Pub Date : 2024-12-27DOI: 10.1186/s13054-024-05198-2
Sanne P. C. van Oosterhout, Anneke G. van der Niet, Wilson F. Abdo, Marianne Boenink, Jelle L. P. van Gurp, Gert Olthuis
Listening and responding to family concerns in organ and tissue donation is generally considered important, but has never been researched in real time. We aimed to explore in real time, (a) which family concerns emerge in the donation process, (b) how these concerns manifest during and after the donor conversation, and (c) how clinicians respond to the concerns during the donor conversation. A qualitative embedded multiple-case study in eight Dutch hospitals was conducted. Thematic analysis was performed based on audio recordings and direct observations of 29 donor conversations and interviews with the family members involved (n = 24). Concerns clustered around six topics: 1) Life-event of a relative’s death, 2) Dying well, 3) Tensions and fears about donation, 4) Experiences of time, 5) Procedural clarity, and 6) Involving (non-)present family. Most concerns occurred in topics 1 and 2. Clinicians mostly responded to concerns by providing information or immediate solutions, while sometimes acknowledgement sufficed. When concerns were highly charged with emotion, the clinicians’ responses were less frequently attuned to families’ needs. Cues of less clearly articulated concerns gained less follow-up. Then, concerns often remained or reappeared. The identified concerns and the distinction between clearly and less clearly articulated concerns may prove valuable for clinicians to improve family support. We advise clinicians to engage with a curious, probing attitude to enhance the dialogue around concerns, elaborate on less clearly articulated concerns and identify the informational needs of the family.
{"title":"Family concerns in organ donor conversations: a qualitative embedded multiple-case study","authors":"Sanne P. C. van Oosterhout, Anneke G. van der Niet, Wilson F. Abdo, Marianne Boenink, Jelle L. P. van Gurp, Gert Olthuis","doi":"10.1186/s13054-024-05198-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05198-2","url":null,"abstract":"Listening and responding to family concerns in organ and tissue donation is generally considered important, but has never been researched in real time. We aimed to explore in real time, (a) which family concerns emerge in the donation process, (b) how these concerns manifest during and after the donor conversation, and (c) how clinicians respond to the concerns during the donor conversation. A qualitative embedded multiple-case study in eight Dutch hospitals was conducted. Thematic analysis was performed based on audio recordings and direct observations of 29 donor conversations and interviews with the family members involved (n = 24). Concerns clustered around six topics: 1) Life-event of a relative’s death, 2) Dying well, 3) Tensions and fears about donation, 4) Experiences of time, 5) Procedural clarity, and 6) Involving (non-)present family. Most concerns occurred in topics 1 and 2. Clinicians mostly responded to concerns by providing information or immediate solutions, while sometimes acknowledgement sufficed. When concerns were highly charged with emotion, the clinicians’ responses were less frequently attuned to families’ needs. Cues of less clearly articulated concerns gained less follow-up. Then, concerns often remained or reappeared. The identified concerns and the distinction between clearly and less clearly articulated concerns may prove valuable for clinicians to improve family support. We advise clinicians to engage with a curious, probing attitude to enhance the dialogue around concerns, elaborate on less clearly articulated concerns and identify the informational needs of the family.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"33 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142888916","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 : 2024-12-27DOI: 10.1186/s13054-024-05168-8
Clément Monet, Thomas Renault, Yassir Aarab, Joris Pensier, Albert Prades, Ines Lakbar, Clément Le Bihan, Mathieu Capdevila, Audrey De Jong, Nicolas Molinari, Samir Jaber
Ultra-protective ventilation is the combination of low airway pressures and tidal volume (Vt) combined with extra corporeal carbon dioxide removal (ECCO2R). A recent large study showed no benefit of ultra-protective ventilation compared to standard ventilation in ARDS (Acute Respiratory Distress Syndrome) patients. However, the reduction in Vt failed to achieve the objective of less than or equal to 3 ml/kg predicted body weight (PBW). The main objective of our study was to assess the feasibility of the ultra-low volume ventilation (Vt ≤ 3 ml/kg PBW) facilitated by ECCO2R in acute respiratory failure patients. Retrospective analysis of a prospective cohort of patients with either high or low blood flow veno-venous ECCO2R devices. A session was defined as a treatment of ECCO2R from the start to the removal of the device (one patient could have one more than one session). Primary endpoint was the proportion of sessions during which a Vt less or equal to 3 ml/kg PBW at 24 h after the start of ECCO2R was successfully achieved for at least 12 h. Secondary endpoints were respiratory variables, rate of adverse events and outcomes. Forty-five ECCO2R sessions were recorded among 41 patients. Ultra-low volume ventilation (tidal volume ≤ 3 ml/kg PBW, success group) was successfully achieved at 24 h in 40.0% sessions (18 out of 45 sessions, confidence interval 25.3–54.6%). At 24 h, tidal volume in the failure group was 4.1 [3.8–4.5] ml/kg PBW compared to 2.1 [1.9–2.5] in the success group (p < 0.001). After multivariate analysis, blood flow rate was significantly associated with success of ultra-low volume ventilation (adjusted OR per 100 ml/min increase 1.51 (95%CI 1.21–1.90, p = 0.0003). Ultra-low volume ventilation (≤ 3 ml/kg PBW) was feasible in 18 out of 45 sessions. Higher blood flow rates were associated with the success of ultra-low volume ventilation.
