Intensive Care Medicine最新文献

Purpose

To investigate the association between dynamic driving pressure (ΔPdyn) and mortality in mechanically ventilated patients with acute brain injury (ABI), and to evaluate whether neurological and pulmonary injury severity modify this relationship.

Methods

This prespecified secondary analysis of the VENTIBRAIN prospective study (NCT04459884) included mechanically ventilated adult patients with ABI (traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, or ischemic stroke). ΔPdyn was calculated daily over the first 14 days as peak inspiratory pressure minus positive end-expiratory pressure (PEEP). Bayesian joint models evaluated the time-varying association between ΔPdyn and mortality at ICU discharge, hospital discharge, and 6 months. Secondary analyses evaluated effect modification by baseline Glasgow Coma Scale (GCS), PaO₂/FiO₂, and ABI subtype.

Results

Among 1,555 patients (median age 59 years, 34.5% female), higher time-varying ΔPdyn was associated with increased ICU mortality (hazard ratio [HR], 1.057 per daily 1cmH₂O; 95% credible interval, 1.037–1.078; posterior probability of HR > 1, 99.9%). Findings were consistent across all ABI subtypes and were similar for static ΔP (plateau pressure minus PEEP). The association was strongest in patients with severe ABI (GCS ≤ 8) and severe hypoxemia (PaO₂/FiO₂ ≤ 100). Results were robust across all outcome timepoints and multiple sensitivity analyses.

Conclusion

Higher time-varying ΔPdyn was associated with increased mortality in this cohort of patients with ABI. Neurological injury severity independently modified the harm from ΔPdyn with a magnitude comparable to severe hypoxemia. Measurement of ΔPdyn may aid risk stratification and ventilation strategies in ABI; future trials should evaluate the effect of reducing ΔPdyn in this population.

Purpose

Family caregivers experience distress when their loved one is in the ICU, particularly in the setting of delirium. Limited English proficiency (LEP) may worsen this experience and contribute to long-term psychological burden. Yet, caregivers with LEP are rarely included in ICU research. Whether caregiver engagement using linguistically tailored delirium assessments improves satisfaction remains unknown.

Methods

We conducted a prospective cohort study in two academic ICUs evaluating delirium detection among English and Spanish-speaking ICU patients. Within this larger study, we performed a substudy of patient–caregiver dyads focused on caregiver satisfaction. Caregivers were assigned to: (1) FAM-CAM group, in which caregivers completed daily FAM-CAM delirium assessments, or (2) control group with no FAM-CAM exposure. All caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) after 3 days. Outcomes included overall satisfaction and subdomains of decision-making and care (0–100 scale). Independent t-tests compared satisfaction by language, FAM-CAM exposure, and patient delirium status.

Results

Among 120 dyads, 63 caregivers preferred English and 57 Spanish. English-speaking caregivers reported higher decision-making satisfaction than Spanish speakers (90.8 vs 85.6, p < 0.05). FAM-CAM exposure improved overall satisfaction across language groups (91.9 vs 84.4, p < 0.01). Patient delirium was linked to lower caregiver satisfaction, but FAM-CAM engagement mitigated this effect, with higher scores among exposed caregivers (90.9 vs 80.3, p < 0.05).

Conclusions

English-speaking caregivers reported higher satisfaction scores than Spanish-speaking caregivers. Engagement with FAM-CAM improved satisfaction across language groups, highlighting its potential to enhance caregiver engagement and promote equity in the ICU.

Purpose: Delayed graft function is the most frequent early complication of kidney transplantation. Pretreatment of kidney donors with cyclosporine has decreased delayed graft function in animal studies by reducing ischemia-reperfusion graft injuries. No randomized clinical trials have assessed the efficacy of cyclosporine pretreatment of brain-dead donors in reducing delayed graft function.

Methods: In this multicenter randomized, double-blind, and placebo-controlled trial, brain-dead donors were randomized (1:1) to receive either 2.5 mg/kg of cyclosporine or a glucose placebo infusion. The kidney transplant candidates were allocated through their donor assignment. The primary outcome was the occurrence of delayed graft function (DGF), defined as the need for at least one hemodialysis within the 7 days after kidney transplantation. Secondary outcomes included early graft function parameters within the 7 days post-transplantation, and 1-year graft and recipient survival.

Results: Between December 17, 2017 and March 3, 2023, 258 donors/331 recipients in the placebo group and 238 donors/312 recipients in the cyclosporine group were included in the modified intention-to-treat analysis. DGF occurred in 46 recipients (13.9%) in the placebo group and in 53 recipients (17.0%) in the cyclosporine group (unadjusted odd ratio = 1·27, 95% CI 0.83-1.95, P = 0.28). No significant between-group differences in the secondary outcomes (early graft function and 1-year graft and recipient survival) were observed.

Conclusion: In this double-blind, randomized controlled clinical trial, a pretreatment of brain-dead donors with a single low dose of cyclosporine did not significantly reduce the occurrence of DGF in kidney transplant recipients.