Journal of critical care最新文献

Background: This study aimed to evaluate the feasibility of using electrogastrography (EGG)/electroenterography (EEnG) to quantitatively visualize gastrointestinal (GI) motor function in critically ill patients.

Methods: EGG/EEnG were performed at baseline and before and after nutrition in critically ill patients with mechanical ventilation. Enteral nutrition varied in content. Dominant frequency (DF), dominant power (DP), and power ratio (PR) were calculated and compared with those from healthy controls (previous study; n = 50).

Results: Data from 20 % of patients were unstable and could not be analyzed. Of the 54 patients analyzed, 41 were on enteral nutrition, and their age and body mass index differed from controls. Gastric DF differed significantly between critically ill patients and controls (p < 0.001). No significant difference was noted in gastric log₁₀ DP between pre- and post-prandial periods in critically ill patients (2.79 vs 2.86, p = 0.328), but controls showed a significant increase (3.04 vs 3.22, p = 0.009). Critically ill patients had lower gastric log₁₀ DP than controls (pre-prandial p = 0.038; post-prandial p = 0.003). In the small intestine, log₁₀ DP did not differ significantly between pre- and post-prandial periods in critically ill patients (1.45 vs 1.52, p = 0.181), but controls showed a significant increase (1.70 vs 1.86, p < 0.001). Critically ill patients had lower small intestinal log₁₀ DP than controls (pre-prandial p = 0.004; post-prandial p < 0.001). PR was inferior in critically ill patients than in controls.

Conclusions: EGG/EEnG could enable quantitative visualization of GI motor function in critically ill patients. Larger studies can determine the association of GI symptoms with risk factors and prognostic factors.

Objectives: This study aims to assess pharmacodynamic target attainment in critically ill patients and identify factors influencing target attainment and mortality outcomes.

Methods: We analysed data from the DOLPHIN trial. Beta-lactam and ciprofloxacin peak and trough concentration were measured within the first 36 h (T1) after initiation of treatment. The study outcome included the rate of pharmacodynamic target attainment of 100 % ƒT_{>1xEpidemiological cut-off value (ECOFF)} for beta-lactams, and of fAUC_0-24h/ECOFF>125 for ciprofloxacin at T1.

Results: The target attainment rates were 78.1 % (n = 228/292) for beta-lactams, and 41.5 % (n = 39/94) for ciprofloxacin, respectively. Lower estimated glomerular filtration rate and higher SOFA score were associated with target attainment. In patients receiving beta-lactams, 28-day mortality was significantly higher in patients who attained 100 % ƒT_>1xECOFF (28.9 % vs. 12.5 %; p = 0.01). In the multivariate analysis, attainment of 100 % ƒT_>4xECOFF, but not 100 % ƒT_>1xECOFF, was associated with a higher 28-day mortality (OR 2.70, 95 % CI 1.36-5.48 vs. OR 1.28, 95 % CI 0.53-3.34).

Conclusions: A high rate of target attainment (100 % ƒT_>1xECOFF) for beta-lactams and a lower rate for ciprofloxacin was observed. Achieving exposures of 100 % ƒT_>4xECOFF was associated with 28-day mortality. The impact of antibiotic target attainment on clinical outcome needs to be a focus of future research.

Background & aims: Medical nutrition therapy (MNT) is fundamental for ICU patients. This post-hoc subgroup analysis of the prospective observational EuroPN survey aimed to assess MNT in the participating Belgian ICUs.

Methods: MNT practices in 9 Belgian ICUs (148 patients) were compared to 77 ICUs (1172 patients) from 11 European countries during the first 15 days for patients staying ≥5 days in ICU - and with the 2019 ESPEN guideline on clinical nutrition in ICU (<70 % of estimated energy expenditure in week 1 and up to 1.3 g/kg/d protein). Additionally, overfeeding was evaluated in the Belgian cohort.