{"title":"Feasibility and safety of ultra-low volume ventilation (≤ 3 ml/kg) combined with extra corporeal carbon dioxide removal (ECCO2R) in acute respiratory failure patients","authors":"Clément Monet, Thomas Renault, Yassir Aarab, Joris Pensier, Albert Prades, Ines Lakbar, Clément Le Bihan, Mathieu Capdevila, Audrey De Jong, Nicolas Molinari, Samir Jaber","doi":"10.1186/s13054-024-05168-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05168-8","url":null,"abstract":"Ultra-protective ventilation is the combination of low airway pressures and tidal volume (Vt) combined with extra corporeal carbon dioxide removal (ECCO2R). A recent large study showed no benefit of ultra-protective ventilation compared to standard ventilation in ARDS (Acute Respiratory Distress Syndrome) patients. However, the reduction in Vt failed to achieve the objective of less than or equal to 3 ml/kg predicted body weight (PBW). The main objective of our study was to assess the feasibility of the ultra-low volume ventilation (Vt ≤ 3 ml/kg PBW) facilitated by ECCO2R in acute respiratory failure patients. Retrospective analysis of a prospective cohort of patients with either high or low blood flow veno-venous ECCO2R devices. A session was defined as a treatment of ECCO2R from the start to the removal of the device (one patient could have one more than one session). Primary endpoint was the proportion of sessions during which a Vt less or equal to 3 ml/kg PBW at 24 h after the start of ECCO2R was successfully achieved for at least 12 h. Secondary endpoints were respiratory variables, rate of adverse events and outcomes. Forty-five ECCO2R sessions were recorded among 41 patients. Ultra-low volume ventilation (tidal volume ≤ 3 ml/kg PBW, success group) was successfully achieved at 24 h in 40.0% sessions (18 out of 45 sessions, confidence interval 25.3–54.6%). At 24 h, tidal volume in the failure group was 4.1 [3.8–4.5] ml/kg PBW compared to 2.1 [1.9–2.5] in the success group (p < 0.001). After multivariate analysis, blood flow rate was significantly associated with success of ultra-low volume ventilation (adjusted OR per 100 ml/min increase 1.51 (95%CI 1.21–1.90, p = 0.0003). Ultra-low volume ventilation (≤ 3 ml/kg PBW) was feasible in 18 out of 45 sessions. Higher blood flow rates were associated with the success of ultra-low volume ventilation.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"101 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142888912","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 : 2024-12-25DOI: 10.1186/s13054-024-05220-7
Gabriella Bottari, Vito Marco Ranieri, Can Ince, Antonio Pesenti, Filippo Aucella, Anna Maria Scandroglio, Claudio Ronco, Jean-Louis Vincent
Sepsis is the result of a dysregulated immune response to infection and is associated with acute organ dysfunction. The syndrome’s complexity is contingent upon the underlying pathology and individual patient characteristics, including their immune response. The involvement of multiple organs and physiological functions adds complexity, with “organ cross-talk” emerging as a pivotal pathophysiological and clinical aspect. This narrative review to evaluate the rationale and available clinical evidence supporting the use of extracorporeal blood purification therapies as adjunctive therapy in patients with sepsis and septic shock. A search of the PubMed, Embase, Web of Science and Scopus databases for relevant literature from August 2002 to May 2024 has been conducted. The search was performed using the terms: 1) “blood purification” or “hemadsorption” or “plasma exchange” AND 2) “sepsis” or “septic shock”. Therefore the authors have focused our discussion on several key areas such as conducting well-designed trials, developing more personalized protocols, ensuring optimal management and monitoring. Given the heterogeneity of patients with sepsis, conducting traditional randomized clinical trials in this domain can be a daunting task. However, statistical techniques such as Bayesian methods, propensity score analysis, and emulated clinical trials using clinical databases hold promise for enhancing comparability between the study groups. Indeed, to comprehend the clinical efficacy of extracorporeal blood purification techniques in patients with sepsis, it is imperative to assemble homogeneous groups of patients receiving uniform treatments. Clinical strategies should be individualized, signaling the end of the “one size fits all” approach in sepsis therapy and the need for personalized treatments. Current suggested best practice for use of cytokine hemadsorption in sepsis.
脓毒症是对感染的免疫反应失调的结果，与急性器官功能障碍有关。该综合征的复杂性取决于潜在的病理和个体患者的特征，包括他们的免疫反应。多器官和生理功能的参与增加了复杂性，“器官串扰”成为关键的病理生理和临床方面。本文综述了支持体外血液净化疗法作为脓毒症和感染性休克患者辅助治疗的基本原理和现有临床证据。检索PubMed、Embase、Web of Science和Scopus数据库，检索2002年8月至2024年5月的相关文献。搜索使用的术语是：1)“血液净化”或“血液吸附”或“血浆交换”和2)“败血症”或“感染性休克”。因此，作者将我们的讨论集中在几个关键领域，如进行精心设计的试验，开发更个性化的方案，确保最佳的管理和监测。鉴于脓毒症患者的异质性，在这一领域进行传统的随机临床试验可能是一项艰巨的任务。然而，统计技术，如贝叶斯方法、倾向评分分析和使用临床数据库的模拟临床试验，有望提高研究组之间的可比性。事实上，为了了解体外血液净化技术在脓毒症患者中的临床疗效，有必要收集接受统一治疗的同质患者组。临床策略应该个性化，标志着败血症治疗中“一刀切”方法的结束和个性化治疗的需要。目前建议的最佳实践使用细胞因子血吸附在败血症。
