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How to assess survival prognosis in patients hospitalized for community-acquired pneumonia in 2024? 如何评估 2024 年社区获得性肺炎住院患者的生存预后?
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-07-12 DOI: 10.1097/MCC.0000000000001189
Julio A Ramirez, Thomas M File

Purpose of review: Community-acquired pneumonia (CAP) is increasingly recognized as a complex, multisystemic disease with the potential to cause both acute and long-term sequelae, significantly impacting patient mortality rates. In this manuscript, the authors review the current methodologies for assessing mortality risk among CAP patients.

Recent findings: The most common prediction scores for ICU care and short-term mortality include Pneumonia Severity Index (PSI), CURB-65, SMART COP, SCAP, and ATS/IDSA criteria. These models have clinical utility in the prediction of short-term mortality, but they have significant limitations in addressing long-term mortality. For patients who are discharged alive from the hospital, we do not have scores to predict long term mortality.

Summary: The development of an optimal prognostic tool for postacute sequelae of CAP is imperative. Such a tool should identify specific populations at increased risk. Moreover, accurately identifying at-risk populations is essential for their inclusion in clinical trials that evaluate potential therapies designed to improve short and long-term clinical outcomes in patients with CAP.

综述的目的:越来越多的人认识到社区获得性肺炎(CAP)是一种复杂的多系统疾病,有可能引起急性和长期后遗症,严重影响患者的死亡率。在这篇手稿中,作者回顾了目前评估 CAP 患者死亡风险的方法:最常见的 ICU 护理和短期死亡率预测评分包括肺炎严重程度指数 (PSI)、CURB-65、SMART COP、SCAP 和 ATS/IDSA 标准。这些模型在预测短期死亡率方面具有临床实用性,但在处理长期死亡率方面有很大的局限性。对于出院后仍存活的患者,我们还没有预测长期死亡率的评分。这种工具应能识别风险增加的特定人群。此外,准确识别高危人群对于将他们纳入临床试验至关重要,这些临床试验将评估旨在改善 CAP 患者短期和长期临床预后的潜在疗法。
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引用次数: 0
Long-term outcomes in critically ill patients with acute respiratory failure. 急性呼吸衰竭重症患者的长期疗效。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-07-18 DOI: 10.1097/MCC.0000000000001196
Mariachiara Ippolito, Alberto Nicolò Galvano, Andrea Cortegiani

Purpose of review: This review aims to explore the latest evidence on long-term outcomes in patients admitted to the ICU because of acute respiratory failure (ARF).

Recent findings: As the survival rate of critically ill patients with acute respiratory failure improves, long-term mortality and disability still influence the quality of life of survivors and their caregivers. Patients admitted to the ICU because of ARF are at risk of developing the postintensive care syndrome, which presents with physical, cognitive and mental symptoms, all of which may impair their quality of life. Caregivers seem to be affected as well, which may lead to intergenerational trauma. The need for more care, including prone positioning, invasive support (e.g. mechanical ventilation, ECMO) and deep sedation are probably adjunctive risk factors for poor long-term outcomes.

Summary: There is not much data on the long-term outcomes of patients who have survived ARF. More follow-up studies should be conducted, especially in centers providing higher levels of costly care (e.g. ECMO). Randomized controlled trials on interventions for ARF should include patient-centered long-term outcomes in addition to mortality rates. The high mortality rates associated with ARF mandate collaboration among multiple centers to achieve an adequate sample size for studying the long-term outcomes of survivors.

综述目的:本综述旨在探讨因急性呼吸衰竭(ARF)而入住重症监护室的患者的长期预后的最新证据:随着急性呼吸衰竭重症患者存活率的提高,长期死亡率和残疾仍然影响着幸存者及其护理人员的生活质量。因急性呼吸衰竭住进重症监护室的患者有可能出现重症监护后综合征,表现为身体、认知和精神症状,所有这些症状都可能损害他们的生活质量。护理人员似乎也会受到影响,这可能会导致代际创伤。需要更多的护理,包括俯卧位、侵入性支持(如机械通气、ECMO)和深度镇静可能是导致长期预后不良的辅助风险因素。应开展更多的随访研究,尤其是在提供更高级别的昂贵护理(如 ECMO)的中心。有关 ARF 干预措施的随机对照试验除死亡率外,还应包括以患者为中心的长期疗效。与 ARF 相关的高死亡率要求多个中心通力合作,以获得足够的样本量来研究幸存者的长期预后。
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引用次数: 0
What are the clinical and research lessons learned from immunomodulators and other therapies during the COVID-19 pandemic? 在 COVID-19 大流行期间,从免疫调节剂和其他疗法中汲取了哪些临床和研究经验教训?
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-06-19 DOI: 10.1097/MCC.0000000000001184
Daniel A Sweeney, Pedro Póvoa

