International Journal of Critical Illness and Injury Science最新文献

Remdesivir is one of the proposed therapies for the corona virus disease 2019 (COVID-19). To assess the effect of remdesivir on mortality, need for invasive mechanical ventilation (IMV) and extracorporeal membrane oxygenation (ECMO), time to clinical improvement, and significant adverse effects. The study protocol was prospectively registered with The International Prospective Register of Systematic Reviews (Registration #CRD42021283221). Randomized controlled trials (RCTs) published in English detailing use of remdesivir in hospitalized patients with COVID-19 were included. Primary outcome was in hospital mortality among patients receiving remdesivir. Secondary outcomes were need for IMV and ECMO, time to clinical recovery, and significant adverse effects associated with remdesivir. Odds ratios (ORs) of worse outcome with 95% confidence interval (CI) in a forest plot were used to show the results of random effects meta-analysis. Remdesivir and placebo had similar in hospital mortality in the pooled analysis of five RCTs (OR: 0.93, 95% CI: 0.82-1.06). The remdesivir group needed less IMV/ECMO (OR: 0.59, 95% CI: 0.46-0.76) and recovered 1.06 days faster than placebo. Remdesivir did not affect transaminitis or renal damage. Trial sequence analysis showed that death has not reached the number of instances needed to predict futility. This meta-analysis shows that remdesivir therapy for COVID-19 is not associated with a mortality benefit. However, there is significant reduction in the need for IMV/ECMO.

Asciminib, a "Specifically Targeting the ABL Myristoyl Pocket" inhibitor, is a new drug in the treatment of tyrosine kinase inhibitor (TKI)-resistant chronic myeloid leukemia (CML). Hemocytopenias associated with asciminib are common adverse events documented by clinical trials. We report a case of precipitous-onset pancytopenia with the initiation of asciminib treatment in a patient with TKI-resistant CML. This case had a confounding array of laboratory findings that evidenced a drug-induced hemophagocytic component. We hope that our case stimulates further reporting of similar cases to enhance the understanding of the pathophysiology underlying asciminib-induced hemocytopenias.

Background: Evaluation of the efficacy and safety of mechanical ventilation settings is a cornerstone of the early phase of the management of acute respiratory distress syndrome (ARDS). This study aimed to evaluate the adherence to currently recommended lung-protective ventilator strategies (tidal volume, plateau pressure, driving pressure, prone positioning, and positive end-expiratory pressure [PEEP]) for adults with moderate-to-severe ARDS in a tertiary care setup, thereby evaluating if lung-protective ventilation is associated with improved outcomes.

Methods: This was an observational study over 1 year in ventilated moderate-to-severe ARDS participants. All participants were mechanically ventilated when required using the protocol followed by the ARDS Network low-tidal volume lung-protective ventilation strategy and monitored.

Results: The total number of participants in the study was 32. Septic shock was the most common cause of ARDS. The mean duration of intensive care unit (ICU) stay was 6.13 (±5.4) days, mean ventilator days were 3.66 (±3.75) days and mortality rate of 71.8%.Adherence to low-tidal volume was 78.12% with an improvement of 36% in the adherent group (P = 0.06). Adherence to high PEEP was 34.38% with a survival of 73% in the adherent group (P = 0.0004). Adherence to prone ventilation was 18.75% with a survival of 33% in the adherent group (P = 0.7).

Conclusion: Intensivists should take an extra effort to focus on evidence-based ventilator strategies and increase adherence to these recommendations in their ICUs to improve patient survival.

Background: Absent or delusional memories are experienced by many patients following an intensive care unit (ICU) stay. Up to 70% may have delusional or hallucinatory intrusive memories, which may persist long term. This study aims to investigate how spiritual health (SH) impacts ICU patients' memories and quality of communication (QoC) between patients and physicians (PP) or nurses (PN).

Methods: This cross-sectional study was conducted across the country on ICU patients discharged from 45 medical centers in 31 provinces of Iran, to evaluate the direct and indirect effects of SH and ICU characteristics on patients' memory. Two valid and standard ICU memory tools (ICU-MT) and SH questionnaires were administered to patients 1 day post-ICU discharge used.

Results: No significant direct effect of SH scores on ICU-MT items was observed. No significant correlation was observed between PP-QoC and PN-QoC variables and primary items of the ICU-MT. Female sex positively correlated with the development of delusional memories (odds ratio [OR]: 1.730, 95% confidence interval [CI]: 1.025-2.915, P < 0.05). Subjects admitted to the medical ICU were less likely to remember being in the ICU (OR: 0.398, 95% CI: 0.159-0.996, P < 0.05), and were less likely to report intrusive memories from their time in the hospital or events that led to their admission (OR: 0.19, 95% CI: 0.086-0.419, P < 0.001).

Conclusions: The results of this study indicate that the spiritual health indirectly increased coping with intrusive memories, however, no direct effect was observed on ICU-MT items. The quality of communication between patients and physicians and nurses significantly mediated development of intrusive memories.

Background: Traffic accidents are a common global cause of mortality and physical disability. This study aimed to investigate traffic accident-related mortality trends across provinces in Iran.

Methods: In this study, information on all deaths caused by traffic accidents in Iran from 2006 to 2020 was collected from the Iranian Legal Medicine Organization, which collects annual data from all 31 Iranian provinces. The national and provincial demographics were assessed, and the trends in mortality rates were assessed over a 15-year span using joinpoint regression based on the log-linear model, with results expressed in terms of annual percentage change (APC). The analysis for the trend was performed using the Joinpoint Regression Program 4.9.0.1.