{"title":"Use of extracorporeal blood purification therapies in sepsis: the current paradigm, available evidence, and future perspectives","authors":"Gabriella Bottari, Vito Marco Ranieri, Can Ince, Antonio Pesenti, Filippo Aucella, Anna Maria Scandroglio, Claudio Ronco, Jean-Louis Vincent","doi":"10.1186/s13054-024-05220-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05220-7","url":null,"abstract":"Sepsis is the result of a dysregulated immune response to infection and is associated with acute organ dysfunction. The syndrome’s complexity is contingent upon the underlying pathology and individual patient characteristics, including their immune response. The involvement of multiple organs and physiological functions adds complexity, with “organ cross-talk” emerging as a pivotal pathophysiological and clinical aspect. This narrative review to evaluate the rationale and available clinical evidence supporting the use of extracorporeal blood purification therapies as adjunctive therapy in patients with sepsis and septic shock. A search of the PubMed, Embase, Web of Science and Scopus databases for relevant literature from August 2002 to May 2024 has been conducted. The search was performed using the terms: 1) “blood purification” or “hemadsorption” or “plasma exchange” AND 2) “sepsis” or “septic shock”. Therefore the authors have focused our discussion on several key areas such as conducting well-designed trials, developing more personalized protocols, ensuring optimal management and monitoring. Given the heterogeneity of patients with sepsis, conducting traditional randomized clinical trials in this domain can be a daunting task. However, statistical techniques such as Bayesian methods, propensity score analysis, and emulated clinical trials using clinical databases hold promise for enhancing comparability between the study groups. Indeed, to comprehend the clinical efficacy of extracorporeal blood purification techniques in patients with sepsis, it is imperative to assemble homogeneous groups of patients receiving uniform treatments. Clinical strategies should be individualized, signaling the end of the “one size fits all” approach in sepsis therapy and the need for personalized treatments. Current suggested best practice for use of cytokine hemadsorption in sepsis. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142884136","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 : 2024-12-24DOI: 10.1186/s13054-024-05216-3
Beulah Augustin, Dongyuan Wu, Lauren Page Black, Andrew Bertrand, Dawoud Sulaiman, Charlotte Hopson, Vinitha Jacob, Jordan A. Shavit, Daniel A. Hofmaenner, Guillaume Labilloy, Leslie Smith, Emilio Cagmat, Kiley Graim, Susmita Datta, Srinivasa T. Reddy, Faheem W. Guirgis
Lipids play a critical role in defense against sepsis. We sought to investigate gene expression and lipidomic patterns of lipid dysregulation in sepsis. Data from four adult sepsis studies were analyzed and findings were investigated in two external datasets. Previously characterized lipid dysregulation subphenotypes of hypolipoprotein (HYPO; low lipoproteins, increased mortality) and normolipoprotein (NORMO; higher lipoproteins, lower mortality) were studied. Leukocytes collected within 24 h of sepsis underwent RNA sequencing (RNAseq) and shotgun plasma lipidomics was performed. Of 288 included patients, 43% were HYPO and 57% were NORMO. HYPO patients exhibited higher median SOFA scores (9 vs 5, p = < 0.001), vasopressor use (67% vs 34%, p = < 0.001), and 28-day mortality (30% vs 16%, p = 0.004). Leukocyte RNAseq identified seven upregulated lipid metabolism genes in HYPO (PCSK9, DHCR7, LDLR, ALOX5, PLTP, FDFT1, and MSMO1) vs. NORMO patients. Lipidomics revealed lower cholesterol esters (CE, adjusted p = < 0.001), lysophosphatidylcholines (LPC, adjusted p = 0.001), and sphingomyelins (SM, adjusted p = < 0.001) in HYPO patients. In HYPO patients, DHCR7 expression strongly correlated with reductions in CE, LPC, and SM (p < 0.01), while PCSK9, MSMO1, DHCR7, PLTP, and LDLR upregulation were correlated with low LPC (p < 0.05). DHCR7, ALOX5, and LDLR correlated with reductions in SM (p < 0.05). Mortality and phenotype comparisons in two external datasets (N = 824 combined patients) corroborated six of the seven upregulated lipid genes (PCSK9, DHCR7, ALOX5, PLTP, LDLR, and MSMO1). We identified a genetic lipid dysregulation signature characterized by seven lipid metabolism genes. Five genes in HYPO sepsis patients most strongly correlated with low CE, LPC, and SMs that mediate cholesterol storage and innate immunity.
{"title":"Multiomic molecular patterns of lipid dysregulation in a subphenotype of sepsis with higher shock incidence and mortality","authors":"Beulah Augustin, Dongyuan Wu, Lauren Page Black, Andrew Bertrand, Dawoud Sulaiman, Charlotte Hopson, Vinitha Jacob, Jordan A. Shavit, Daniel A. Hofmaenner, Guillaume Labilloy, Leslie Smith, Emilio Cagmat, Kiley Graim, Susmita Datta, Srinivasa T. Reddy, Faheem W. Guirgis","doi":"10.1186/s13054-024-05216-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05216-3","url":null,"abstract":"Lipids play a critical role in defense against sepsis. We sought to investigate gene expression and lipidomic patterns of lipid dysregulation in sepsis. Data from four adult sepsis studies were analyzed and findings were investigated in two external datasets. Previously characterized lipid dysregulation subphenotypes of hypolipoprotein (HYPO; low lipoproteins, increased mortality) and normolipoprotein (NORMO; higher lipoproteins, lower mortality) were studied. Leukocytes collected within 24 h of sepsis underwent RNA sequencing (RNAseq) and shotgun plasma lipidomics was performed. Of 288 included patients, 43% were HYPO and 57% were NORMO. HYPO patients exhibited higher median SOFA scores (9 vs 5, p = < 0.001), vasopressor use (67% vs 34%, p = < 0.001), and 28-day mortality (30% vs 16%, p = 0.004). Leukocyte RNAseq identified seven upregulated lipid metabolism genes in HYPO (PCSK9, DHCR7, LDLR, ALOX5, PLTP, FDFT1, and MSMO1) vs. NORMO patients. Lipidomics revealed lower cholesterol esters (CE, adjusted p = < 0.001), lysophosphatidylcholines (LPC, adjusted p = 0.001), and sphingomyelins (SM, adjusted p = < 0.001) in HYPO patients. In HYPO patients, DHCR7 expression strongly correlated with reductions in CE, LPC, and SM (p < 0.01), while PCSK9, MSMO1, DHCR7, PLTP, and LDLR upregulation were correlated with low LPC (p < 0.05). DHCR7, ALOX5, and LDLR correlated with reductions in SM (p < 0.05). Mortality and phenotype comparisons in two external datasets (N = 824 combined patients) corroborated six of the seven upregulated lipid genes (PCSK9, DHCR7, ALOX5, PLTP, LDLR, and MSMO1). We identified a genetic lipid dysregulation signature characterized by seven lipid metabolism genes. Five genes in HYPO sepsis patients most strongly correlated with low CE, LPC, and SMs that mediate cholesterol storage and innate immunity.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142879685","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 : 2024-12-22DOI: 10.1186/s13054-024-05226-1