Purpose of review: The development and use of immunomodulators and other therapies during the coronavirus disease 2019 (COVID-19) pandemic provided several lessons with respect to these therapies, and to how medical researchers and clinicians should approach the next pandemic.

Recent findings: New or repurposed therapies, particularly immunomodulator treatments, for the treatment of an infectious disease will always be associated with inherent patient risk and this was the case during the COVID-19 pandemic. The concomitant development and use of effective antimicrobial therapies along with close monitoring for secondary infections is paramount for patient safety and treatment success. The development of immunomodulators and other therapies during the COVID-19 pandemic further highlighted the importance of maintaining high standards for medical research for all potential treatment with large double-blind placebo-controlled trials and peer review being the best mode of disseminating medical results rather than social media outlets.

Summary: The next new and emerging pandemic will undoubtedly share many of the same challenges posed by COVID-19. It is important that researchers and clinicians learn from this experience, adhere to tried and true clinical care, all the while conducting high quality research aimed at developing definitive treatments.

审查目的:2019年冠状病毒病(COVID-19)大流行期间免疫调节剂和其他疗法的开发和使用为这些疗法以及医学研究人员和临床医生如何应对下一次大流行提供了一些经验教训:用于治疗传染病的新疗法或改变用途的疗法,尤其是免疫调节剂疗法,总是与固有的患者风险相关联,COVID-19 大流行期间的情况就是如此。同时开发和使用有效的抗菌疗法,并密切监测继发感染,对患者安全和治疗成功至关重要。在 COVID-19 大流行期间,免疫调节剂和其他疗法的开发进一步凸显了对所有潜在疗法保持高标准医学研究的重要性,大型双盲安慰剂对照试验和同行评审是传播医学成果的最佳模式,而不是社交媒体渠道。重要的是,研究人员和临床医生要从中吸取经验教训,坚持尝试真正的临床治疗,同时开展旨在开发确切治疗方法的高质量研究。
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引用次数: 0
Implications of frailty before and after intensive care unit admission. 入住重症监护室前后身体虚弱的影响。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-07-24 DOI: 10.1097/MCC.0000000000001197
Joshua I Gordon, Nathan E Brummel

Purpose of review: In the decade since the first publications related to frailty in those with critical illness, the study of frailty has rapidly increased. The purpose of this review is to update the reader on recent advances across several important areas of frailty research: how best to identify frailty in those with critical illness, studies describing the relationship between frailty and delirium, and how frailty affects outcomes for those with coronavirus disease 2019 (COVID-19), which, despite rates and severity of acute infection declining, still tremendously impacts patients long after the acute infection, resulting in symptoms of long COVID-19.

Recent findings: A number of frailty assessment tools exist, to date, the Clinical Frailty Scale based on the deficit accumulation approach to defining frailty, is the most commonly used in ICU studies. Several novel frailty instruments for the ICU are being developed. Because tools assessing frailty by the phenotypic and deficit accumulation approaches identify different populations, careful choice of a frailty assessment tool is warranted.Frailty and delirium are hypothesized to represent different clinical expressions of a similar underlying vulnerability, thus identifying frailty may be a useful means by which to identify patients at high risk of becoming delirious. Recent studies show that frailty at ICU admission is a predictor of the development of delirium.Finally, frailty and its outcomes were studied in patients with COVID-19. As with other causes of critical illness, frailty was highly prevalent in those admitted to the ICU and is associated with greater mortality. Frailty was also associated with increased decisions to limit life support treatments, but these decisions were not different among those admitted with COVID-19 or for other reasons.

