Intensive Care Medicine最新文献

Rationale

Most cases of acute kidney injury (AKI) resolve within 72 h. However, a small number of patients with persistent severe AKI have significantly worse outcomes. We sought to describe the occurrence, impact on outcome and risk factors associated with persistent severe AKI in critically ill patients using a standardized definition.

Methods

Retrospective cohort study, investigating critically ill patients admitted to one of 16 hospitals from October 2010 to June 2018. We defined persistent severe AKI as Kidney Disease: Improving Global Outcomes stage 2–3 AKI that progressed to and persisted at stage 3 for ≥ 72 h. Risk factors for persistent severe AKI and its association with outcomes were assessed using the super learner algorithm, integrating LASSO logistic regression and XGBoost, and multivariate logistic regression or Cox proportional hazards models, using no persistent severe AKI as the comparator.

Measurements and main results

Of 65,119/190,550 (34.2%) patients with stage 2–3 AKI, 8,059 (12.4%) had persistent severe AKI. Severe, early community-acquired AKI, high fluid balance, multiple organ dysfunction, sepsis and shock were important risk factors. Persistent severe AKI was associated with an increased risk of 90-day mortality (HR 1.5, 95% CI 1.4–1.6), hospital readmission (OR 2.0, 95% CI 1.8–2.3), and with a lower probability of renal recovery (OR 0.14, 95% CI 0.13, 0.15).

Conclusions

Persistent severe AKI is an uncommon, but important complication in critically ill patients, associated with an increased risk of renal non-recovery, hospital readmission and death, and an important target for therapeutic development.

Purpose

To determine whether a liberal transfusion strategy (≥ 9 g/dL) improves neurological outcomes in adults with acute brain injury (ABI).

Method

We systematically searched MEDLINE, EMBASE, the Cochrane Library, and trial registries for randomized controlled trials comparing liberal (≥ 9 g/dL) vs. restrictive (≥ 7 g/dL) transfusion in adults with ABI (traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage) and Glasgow Coma Scale ≤ 13. Frequentist, Bayesian, and trial sequential analyses were used. The primary outcome was favorable neurological status at 180 days.

Results

Four randomized controlled trials (N = 1853; 922 liberal, 931 restrictive) were included. The pooled frequentist risk ratio (RR) for favorable neurological outcome was 0.84 (95% CI 0.65–1.09; I² = 58%). In a pre-specified sensitivity analysis including only low-risk-of-bias trials, the results suggested a potential benefit in favor of the liberal strategy (RR 0.74 [95% CI 0.63–0.87]) with no heterogeneity (I² = 0%). Subgroup analyses for patients with traumatic brain injury or stratified by initial Glasgow coma scale were consistent with the main findings. Bayesian analyses showed that the estimated treatment effect depended on the assumptions and priors used, with an unfavorable prior derived from one trial with distinct protocol appearing less likely than neutral or favorable priors. Trial sequential analysis indicated that current evidence is insufficient to confirm a definitive effect. Secondary outcomes did not differ significantly between groups.

Conclusions

This review did not provide definitive evidence of a neurological benefit from liberal transfusion strategies in acute brain injury. Both frequentist and Bayesian analyses highlight the influence of a single trial on the overall effect estimate and heterogeneity. However, sensitivity analyses excluding this trial and focusing on studies with low risk of bias suggested that liberal transfusion strategies could improve neurological outcomes. Future research should focus on identifying patient subgroups most likely to benefit, guiding a more individualized approach.

Purpose

This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO).

Methods

In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), “double-robust” approximation (DR), traditional regression (TR), and mixed-effects model (MEM).

Results

Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10–18) hours/day, compared to 10 (7–14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67–5.11), 3.35 (1.55–5.14), 3.95 (2.63–5.28), and 3.72 (2.5–4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15–0.76), 0.23 (0.10–0.50), 0.42 (0.23–0.77), and 0.48 (0.16–0.49), and for in-hospital mortality were 0.38 (0.11–1.27), 0.43 (0.14–1.26), 0.47 (0.22–0.91), and 0.46 (0.12–1.43) in the respective models.

Conclusion

In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation.

Trial Registration Number

ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022. Study Type: Observational.

Purpose

INHALE investigated the impact of seeking pathogens by PCR on antibiotic stewardship and clinical outcomes in hospital-acquired and ventilator-associated pneumonia (HAP and VAP).

Methods

This pragmatic multicentre, open-label RCT enrolled adults and children with suspected HAP and VAP at 14 ICUs. Patients were randomly allocated to standard of care, or rapid in-ICU syndromic PCR coupled with optional prescribing guidance. Co-primary outcomes were superiority in antibiotic stewardship at 24 h and non-inferiority in clinical cure of pneumonia 14 days post-randomisation. Secondary outcomes included mortality, ICU length of stay and evolution of clinical scores.

Results

554 eligible patients were recruited from 5th July 2019 to 18th August 2021, with a COVID-enforced pause from 16th March 2020 and 9th July 2020. Data were analysed for 453 adults and 92 children (68.4% male; 31.6% female). ITT analysis showed 205/268 (76.5%) reviewable intervention patients receiving antibacterially appropriate and proportionate antibiotics at 24 h, versus 147/263 (55.9%) standard-of-care patients (estimated difference 21%; 95% CI 13–28%). However, only 152/268 (56.7%) intervention patients were deemed cured of pneumonia at 14 days, versus 171/265 (64.5%) standard-of-care patients (estimated difference − 6%, 95% CI − 15 to 2%; predefined non-inferiority margin -13%). Secondary mortality and ΔSOFA outcomes narrowly favoured the control arm, without clear statistical significance.

Conclusions

In-ICU PCR for pathogens resulted in improved antibiotic stewardship. However, non-inferiority was not demonstrated for cure of pneumonia at 14 days. Further research should focus on clinical effectiveness studies to elucidate whether antibiotic stewardship gains achieved by rapid PCR can be safely and advantageously implemented.