Lamamri Myriam, Arnaud Foucrier, Emmanuel Weiss
<p>To the editor, </p><p>The optimal transfusion strategy for patients with acute brain injury remains a topic of intense debate. Recent large scale randomized controlled trials, such as HEMOTION study, have compared restrictive versus liberal transfusion thresholds [1]. While the TRA4IN study suggested that a more liberal threshold (9 g/dL) was associated with better neurological outcomes, HEMOTION study, focusing specifically on moderate-to-severe traumatic brain injury, failed to demonstrate a significant difference between liberal (10 g/dL) and restrictive (7 g/dL) strategies [2].</p><p>However, these studies primarily focused on the hemoglobin threshold, neglecting a potentially critical factor: the age of transfused red blood cells (RBC). Accumulating evidence suggests that the storage time of RBC can significantly impact their functional properties, including oxygen carrying capacity and ability to modulate inflammation [3] [4]. Storage lesions of red blood cell are proportional to storage duration [5]. Additionally, the number of days beyond which a RBC unit is considered old differs among studies.</p><p>Large meta-analyses of medical patients have yielded inconsistent results regarding the impact of fresh blood component transfusion on in-hospital mortality, failing to provide conclusive evidence of a survival benefit [6]. Yet, limited clinical data exists specifically linking RBC age to neurological outcomes in acute brain injury. Although a few smaller studies have explored this relationship, the results have not been conclusive in small numbers of patients [7] [8].</p><p>The evidence regarding this question is heterogeneous, with studies reporting conflicting findings in diverse population. Considering the susceptibility of the injured brain to hypoxic damage and given the lack of a universal threshold for significantly impaired oxygen carrying capacity, the age of RBC remains a critical variable.</p><p>The discrepancy between the TRAIN and HEMOTION studies may be partially explained by differences in the age of transfused RBC despite differences between inclusion criteria. It is plausible that the beneficial effects observed in the TRAIN study were not solely due to the higher hemoglobin threshold but also to the use of younger RBC with potentially superior oxygen carrying capacity.</p><p>Therefore, future studies should collect data on RBC age and explore its potential impact on neurological outcomes in acute brain injury. Randomized controlled trials specifically designed to evaluate the effects of RBC age, in combination with different hemoglobin thresholds, are needed to provide more definitive evidence.</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>Turgeon AF, Fergusson DA, Clayton L, et al. Liberal or restrictive transfusion strategy in patients with traumatic brain injury. N Engl J Med. 202
致编辑，急性脑损伤患者的最佳输血策略仍然是一个激烈争论的话题。最近的大规模随机对照试验，如HEMOTION研究，比较了限制性和自由输血阈值[10]。虽然TRA4IN研究表明，更宽松的阈值（9 g/dL）与更好的神经预后相关，但专注于中重度创伤性脑损伤的HEMOTION研究未能证明宽松（10 g/dL）和限制性（7 g/dL）策略之间存在显著差异[2]。然而，这些研究主要集中在血红蛋白阈值上，而忽略了一个潜在的关键因素：输血红细胞（RBC）的年龄。越来越多的证据表明，红细胞的储存时间可以显著影响其功能特性，包括携氧能力和调节炎症的能力[3][4]。红细胞贮藏损伤与贮藏时间成正比。此外，在不同的研究中，红细胞单位被认为衰老的天数也不同。对医疗患者的大型荟萃分析得出了不一致的结果，即新鲜血液成分输血对住院死亡率的影响，未能提供结论性证据证明其对生存有好处。然而，有限的临床数据存在特异性地将RBC年龄与急性脑损伤的神经预后联系起来。尽管一些较小的研究已经探讨了这种关系，但在少数患者中，结果并不是决定性的。关于这个问题的证据是不同的，研究报告了不同人群的相互矛盾的结果。考虑到脑损伤对缺氧损伤的易感性，以及考虑到携带氧能力明显受损缺乏普遍的阈值，红细胞的年龄仍然是一个关键变量。尽管纳入标准不同，但TRAIN和HEMOTION研究之间的差异可以部分解释为输血红细胞年龄的差异。在TRAIN研究中观察到的有益效果似乎不仅仅是由于较高的血红蛋白阈值，而且还由于使用了具有潜在优越携氧能力的年轻红细胞。因此，未来的研究应收集RBC年龄的数据，并探讨其对急性脑损伤神经预后的潜在影响。需要专门设计的随机对照试验来评估RBC年龄与不同血红蛋白阈值的影响，以提供更明确的证据。在本研究中没有生成或分析数据集。Turgeon AF, Fergusson DA, Clayton L，等。外伤性脑损伤患者的自由或限制性输血策略。中华医学杂志，2014;31(8):722 - 735。https://doi.org/10.1056/NEJMoa2404360.Article CAS PubMed谷歌学者Taccone FS， Rynkowski Bittencourt C, Møller K，等。急性脑损伤患者的限制性与自由输血策略：TRAIN随机临床试验《美国医学协会杂志》上。332(19): 1623 - 2024; 33。https://doi.org/10.1001/jama.2024.20424.Article中科院PubMed谷歌学者Tinmouth A， Fergusson D, Yee IC, Hebert PC。危重病人红细胞储存的临床后果。46输血。2006;(11):2014 - 27所示。[文章]Stapley R， Owusu B, Brandon A, Cusick M, Rodriguez C, Marques M，等。红细胞储存增加一氧化氮和亚硝酸盐清除率：对输血相关毒性的影响。中国生物医学工程学报；2012;31(3):369 - 369。文章中科院PubMed bbb学者Marik PE， Sibbald WJ。储血输注对脓毒症患者氧输送的影响。《美国医学协会杂志》上。1993; 269(23): 3024 - 9。王丹，孙军，Solomon SB, Klein HG, Natanson C.老年人输血与死亡风险的meta分析。输血。2012;52(6):1184 - 95。https://doi.org/10.1111/j.1537-2995.2011.03466.x.Article PubMed谷歌学者Yamal JM， Benoit JS, Doshi P，等。外伤性脑损伤中输血、红细胞储存年龄和血氧、长期神经系统预后和死亡率的关系。创伤急症护理杂志，2015;79(5):843-9。https://doi.org/10.1097/TA.0000000000000834.Article CAS PubMed PubMed Central bbb学者ruel - lalibert<e:1> J, Lessard Bonaventure P, Fergusson D，等。输血红细胞年龄对创伤性脑损伤后神经系统预后的影响（ABLE-tbi研究）：血液年龄评估（ABLE）试验的嵌套研究。中国生物医学工程学报，2019;36(6):696-705。https://doi.org/10.1007/s12630-019-01326-7.Article PubMed谷歌学者下载参考资料无资助。 作者与单位：sdm - PARABOL， AP-HP, Hôpital Beaujon, Clichy, france amri Myriam, Arnaud Foucrier &；法国克利希100 Boulevard du General Leclerc， 92110， Beaujon大学附属医院麻醉科和重症监护科查看作者出版物您也可以在PubMed b谷歌scholararaud FoucrierView作者出版物您也可以在PubMed谷歌scholaremanmanuelweissview作者出版物您也可以在PubMed谷歌ScholarContributionsML， AF，《娱乐周刊》撰写并批准了稿件。通讯作者Lamamri Myriam通讯。对参与者的伦理批准和同意不适用。利益竞争作者声明没有利益竞争。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并访问permissionsCite这篇文章。脑损伤中的红细胞输注：仅仅是血红蛋白阈值的问题吗？危重护理28,430（2024）。https://doi.org/10.1186/s13054-024-05226-1Download citation：收稿日期：2024年12月13日接受日期：2024年12月19日发布日期：2024年12月22日doi: https://doi.org/10.1186/s13054-024-05226-1Share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，本文目前没有可共享链接。复制到剪贴板由施普林格自然共享内容倡议提供