Summary: Frailty in those with critical illness is an emerging field of study. Future work to define the optimal means by which to identify this syndrome and how best to manage critically ill patients with frailty are needed.

综述的目的:自第一篇与危重症患者虚弱相关的文章发表以来的十年间,对虚弱的研究迅速增加。本综述旨在向读者介绍虚弱研究的几个重要领域的最新进展:如何最好地识别危重症患者的虚弱程度、描述虚弱与谵妄之间关系的研究,以及虚弱如何影响 2019 年冠状病毒病(COVID-19)患者的预后,尽管急性感染的发病率和严重程度有所下降,但在急性感染后的很长一段时间内,COVID-19 仍对患者产生巨大影响,导致患者出现长期的 COVID-19 症状:目前有许多虚弱程度评估工具,其中基于赤字累积法定义虚弱程度的临床虚弱程度量表是重症监护病房研究中最常用的工具。目前正在为重症监护病房开发几种新的虚弱评估工具。据推测,虚弱和谵妄代表了类似潜在脆弱性的不同临床表现,因此识别虚弱可能是识别高谵妄风险患者的有效手段。最近的研究表明,入住重症监护病房时的虚弱程度是谵妄发生的一个预测因素。最后,我们对 COVID-19 患者的虚弱程度及其结果进行了研究。与其他原因导致的危重病一样,体弱在入住重症监护室的患者中非常普遍,并与死亡率升高有关。体弱还与限制生命支持治疗的决定增多有关,但这些决定在因 COVID-19 或其他原因入院的患者中并无不同:总结:危重症患者的体弱是一个新兴的研究领域。今后的工作需要确定识别这种综合征的最佳方法,以及如何以最佳方式管理患有虚弱症的危重病人。
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引用次数: 0
Meeting complex multidimensional needs in older patients and their families during and beyond critical illness. 满足老年患者及其家人在危重病期间和之后的复杂的多方面需求。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-07-11 DOI: 10.1097/MCC.0000000000001188
Erminio Santangelo, Hannah Wozniak, Margaret S Herridge

Purpose of review: To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions.

Recent findings: Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients.

Summary: The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.

综述的目的:强调老年重症患者新出现的危机,回顾这些患者和护理人员所面临的多维发病率的独特负担以及潜在的干预措施:危重病后的身体、心理和认知后遗症在国际重症监护病房结果文献中是频繁、持久和强大的。老年患者更容易受到危重病及其治疗的多系统后遗症的影响,由此导致的多维发病率可能是深远的、慢性的,并严重影响患者和家属的功能独立性、向社区的过渡以及生活质量。最近的数据加强了基线功能状态、健康轨迹和慢性疾病作为 ICU 后长期功能障碍关键决定因素的重要性。摘要:本文概述了老年危重症幸存者的预后、减轻患者长期发病率的干预措施以及对家属和护理人员的影响。采用多模式纵向方法对患者进行一年或多年的随访,可以更好地了解脆弱的老年患者和家属所面临的多维发病率,并详细了解这一特殊人群的康复轨迹,以优化治疗结果、护理指令目标以及对重症监护室治疗的持续知情同意。
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引用次数: 0
Cancer and sepsis: future challenges for long-term outcome. 癌症与败血症:长期疗效的未来挑战。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-05-31 DOI: 10.1097/MCC.0000000000001173
Antoine Bianchi, Djamel Mokart, Marc Leone

Purpose of review: The purpose of this review is to investigate the long-term outcomes of cancer patients who experience sepsis or septic shock.

Recent findings: Sepsis is a frequent cause of ICU admission in cancer patients, accounting for approximately 15% of such cases. Short-term mortality rates among these patients vary widely across studies, but they are consistently found to be slightly higher than those of noncancer patients. However, there is a lack of evidence regarding the long-term outcomes of cancer patients who have experienced sepsis or septic shock. The few available studies have reported relatively high mortality rates, reaching around 80% in a few cohort studies. Although several observational studies have noted a decrease in 1-year mortality rates over time, observational data also suggest that sepsis may increase the risk of cancer in the long run.