Results: During the study period, 291,774 traffic accident-related deaths occurred in Iran, of which 78.6% were men and 21.4% were women. The mean age of the deceased was 37.75 ± 20.89 years. The mortality rate has dropped from 39/100,000 in 2006 to 18.3/100,000 in 2020. In total, the national mortality rate APC for 2006-2015 was -6.3% (P < 0.05) and for 2015-2020 was - 1.70% (P > 0.05).

Conclusions: Despite the overall decreasing national trend in Iran's traffic accident-related mortality over the study period, the provincial variability was noted. Therefore, it seems necessary to design and conduct epidemiological studies in different areas and provinces, for a better and more accurate understanding of the factors affecting the occurrence of traffic accident-related deaths, resulting in more focused and measurable interventions.

Background: Dexmedetomidine is used in neurocritical care units (NCCUs) due to the light, dose-dependent sedation, and anxiolysis provided. It is unknown how to dose dexmedetomidine in obese patients. The primary objective is to assess the ability to achieve the goal Richmond Agitation Sedation Scale (RASS) measurements in obese patients with a neurological injury who are solely on dexmedetomidine before and after an institutional dosing change from actual body weight (ABW) to adjusted body weight (AdjBW).

Methods: This study included patients admitted to the NCCU with a neurological condition, required dexmedetomidine for at least 8 h as a sole sedative, and weighed ≥120% of ideal body weight. Percentage of RASS measurements within the goal range (-1 to +1) during the first 48 h while on dexmedetomidine were compared between patients dosed on ABW and on AdjBW.

Results: Sixty-eight patients in the ABW cohort and 72 patients in the AdjBW cohort were included. There were no statistical differences between the two groups (ABW vs. AdjBW) in the percent of RASS measurements in the goal range (53.2% ± 34.8% vs. 55% ± 37%; P = 0.78), mean weight (99.2 ± 26 vs. 96.8 ± 20.9 kg; P = 0.55), or the average dose of dexmedetomidine required to achieve first goal RASS score (0.4 ± 0.3 vs. 0.4 ± 0.3 mcg/kg/h; P = 0.98).

Conclusions: Dosing dexmedetomidine using AdjBW in obese critically ill neurologically injured patients for ongoing sedation resulted in no statistical difference in the percent of RASS measurements within the goal when compared to ABW dosing. Further studies are warranted.

Background: Incorporating clinical pharmacists on the medical team has been associated with fewer medication errors and increased error interception. Due to the logistical complexities of the intravenous (IV) N-acetylcysteine (NAC) regimen for acetaminophen toxicity, many opportunities for medication errors exist. A pharmacist-based toxicology consultation service was implemented at our institution, allowing pharmacists to formally aid in the management of toxicology patients throughout their hospital admission, including those with acetaminophen toxicity. The purpose of this study was to evaluate the effect of a house-wide pharmacist-based toxicology consult service on errors associated with IV NAC treatment for patients admitted with acetaminophen toxicity.

Methods: A retrospective, pre-post cohort study was conducted on patients who received IV NAC for acetaminophen toxicity. The intervention evaluated was the implementation of a pharmacist-based toxicology consult service, known as the pharmacy toxicology team. The primary end point was the incidence of an error associated with IV NAC. An error was defined as the composite of inappropriate dose, administration rate, initiation, continuation, or discontinuation.

Results: Eighty-four patients were included; 30 patients in the pregroup, and 54 patients in the postgroup. Fewer patients experienced an error in the postgroup compared to the pregroup (30% vs 63%, P = 0.003).

Conclusion: The implementation of this unique pharmacist-based toxicology consult service was associated with fewer patients experiencing an error related to IV NAC therapy for acetaminophen toxicity. Application of this data may aid in the justification for development of clinical pharmacist-based toxicology consult services at other institutions.

Background: Surgery is a well-known and effective method of treating lumbar intervertebral disc herniation. The present study aimed to compare the effects of administering tranexamic acid (TXA), nitroglycerin (NTG), and remifentanil (REF) on hemorrhage prevention during herniated lumbar intervertebral disc surgery.

Methods: A double-blind clinical trial was conducted on 135 participants undergoing lumbar intervertebral disc surgery. A randomized block design was used for subject assignment to three groups including TXA, NTG, and REF. The hemodynamic parameters, bleeding rate, hemoglobin level, and the amount of infused propofol were measured and recorded after surgery. Data were then analyzed in SPSS software using Chi-square test and analysis of variance.

Results: The mean age of participants in the study was 42.12 ± 7.93 years, and all three groups were equal in terms of demographic characteristics (P > 0.05). The mean arterial pressure (MAP) of the TXA and NTG groups was notably higher than the REF group (P < 0.008). The mean heart rate (HR) of the TXA and NTG groups was notably higher than the REF group (P < 0.05). The propofol dosage used in the TXA group was higher than the two groups of NTG and REF (P < 0.001).

Conclusion: Among participants undergoing lumbar intervertebral disc surgery, the greatest MAP variability was observed in the NTG group. Higher mean HR and propofol consumption was observed in the NTG and TXA groups when compared to REF. No statistically significant differences were noted between groups in oxygen saturation or bleeding risk. Based on these findings, REF may be considered a preferred surgical adjunct over TXA and NTG during lumbar intervertebral disc surgery.

The fields of Obstetrics and Gynecology and Critical Care often share medically and surgically complex patients. Peripartum anatomic and physiologic changes can predispose or exacerbate certain conditions and rapid action is often needed. This review discusses some of the most common conditions responsible for the admission of obstetrical and gynecological patients to the critical care unit. We will consider both obstetrical and gynecologic concepts including postpartum hemorrhage, antepartum hemorrhage, abnormal uterine bleeding, preeclampsia and eclampsia, venous thromboembolism, amniotic fluid embolism, sepsis and septic shock, obstetrical trauma, acute abdomen, malignancies, peripartum cardiomyopathy, and substance abuse. This article aims to be a primer for the Critical Care provider.