{"title":"Red blood cell transfusion in brain injury: Is it solely a matter of hemoglobin threshold?","authors":"Lamamri Myriam, Arnaud Foucrier, Emmanuel Weiss","doi":"10.1186/s13054-024-05226-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05226-1","url":null,"abstract":"<p>To the editor, </p><p>The optimal transfusion strategy for patients with acute brain injury remains a topic of intense debate. Recent large scale randomized controlled trials, such as HEMOTION study, have compared restrictive versus liberal transfusion thresholds [1]. While the TRA4IN study suggested that a more liberal threshold (9 g/dL) was associated with better neurological outcomes, HEMOTION study, focusing specifically on moderate-to-severe traumatic brain injury, failed to demonstrate a significant difference between liberal (10 g/dL) and restrictive (7 g/dL) strategies [2].</p><p>However, these studies primarily focused on the hemoglobin threshold, neglecting a potentially critical factor: the age of transfused red blood cells (RBC). Accumulating evidence suggests that the storage time of RBC can significantly impact their functional properties, including oxygen carrying capacity and ability to modulate inflammation [3] [4]. Storage lesions of red blood cell are proportional to storage duration [5]. Additionally, the number of days beyond which a RBC unit is considered old differs among studies.</p><p>Large meta-analyses of medical patients have yielded inconsistent results regarding the impact of fresh blood component transfusion on in-hospital mortality, failing to provide conclusive evidence of a survival benefit [6]. Yet, limited clinical data exists specifically linking RBC age to neurological outcomes in acute brain injury. Although a few smaller studies have explored this relationship, the results have not been conclusive in small numbers of patients [7] [8].</p><p>The evidence regarding this question is heterogeneous, with studies reporting conflicting findings in diverse population. Considering the susceptibility of the injured brain to hypoxic damage and given the lack of a universal threshold for significantly impaired oxygen carrying capacity, the age of RBC remains a critical variable.</p><p>The discrepancy between the TRAIN and HEMOTION studies may be partially explained by differences in the age of transfused RBC despite differences between inclusion criteria. It is plausible that the beneficial effects observed in the TRAIN study were not solely due to the higher hemoglobin threshold but also to the use of younger RBC with potentially superior oxygen carrying capacity.</p><p>Therefore, future studies should collect data on RBC age and explore its potential impact on neurological outcomes in acute brain injury. Randomized controlled trials specifically designed to evaluate the effects of RBC age, in combination with different hemoglobin thresholds, are needed to provide more definitive evidence.</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>Turgeon AF, Fergusson DA, Clayton L, et al. Liberal or restrictive transfusion strategy in patients with traumatic brain injury. N Engl J Med. 202","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"82 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869966","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In septic shock, the classic fluid resuscitation strategy can lead to a potentially harmful positive fluid balance. This multicenter, randomized, single-blind, parallel, controlled pilot study assessed the effectiveness of a restrictive fluid strategy aiming to limit daily volume. Patients 18–85 years’ old admitted to the ICU department of three French hospitals were eligible for inclusion if they had septic shock and were in the first 24 h of vasopressor infusion. Exclusion criteria were acute kidney injury requiring renal replacement therapy, end stage chronic kidney disease, and severe malnutrition. Patients were electronically randomized 1:1 to either an optimized fluid restriction (reducing fluid intake as much as possible in terms of maintenance fluids and fluids for drug dilution during the first 7 days) or standard fluid strategy. The primary outcome was cumulative fluid balance (ml/kg) in the first 5 days. Patients and statisticians were blinded to group arm, but not clinicians. Between September 2021 and February 2023, 1201 patients were screened and 50 included, with two in the control group withdrawing, thus 48 patients were analyzed (24 in each group). In the first 5 days, the optimized restrictive strategy and control groups received 89.7 (IQR 35; 128.9) and 114.3 (IQR 78.8; 168.5) ml/kg of fluid, respectively (mean difference: 35.9 ml/kg [0.0; 71.8], p = 0.0506). After 5 days, the median cumulative fluid balance was 6.9 (IQR − 13.7; 52.1) and 35.0 (IQR − 7.9; 40.2) ml/kg in the optimized restrictive strategy and control groups, respectively (absolute difference 13.2 [95%CI − 15.2; 41.6], p = 0.42). After 28 days, mortality and the numbers of days alive without life support were similar between groups. The main adverse events were severe hypernatremia in 1 and 2 patients in the fluid restriction strategy and control groups, respectively, and acute kidney injury KDIGO 3 in 4 and 7 patients in the fluid restriction strategy and control groups, respectively. In ICU patients with septic shock, an optimized restrictive fluid strategy targeting hidden fluid intakes did not reduce the overall fluid balance at day 5. Trial registration ClinicalTrials.gov identifier NCT04947904, registered on 1 July 2021.
在感染性休克中，经典的液体复苏策略可能导致潜在有害的体液正平衡。这项多中心、随机、单盲、平行、对照的初步研究评估了旨在限制每日量的限制性液体策略的有效性。法国三家医院ICU收治的18-85岁患者，如果发生感染性休克并在前24小时输注血管加压素，则符合纳入条件。排除标准为需要肾脏替代治疗的急性肾损伤、终末期慢性肾病和严重营养不良。患者以1:1的比例进行电子随机分组，采用优化的液体限制（在前7天内尽可能减少维持液体和药物稀释液体的摄入）或标准液体策略。主要终点是前5天的累积体液平衡（ml/kg）。患者和统计学家对实验组不知情，但临床医生不知情。2021年9月至2023年2月，共筛选1201例患者，纳入50例，对照组2例退出，共分析48例患者（每组24例）。前5天，优化限制策略组和对照组分别获得89.7 (IQR 35；128.9)和114.3 (IQR 78.8；168.5) ml/kg流体(平均差值：35.9 ml/kg [0.0；[71.8], p = 0.0506)。5天后，累积体液平衡中位数为6.9 (IQR−13.7；52.1)和35.0 (IQR−7.9；优化限制策略组和对照组分别为40.2 ml/kg(绝对差值13.2 [95%CI−15.2；[41.6], p = 0.42)。28天后，两组之间的死亡率和无生命维持的存活天数相似。限液组和对照组的主要不良事件分别为1例和2例严重高钠血症，4例和7例急性肾损伤KDIGO 3。在感染性休克ICU患者中，针对隐性液体摄入的优化限制性液体策略并未降低第5天的总体液体平衡。ClinicalTrials.gov识别码NCT04947904，于2021年7月1日注册。