Summary: As cancer is becoming a chronic disease, there is an urgent need for studies on the quality of life of cancer patients who have experienced sepsis. The relationship between sepsis and cancer extends beyond its impact on the progression of cancer, as sepsis might also contribute to the development of cancer.

综述目的:本综述旨在研究发生败血症或脓毒性休克的癌症患者的长期预后:脓毒症是癌症患者入住重症监护病房的常见原因,约占此类病例的 15%。不同研究发现,这些患者的短期死亡率差异很大,但始终略高于非癌症患者。然而,目前还缺乏有关经历过败血症或脓毒性休克的癌症患者长期预后的证据。现有的几项研究都报告了相对较高的死亡率,在几项队列研究中达到了 80% 左右。尽管一些观察性研究指出,随着时间的推移,1 年期死亡率有所下降,但观察性数据也表明,从长远来看,败血症可能会增加患癌症的风险。摘要:由于癌症正在成为一种慢性疾病,因此迫切需要对经历过败血症的癌症患者的生活质量进行研究。脓毒症与癌症之间的关系不仅仅是对癌症进展的影响,因为脓毒症还可能导致癌症的发展。
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引用次数: 0
Sepsis phenotypes, subphenotypes, and endotypes: are they ready for bedside care? 败血症表型、亚表型和内型:床旁护理准备好了吗?
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-06-07 DOI: 10.1097/MCC.0000000000001178
Sias J Scherger, Andre C Kalil

Purpose of review: Sepsis remains a leading global cause of morbidity and mortality, and despite decades of research, no effective therapies have emerged. The lack of progress in sepsis outcomes is related in part to the significant heterogeneity of sepsis populations. This review seeks to highlight recent literature regarding sepsis phenotypes and the potential for further research and therapeutic intervention.

Recent findings: Numerous recent studies have elucidated various phenotypes, subphenotypes, and endotypes in sepsis. Clinical parameters including vital sign trajectories and microbial factors, biomarker investigation, and genomic, transcriptomic, proteomic, and metabolomic studies have illustrated numerous differences in sepsis populations with implications for prediction, diagnosis, treatment, and prognosis of sepsis.

Summary: Sepsis therapies including care bundles, fluid resuscitation, and source control procedures may be better guided by validated phenotypes than universal application. Novel biomarkers may improve upon the sensitivity and specificity of existing markers and identify complications and sequelae of sepsis. Multiomics have demonstrated significant differences in sepsis populations, most notably expanding our understanding of immunosuppressed sepsis phenotypes. Despite progress, these findings may be limited by modest reproducibility and logistical barriers to clinical implementation. Further studies may translate recent findings into bedside care.