Results: The Belgian cohort had longer median ICU and hospital length of stay, higher emergency room admission rates and delayed MNT initiation compared to overall (EN: day 2.5 [2.0;4.0] vs 2.0 [2.0;4.0] and PN: day 5.0 [3.0,7.0] vs 2.0 [2.0,4.0]). They received more often EN than PN. In week 1 overfeeding was on average present in 30 % (energy) and 15 % (protein) of observation days.

Conclusion: Similar to overall, the Belgian subgroup received a daily average moderate caloric and low protein intake. The gradual intake increase aligned with ESPEN guidelines, though temporary overfeeding occurred in about one third of the patients.

Background: Acute kidney injury (AKI) is common in hospitalized patients. Administration of iodinated contrast may impede kidney recovery but avoiding contrast may delay diagnosis and therapeutic interventions. There is limited data on the impact of contrast exposure in patients with established AKI receiving renal replacement therapy (RRT).

Methods: We conducted a retrospective cohort study which included all patients with AKI who received RRT at St Michael's Hospital in Toronto, Canada, from January 2007 to December 2022. The exposure was the receipt of iodinated contrast during the 14 days following RRT initiation and while the patient was still RRT-dependent. The primary outcome was RRT dependence at hospital discharge.

Results: 1597 patients with AKI received RRT and 754 patients were included in our analysis. Of these, 185 patients received iodinated contrast. After propensity score weighting, the exposure to contrast was associated with a higher likelihood of RRT dependence at hospital discharge (Odds Ratio 1.73, 95 % confidence interval 1.13-2.53).

Conclusion: The receipt of contrast in patients with AKI receiving RRT was associated with an increased risk of RRT dependence at hospital discharge. Contrast exposure in RRT-dependent patients may delay recovery from AKI. The benefits of contrast should be carefully weighed against this risk in patients with AKI receiving RRT.

Objective: To assess the association of serum glycocalyx shedding components (Heparan sulfate, HS; Hyaluronic acid, HA; Syndecan-1, Sdc-1) with outcomes after CA.

Methods: Patients who were comatose for >24 h after CA in the intensive care unit (ICU) of the Affiliated Hospital of Xuzhou Medical University from 9/2021 to 04/2023 were enrolled. Serum samples were collected 24 h after CA to measure the concentrations of glycocalyx shedding components. The outcomes were the 30-day Cerebral Performance Categories (CPC) scale and 30-day mortality. The association of glycocalyx shedding with outcomes was examined by regression analysis. The area under the curve was used to evaluate the value of glycocalyx shedding for predicting outcomes. Sensitivity analysis and subgroup analysis were conducted.

Results: 111 patients were enrolled. The unfavorable group (CPC 3-5, n = 69) had significantly higher serum concentrations of HA and Sdc-1 than the favorable group (CPC 1-2, n = 42) (HA:149.7 ng/ml vs. 824.8 ng/ml, P < 0.001; Sdc-1: 303.8 ng/L vs. 447.0 ng/L, P = 0.026)but not HS. Elevated serum HA concentrations was an independent risk factor for unfavorable 30-day neurological function (OR = 2.485, 95 % CI = 1.656-3.729). For the 30-day mortality, the nonsurvivor group (n = 53) had significantly higher serum concentrations of HA, HS and Sdc-1 (HA: 177.3 ng/ml vs. 1106.7 ng/ml, P < 0.001; HS: 2403.7 ng/ml vs. 3383.3 ng/ml P = 0.030; Sdc-1: 352.1 ng/L vs. 487.8 ng/L, P = 0.005) than the survivor group (n = 58). However, only elevated serum HA and Sdc-1 concentrations are independent risk factors for 30-day mortality (HA: HR = 2.321, 95 % CI = 1.776-3.035; Sdc-1: HR = 1.702, 95 % CI = 1.038-2.792).

Conclusions: Elevated serum HA at 24 h after CA is an independent risk factor for 30-day unfavorable neurological function or mortality and elevated serum Sdc-1 concentrations is an independent risk factor for 30-day mortality. Our results suggested the potential value of serum glycocalyx shedding components as predictors for the outcomes in post-CA patients.