{"title":"Impact on fluid balance of an optimized restrictive strategy targeting non-resuscitative fluids in intensive care patients with septic shock: a single-blind, multicenter, randomized, controlled, pilot study","authors":"Nicolas Boulet, Jean-Pierre Quenot, Chris Serrand, Nadiejda Antier, Sylvain Garnier, Aurèle Buzancais, Laurent Muller, Claire Roger, Jean-Yves Lefrant, Saber Davide Barbar","doi":"10.1186/s13054-024-05155-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05155-z","url":null,"abstract":"In septic shock, the classic fluid resuscitation strategy can lead to a potentially harmful positive fluid balance. This multicenter, randomized, single-blind, parallel, controlled pilot study assessed the effectiveness of a restrictive fluid strategy aiming to limit daily volume. Patients 18–85 years’ old admitted to the ICU department of three French hospitals were eligible for inclusion if they had septic shock and were in the first 24 h of vasopressor infusion. Exclusion criteria were acute kidney injury requiring renal replacement therapy, end stage chronic kidney disease, and severe malnutrition. Patients were electronically randomized 1:1 to either an optimized fluid restriction (reducing fluid intake as much as possible in terms of maintenance fluids and fluids for drug dilution during the first 7 days) or standard fluid strategy. The primary outcome was cumulative fluid balance (ml/kg) in the first 5 days. Patients and statisticians were blinded to group arm, but not clinicians. Between September 2021 and February 2023, 1201 patients were screened and 50 included, with two in the control group withdrawing, thus 48 patients were analyzed (24 in each group). In the first 5 days, the optimized restrictive strategy and control groups received 89.7 (IQR 35; 128.9) and 114.3 (IQR 78.8; 168.5) ml/kg of fluid, respectively (mean difference: 35.9 ml/kg [0.0; 71.8], p = 0.0506). After 5 days, the median cumulative fluid balance was 6.9 (IQR − 13.7; 52.1) and 35.0 (IQR − 7.9; 40.2) ml/kg in the optimized restrictive strategy and control groups, respectively (absolute difference 13.2 [95%CI − 15.2; 41.6], p = 0.42). After 28 days, mortality and the numbers of days alive without life support were similar between groups. The main adverse events were severe hypernatremia in 1 and 2 patients in the fluid restriction strategy and control groups, respectively, and acute kidney injury KDIGO 3 in 4 and 7 patients in the fluid restriction strategy and control groups, respectively. In ICU patients with septic shock, an optimized restrictive fluid strategy targeting hidden fluid intakes did not reduce the overall fluid balance at day 5. Trial registration ClinicalTrials.gov identifier NCT04947904, registered on 1 July 2021. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"83 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869954","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 : 2024-12-20DOI: 10.1186/s13054-024-05211-8
Sami Barrit, Mejdeddine Al Barajraji, Salim El Hadwe, Alexandre Niset, Brandon Foreman, Soojin Park, Christos Lazaridis, Lori Shutter, Brian Appavu, Matthew P. Kirschen, Felipe A. Montellano, Verena Rass, Nathan Torcida, Daniel Pinggera, Emily Gilmore, Nawfel Ben-Hamouda, Nicolas Massager, Francis Bernard, Chiara Robba, Fabio Silvio Taccone
Intracranial multimodal monitoring (iMMM) is increasingly used in neurocritical care, but a lack of standardization hinders its evidence-based development. Here, we devised core outcome sets (COS) and reporting guidelines to harmonize iMMM practices and research. An open, decentralized, three-round Delphi consensus study involved experts between December 2023 and June 2024. Items—spanning three domains: (i) patient characteristics, (ii) practices, and (iii) outcomes—with ≥ 75% agreement were classified as strong agreement, while those with 50–75% were reconsidered in subsequent rounds, requiring ≥ 66% for moderate agreement. An international, multidisciplinary panel comprised 58 neurocritical physicians and researchers with low attrition (12%). They were predominantly from Western regions (96%), actively involved in iMMM (82%), at least weekly (72.4%), with more than 10 years of specific experience (57%). Of the 127 items assessed for inclusion in COS and reporting guidelines, 45 (35.4%) reached strong and 8 (6.3%) moderate agreement. Main strong agreement items were: (i) demographics: age (98%) and sex/gender (90%); comorbidities: coagulation/platelet disorders (95%); initial scoring: Glasgow Coma Scale (97%) and pathology-specific scores (90%); active treatments: antithrombotics (95%) (ii) clinical practice: iMMM implantation indications (98%) and iMMM-guided interventions (91%); surgical practice: targeting strategies (97%) and concomitant external ventricular drainage (97%); technical details: recording modalities (98%); (iii) monitoring parameters: duration (97%) and triggered interventions (95%); standardized outcome reporting (93%); surgical complications (e.g., postoperative intracranial hemorrhages, CNS infections, and probe misplacement, all > 90%) and adverse events (accidental dislodgement, probe breakage, and technical malfunctions, all > 90%). This consensus establishes foundational COS and reporting guidelines for iMMM in neurocritical care. These harmonization tools can enhance research quality, comparability, and reproducibility, facilitating evidence-based practices for this emerging technology. However, challenges remain in developing purpose-specific guidelines and adapting them to diverse clinical and research settings.
