrence of a HAE during RRT and mortality, dialysis dependence, length of stay, RRT-free days, ventilator-free days or vasoactive-free days, respectively. There was, however, a significant association between multiple haemodynamic adverse events and all-cause mortality at 90 days.

Conclusions: In this secondary analysis of the STARRT-AKI trial, the use of intermittent RRT modalities and higher severity of illness were associated with HAE during RRT. These events were not significantly associated with adverse clinical outcomes, apart from a significant association between multiple HAE and all-cause mortality at 90 days.

Background: Megadose sodium ascorbate has shown promise as a treatment to reverse the pathophysiological effects of ovine Gram-negative sepsis. In human septic shock, lower doses of sodium ascorbate improved urine output and reduced vasopressor requirements compared with placebo. We sought to determine the minimum therapeutic dose of sodium ascorbate required to reverse sepsis-induced cardiovascular and renal dysfunction in sheep.

Methods: Healthy young adult sheep were instrumented with renal artery flow probes, and oxygen-sensing and laser Doppler probes in the kidneys. Non-anaesthetised animals were infused with live Escherichia coli for 31-h. At 23.5-h of sepsis, four groups (n = 7-8/group) received fluid resuscitation (30 mL/kg Hartmann's solution) and were randomized to intravenous sodium ascorbate (1.0, 2.0, or 3.0 g/kg) or vehicle, delivered as a bolus followed by 7-h infusion. Norepinephrine was titrated to maintain mean arterial pressure (MAP) at ~ 70 mmHg.

Results: At 23-h of sepsis, animals developed hypotension, hyperlactatemia, acute kidney injury, and renal medullary hypoxia. Vehicle-treated sheep required escalating doses of norepinephrine (from 0.4 to 0.8 ± 0.2 µg/kg/min) to restore MAP. Sodium ascorbate at 3.0 g/kg (achieving plasma ascorbate levels of ~ 10 mmol/L) rapidly restored MAP, allowing withdrawal of norepinephrine in half the animals (P = 0.007). Lower doses of sodium ascorbate (1.0 and 2.0 g/kg) had no significant effect on vasopressor requirements. The improvements in renal medullary oxygenation (25.2 ± 3.3 to 43.4 ± 4.5 mmHg, P = 0.04) and urine flow (from 0.5 ± 0.2 to 6.9 ± 2.4 ml/kg/h, P < 0.0001) were dose-dependent. Renal medullary tissue protein expression of nuclear factor kappa-light chain-enhancer B was significantly reduced with 3.0 g/kg of sodium ascorbate (to -52.9 ± 13.3%, P = 0.0005) and phosphorylated endothelial nitric oxide synthase at Ser-1177 was upregulated (to +219.5 ± 51.4%, P = 0.04) compared with vehicle-treated sheep.

Conclusions: In established ovine Gram-negative sepsis, only 3.0 g/kg sodium ascorbate effectively restored cardiovascular and renal dysfunction, which was associated with suppression of renal inflammatory signalling and restoration of endothelial nitric oxide activity. These findings demonstrate a clear dose-dependent therapeutic threshold, where achieving plasma ascorbate concentrations of ~ 10 mmol/L is essential to elicit multi-organ protection.