综述目的:败血症仍然是全球发病和死亡的主要原因,尽管经过几十年的研究,但仍未出现有效的疗法。脓毒症治疗缺乏进展的部分原因与脓毒症患者的显著异质性有关。本综述旨在强调有关败血症表型的最新文献以及进一步研究和治疗干预的潜力:最近的大量研究阐明了败血症的各种表型、亚表型和终末型。包括生命体征轨迹和微生物因素在内的临床参数、生物标志物调查以及基因组学、转录组学、蛋白质组学和代谢组学研究已经说明了脓毒症人群中的许多差异,这些差异对脓毒症的预测、诊断、治疗和预后具有重要意义。新型生物标志物可提高现有标志物的灵敏度和特异性,并识别败血症的并发症和后遗症。多组学已证明脓毒症人群存在显著差异,尤其是扩大了我们对免疫抑制性脓毒症表型的了解。尽管取得了进展,但这些发现可能会受到可重复性不高和临床实施的后勤障碍的限制。进一步的研究可将最新发现转化为床边护理。
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引用次数: 0
Intensive care for the long-term. 长期强化护理。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-10-01 Epub Date: 2024-09-05 DOI: 10.1097/MCC.0000000000001195
Sharon Einav
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引用次数: 0
Manual mastery vs. mechanized magic: current opinions on manual vs. mechanical chest compressions. 手动操作与机械化魔法:关于手动胸外按压与机械胸外按压的当前观点。
IF 3.3 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-09-10 DOI: 10.1097/mcc.0000000000001208
Conor Crowley,Justin Salciccioli,Helen Pocock,Ari Moskowitz
PURPOSE OF REVIEWMechanical chest compression devices are increasingly deployed during cardiopulmonary resuscitation. We discuss the data supporting the use of mechanical chest compression devices during cardiac arrest and provide an opinion about the future of the technology.RECENT FINDINGSMultiple randomized trials investigating the use of mechanical chest compression devices for out-of-hospital cardiac arrest have not demonstrated improved outcomes. There is little prospective evidence to support the use of mechanical chest compression devices in other settings. Data from observational studies do not support the routine use of mechanical chest compression devices for in-hospital cardiac arrest, but there may be a role for mechanical chest compressions for cardiac arrest in procedural areas and cardiac arrest prior to cannulation for extracorporeal membrane oxygenation.SUMMARYMechanical chest compression devices offer a solution to some of the human limiting factors of resuscitation, but have failed to demonstrate meaningful improvement in outcomes from cardiac arrest. Routine use of mechanical chest compression devices during cardiac arrest is not supported by evidence.
综述目的在心肺复苏过程中,越来越多地使用机械胸外按压装置。我们讨论了支持在心脏骤停期间使用机械胸外按压装置的数据,并对该技术的未来发展发表了看法。几乎没有前瞻性证据支持在其他情况下使用机械胸外按压装置。观察性研究的数据不支持在院内心脏骤停时常规使用机械胸外按压装置,但机械胸外按压装置可能在手术区心脏骤停和体外膜肺氧合插管前心脏骤停时发挥作用。在心脏骤停期间常规使用机械胸外按压装置没有证据支持。
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引用次数: 0
Light, sleep and circadian rhythm in critical illness. 危重病人的光线、睡眠和昼夜节律。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-05-28 DOI: 10.1097/MCC.0000000000001163
Heather Perry, Athina Alight, M Elizabeth Wilcox

Purpose of review: Sleep and circadian disruption (SCD) are associated with worse outcomes in the ICU population. We discuss sleep, circadian physiology, the role of light in circadian entrainment and its possible role in treating SCD, with special attention to the use of light therapies and ICU design.

Recent findings: The American Thoracic Society recently published an official research statement highlighting key areas required to define and treat ICU SCD. Recent literature has been predominantly observational, describing how both critical illness and the ICU environment might impair normal sleep and impact circadian rhythm. Emerging consensus guidance outlines the need for standardized light metrics in clinical trials investigating effects of light therapies. A recent proof-of-concept randomized controlled trial (RCT) showed improvement in delirium incidence and circadian alignment from ICU room redesign that included a dynamic lighting system (DLS).

Summary: Further investigation is needed to define the optimal physical properties of light therapy in the ICU environment as well as timing and duration of light treatments. Work in this area will inform future circadian-promoting design, as well as multicomponent nonpharmacological protocols, to mitigate ICU SCD with the objective of improving patient outcomes.

综述目的:睡眠和昼夜节律紊乱(SCD)与重症监护室患者的不良预后有关。我们讨论了睡眠、昼夜节律生理学、光在昼夜节律调节中的作用及其在治疗 SCD 中可能发挥的作用,特别关注光疗法的使用和 ICU 的设计:美国胸科学会最近发表了一份官方研究声明,强调了界定和治疗重症监护病房 SCD 所需的关键领域。最近的文献主要是观察性的,描述了重症疾病和重症监护室环境如何损害正常睡眠和影响昼夜节律。正在形成的共识指南概述了在研究光疗法效果的临床试验中采用标准化光指标的必要性。最近的一项概念验证随机对照试验(RCT)显示,重新设计包括动态照明系统(DLS)在内的重症监护病房后,谵妄发生率和昼夜节律调整均有所改善:需要进行进一步调查,以确定 ICU 环境中光疗法的最佳物理特性以及光疗法的时间和持续时间。该领域的工作将为未来的昼夜节律促进设计以及多成分非药物疗法方案提供信息,以减轻重症监护室 SCD,从而改善患者预后。
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引用次数: 0
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Current Opinion in Critical Care
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