{"title":"Intracranial multimodal monitoring in neurocritical care (Neurocore-iMMM): an open, decentralized consensus","authors":"Sami Barrit, Mejdeddine Al Barajraji, Salim El Hadwe, Alexandre Niset, Brandon Foreman, Soojin Park, Christos Lazaridis, Lori Shutter, Brian Appavu, Matthew P. Kirschen, Felipe A. Montellano, Verena Rass, Nathan Torcida, Daniel Pinggera, Emily Gilmore, Nawfel Ben-Hamouda, Nicolas Massager, Francis Bernard, Chiara Robba, Fabio Silvio Taccone","doi":"10.1186/s13054-024-05211-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05211-8","url":null,"abstract":"Intracranial multimodal monitoring (iMMM) is increasingly used in neurocritical care, but a lack of standardization hinders its evidence-based development. Here, we devised core outcome sets (COS) and reporting guidelines to harmonize iMMM practices and research. An open, decentralized, three-round Delphi consensus study involved experts between December 2023 and June 2024. Items—spanning three domains: (i) patient characteristics, (ii) practices, and (iii) outcomes—with ≥ 75% agreement were classified as strong agreement, while those with 50–75% were reconsidered in subsequent rounds, requiring ≥ 66% for moderate agreement. An international, multidisciplinary panel comprised 58 neurocritical physicians and researchers with low attrition (12%). They were predominantly from Western regions (96%), actively involved in iMMM (82%), at least weekly (72.4%), with more than 10 years of specific experience (57%). Of the 127 items assessed for inclusion in COS and reporting guidelines, 45 (35.4%) reached strong and 8 (6.3%) moderate agreement. Main strong agreement items were: (i) demographics: age (98%) and sex/gender (90%); comorbidities: coagulation/platelet disorders (95%); initial scoring: Glasgow Coma Scale (97%) and pathology-specific scores (90%); active treatments: antithrombotics (95%) (ii) clinical practice: iMMM implantation indications (98%) and iMMM-guided interventions (91%); surgical practice: targeting strategies (97%) and concomitant external ventricular drainage (97%); technical details: recording modalities (98%); (iii) monitoring parameters: duration (97%) and triggered interventions (95%); standardized outcome reporting (93%); surgical complications (e.g., postoperative intracranial hemorrhages, CNS infections, and probe misplacement, all > 90%) and adverse events (accidental dislodgement, probe breakage, and technical malfunctions, all > 90%). This consensus establishes foundational COS and reporting guidelines for iMMM in neurocritical care. These harmonization tools can enhance research quality, comparability, and reproducibility, facilitating evidence-based practices for this emerging technology. However, challenges remain in developing purpose-specific guidelines and adapting them to diverse clinical and research settings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142858467","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 : 2024-12-20DOI: 10.1186/s13054-024-05187-5
Rong Li, JuanJuan Wang, Qian Li, QianYue Guo, Jun Kang Zhao, James Cheng-Chung Wei, Li-Yun Zhang
<p>Dear Editors,</p><p>We read with great interest the article by You et al., which presents a retrospective analysis of South Korean healthcare insurance data comparing the efficacy of baricitinib and tocilizumab in COVID-19 patients receiving mechanical ventilation (MV) [1]. We commend the authors for their valuable contribution to this field, but we believe the following points warrant further consideration in order to enhance the interpretability and clinical applicability of the results.</p><p>Firstly, the study spans a relatively long period from October 8, 2020, to October 31, 2022, which may present challenges to data stability and consistency. Given the ongoing nature of the COVID-19 pandemic, many patients may have experienced multiple infections. Studies have demonstrated that recurrent COVID-19 infections not only elevate the overall disease burden in affected individuals but also increase the risk of pulmonary sequelae by 254% in reinfected patients, along with a significantly higher risk of all-cause mortality [2]. Moreover, the multiple variants of the SARS-CoV-2 virus over time could influence its pathogenicity, virulence, and immune escape potential, which in turn may impact treatment efficacy and patient prognosis [3]. Although propensity score matching accounts for some confounding factors, the potential effects of temporal fluctuations in COVID-19 infection and reinfection may not have been fully addressed, which could undermine the reliability of the study's findings.</p><p>Furthermore, we note that the study does not clearly specify the baseline treatment regimens, particularly with regard to the use of corticosteroids. According to current clinical guidelines, corticosteroids are commonly used as a standard treatment for COVID-19 patients requiring oxygen support, and antiviral agents and other immunomodulators are also widely utilized [4].. Baricitinib and tocilizumab modulate the immune response by inhibiting specific cytokines, improving clinical outcomes, but the concurrent use of corticosteroids could potentially influence the effectiveness of these drugs. To provide a more comprehensive assessment of the therapeutic effects of baricitinib and tocilizumab, we suggest that the authors include detailed information regarding baseline treatment regimens, particularly concerning corticosteroid and other immunomodulator use. Additionally, subgroup analysis based on corticosteroid use could offer deeper insights into optimizing treatment strategies.</p><p>Moreover, the manuscript does not provide specific data on the doses and duration of treatment with baricitinib and tocilizumab. In current clinical practice, the standard regimen for baricitinib is typically 4 mg daily for 14 days or until patient discharge, while the dose of tocilizumab (1 or 2 doses) and the treatment duration may vary depending on the individual. Clarifying drug dosage and treatment duration would help better assess the stability and reproducibility of t
{"title":"Comments on “Baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study”","authors":"Rong Li, JuanJuan Wang, Qian Li, QianYue Guo, Jun Kang Zhao, James Cheng-Chung Wei, Li-Yun Zhang","doi":"10.1186/s13054-024-05187-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05187-5","url":null,"abstract":"<p>Dear Editors,</p><p>We read with great interest the article by You et al., which presents a retrospective analysis of South Korean healthcare insurance data comparing the efficacy of baricitinib and tocilizumab in COVID-19 patients receiving mechanical ventilation (MV) [1]. We commend the authors for their valuable contribution to this field, but we believe the following points warrant further consideration in order to enhance the interpretability and clinical applicability of the results.</p><p>Firstly, the study spans a relatively long period from October 8, 2020, to October 31, 2022, which may present challenges to data stability and consistency. Given the ongoing nature of the COVID-19 pandemic, many patients may have experienced multiple infections. Studies have demonstrated that recurrent COVID-19 infections not only elevate the overall disease burden in affected individuals but also increase the risk of pulmonary sequelae by 254% in reinfected patients, along with a significantly higher risk of all-cause mortality [2]. Moreover, the multiple variants of the SARS-CoV-2 virus over time could influence its pathogenicity, virulence, and immune escape potential, which in turn may impact treatment efficacy and patient prognosis [3]. Although propensity score matching accounts for some confounding factors, the potential effects of temporal fluctuations in COVID-19 infection and reinfection may not have been fully addressed, which could undermine the reliability of the study's findings.</p><p>Furthermore, we note that the study does not clearly specify the baseline treatment regimens, particularly with regard to the use of corticosteroids. According to current clinical guidelines, corticosteroids are commonly used as a standard treatment for COVID-19 patients requiring oxygen support, and antiviral agents and other immunomodulators are also widely utilized [4].. Baricitinib and tocilizumab modulate the immune response by inhibiting specific cytokines, improving clinical outcomes, but the concurrent use of corticosteroids could potentially influence the effectiveness of these drugs. To provide a more comprehensive assessment of the therapeutic effects of baricitinib and tocilizumab, we suggest that the authors include detailed information regarding baseline treatment regimens, particularly concerning corticosteroid and other immunomodulator use. Additionally, subgroup analysis based on corticosteroid use could offer deeper insights into optimizing treatment strategies.</p><p>Moreover, the manuscript does not provide specific data on the doses and duration of treatment with baricitinib and tocilizumab. In current clinical practice, the standard regimen for baricitinib is typically 4 mg daily for 14 days or until patient discharge, while the dose of tocilizumab (1 or 2 doses) and the treatment duration may vary depending on the individual. Clarifying drug dosage and treatment duration would help better assess the stability and reproducibility of t","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142867111","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 : 2024-12-20DOI: 10.1186/s13054-024-05219-0
Xiao-xiu Luo, Jia-jia Li, Fu-xun Yang, Yu Lei, Fan Zeng, Yun-ping Lan, Chun Pan, Xiao-bo Huang, Rong-an Liu, Jing-chao Luo
Perioperative airway management and oxygenation maintenance during central airway obstruction (CAO) treatment pose great challenges. While veno-venous extracorporeal membrane oxygenation (V-V ECMO) shows promise as a bridge therapy, optimal implementation and management strategies remain lacking. We present our experience with V-V ECMO in CAO management from a high-volume center. We retrospectively analyzed 29 consecutive patients who received V-V ECMO support for CAO between 2015 and 2023. Patient demographics, clinical characteristics, ECMO cannulation and operation parameters, interventional procedures, complications, and outcomes were reviewed. Among patients with median airway diameter of 4.5 mm (IQR 2–5 mm), etiologies included primary tumors (n = 17), metastases (n = 7), and post-intubation/tracheostomy stenosis (n = 5). Treatment comprised bronchoscopic interventions (n = 9) and surgical procedures (thoracic = 15, head/neck = 5). Using predominantly femoral-jugular cannulation (n = 27), we implemented a minimal anticoagulation protocol (catheter flush with 5U/mL heparin only). All patients survived through 6-month follow-up with minimal ECMO-related complications. The application of V-V ECMO with minimal anticoagulation demonstrates safety and efficacy as a bridging support in the therapeutic approach to CAO.
{"title":"Veno-venous extracorporeal membrane oxygenation as a bridge in central airway obstruction: experience from a high-volume center","authors":"Xiao-xiu Luo, Jia-jia Li, Fu-xun Yang, Yu Lei, Fan Zeng, Yun-ping Lan, Chun Pan, Xiao-bo Huang, Rong-an Liu, Jing-chao Luo","doi":"10.1186/s13054-024-05219-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05219-0","url":null,"abstract":"Perioperative airway management and oxygenation maintenance during central airway obstruction (CAO) treatment pose great challenges. While veno-venous extracorporeal membrane oxygenation (V-V ECMO) shows promise as a bridge therapy, optimal implementation and management strategies remain lacking. We present our experience with V-V ECMO in CAO management from a high-volume center. We retrospectively analyzed 29 consecutive patients who received V-V ECMO support for CAO between 2015 and 2023. Patient demographics, clinical characteristics, ECMO cannulation and operation parameters, interventional procedures, complications, and outcomes were reviewed. Among patients with median airway diameter of 4.5 mm (IQR 2–5 mm), etiologies included primary tumors (n = 17), metastases (n = 7), and post-intubation/tracheostomy stenosis (n = 5). Treatment comprised bronchoscopic interventions (n = 9) and surgical procedures (thoracic = 15, head/neck = 5). Using predominantly femoral-jugular cannulation (n = 27), we implemented a minimal anticoagulation protocol (catheter flush with 5U/mL heparin only). All patients survived through 6-month follow-up with minimal ECMO-related complications. The application of V-V ECMO with minimal anticoagulation demonstrates safety and efficacy as a bridging support in the therapeutic approach to CAO.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"100 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142858454","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 : 2024-12-19DOI: 10.1186/s13054-024-05200-x
Céline Monard, Nicolas Tebib, Bastien Trächsel, Tatiana Kelevina, Antoine Guillaume Schneider
Oliguria diagnosis includes the normalization of urine output (UO) by body weight. However, the rational and the method to apply to normalize UO to body weight are unclear. We aimed to explore the impact of the method applied to normalize UO on oliguria incidence and association with outcomes. We included all adult patients admitted to a Swiss (derivation cohort) and a US (MIMIC-IV database, validation cohort) ICU, except those on maintenance hemodialysis, who declined consent or had < 6 consecutive UO measurements. Among a panel of candidate variables (ideal body weight, body mass index, body surface area and adjusted body weight), we identified the best predictor for UO (i.e. the variable that was most closely associated with mean UO during ICU stay). We then compared oliguria incidence and association with 90-day mortality and acute kidney disease (AKD) at hospital discharge, according to whether UO was normalized by actual body weight (ABW) or the identified best UO predictor. The derivation and validation cohorts included respectively 15 322 and 28 610 patients. Those in the validation cohort were heavier (mean ABW 81 versus 75 kg) older (65 versus 62 years) and had a lower SAPS-II score (38 versus 43). The best UO predictor was ideal body weight (IBW). Oliguria incidence increased almost linearly across weight categories with ABW normalization but remained constant with IBW normalization. Using IBW for UO normalization rather than ABW improved the association between oliguria and 90-day mortality and AKD. It increased the proportion of patients correctly classified from 37.6 to 48.3% (mortality) and from 37.8 to 47% (AKD). All findings persisted after correction for sex and SAPS-II score and were confirmed in sensitivity analyses. UO normalization by IBW lead to a stable incidence of oliguria across categories of weight and improved the association between oliguria and outcomes. IBW should be preferred to normalize UO in critically ill patients.
{"title":"Comparison of methods to normalize urine output in critically ill patients: a multicenter cohort study","authors":"Céline Monard, Nicolas Tebib, Bastien Trächsel, Tatiana Kelevina, Antoine Guillaume Schneider","doi":"10.1186/s13054-024-05200-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05200-x","url":null,"abstract":"Oliguria diagnosis includes the normalization of urine output (UO) by body weight. However, the rational and the method to apply to normalize UO to body weight are unclear. We aimed to explore the impact of the method applied to normalize UO on oliguria incidence and association with outcomes. We included all adult patients admitted to a Swiss (derivation cohort) and a US (MIMIC-IV database, validation cohort) ICU, except those on maintenance hemodialysis, who declined consent or had < 6 consecutive UO measurements. Among a panel of candidate variables (ideal body weight, body mass index, body surface area and adjusted body weight), we identified the best predictor for UO (i.e. the variable that was most closely associated with mean UO during ICU stay). We then compared oliguria incidence and association with 90-day mortality and acute kidney disease (AKD) at hospital discharge, according to whether UO was normalized by actual body weight (ABW) or the identified best UO predictor. The derivation and validation cohorts included respectively 15 322 and 28 610 patients. Those in the validation cohort were heavier (mean ABW 81 versus 75 kg) older (65 versus 62 years) and had a lower SAPS-II score (38 versus 43). The best UO predictor was ideal body weight (IBW). Oliguria incidence increased almost linearly across weight categories with ABW normalization but remained constant with IBW normalization. Using IBW for UO normalization rather than ABW improved the association between oliguria and 90-day mortality and AKD. It increased the proportion of patients correctly classified from 37.6 to 48.3% (mortality) and from 37.8 to 47% (AKD). All findings persisted after correction for sex and SAPS-II score and were confirmed in sensitivity analyses. UO normalization by IBW lead to a stable incidence of oliguria across categories of weight and improved the association between oliguria and outcomes. IBW should be preferred to normalize UO in critically ill patients.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142848837","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}
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