Background: In critically ill patients with acute kidney injury (AKI), a fluid balance (FB) > 2 L at 72 h after AKI diagnosis is associated with adverse outcomes. Identification of patients at high-risk for such fluid accumulation may help prevent it.

Methods: We used Australian electronic medical record (EMR)-based clinical data to develop the "AKI-FB risk score", validated it in a British cohort and used it to predict a positive FB >2 L at 72 h after AKI diagnosis.

Results: We developed the AKI-FB score in 32,030 patients with a median age of 63 years and a median APACHE 2 score of 16. We validated it in 4465 patients, with significant differences in admission diagnoses and interventions. The key score variables were admission after trauma, sepsis or septic shock, and, on the day of AKI diagnosis, highest creatinine, daily cumulative FB, mechanical ventilation, noradrenaline use, noradrenaline equivalent dose >0.07 μg/kg/min, lactate ≥2 mmol/L, transfusion, and nutritional support. A score threshold of 32 had a sensitivity of 75 % and a specificity of 72 % for predicting a > 2 L positive FB with an AUC-ROC of 0.805; 95 % CI 0.799 to 0.810. External validation demonstrated an AUC of 0.761 (95 % CI 0.746 to 0.775).

Conclusion: We developed and validated the "AKI-FB risk score" to predict patients who developed a positive FB >2 L within 72 h of AKI diagnosis. This prediction score was robust and facilitated the identification of high-risk AKI patients who could be the tarted for preventive measures and be included in future clinical trials of FB management.

Purpose: Onco-hematological (OH) patients face significant cardiovascular risks due to malignancy and drug toxicity. Data are limited on the characteristics and outcomes of OH patients with cardiogenic shock (CS) in intensive care units (ICUs).

Methods: This multicenter retrospective study included 214 OH patients with CS across 22 ICUs (2010-2021). The objectives were to (i) identify risk factors for 30-day mortality, (ii) describe early and long-term outcomes, and (iii) assess the prognostic impact of malignancy by comparing OH patients to a control group of CS patients.

Results: The 30-day survival rate was 44.8 %. Multivariate analysis identified previous cardiomyopathy (OR = 1.61), acute kidney injury (OR = 1.62), lactate levels (OR = 1.08 per 1 mmol/L), pulmonary embolism (OR = 3.04), invasive mechanical ventilation (OR = 3.48), and epinephrine use (OR = 2.09) as factors associated with 30-day mortality. Among ICU survivors, 54 % were alive at 1 year with a median left ventricular ejection fraction of 52 %. OH malignancy was significantly associated with 30-day mortality (HR 2.54).

Conclusion: The prognosis for OH patients with CS in the ICU is poor, with epinephrine use associated with worse outcomes. Further research is needed to refine risk stratification and improve treatments for this population.

The optimal modalities of kidney replacement therapy (KRT) in the ICU remain debated. Intermittent haemodialysis (IHD) and continuous veno-venous haemofiltration (CVVH) are the two main methods. Intermittent haemodialysis requires a water treatment system, which may not be available in all jurisdictions. We report the experience of an innovative strategy of intermittent KRT without water treatment system. Based on the manufacturer's recommendations, the dialysate flow during "CVVHDF post" (post-dilution continuous veno-venous haemodiafiltration) mode was increased by connecting the substitution pump in parallel with the dialysate pump using a Y-connector. This doubled the flow rate of dialysate, allowing for 9000 mL/h during intermittent KRT sessions at a blood flow rate of 250 mL/min. We called this technique "water treatment-free prolonged intermittent kidney replacement therapy" (WTF-PIKRT). We report our experience in 18 patients who underwent 88 WTF-PIKRT sessions (median duration 5 h (IQR [4, 6])) between August 2019 and May 2020. The median urea reduction ratio was 38 % (IQR [29,49]). Hypotension occurred during 21.6 % of sessions. Hypokalemia or hypophosphatemia occurred in less than 5 % of sessions. WTF-PIKRT represents an attractive alternative to conventional IHD when a water treatment system is not available. Despite its lower efficacy compared with IHD, it may have significant organizational and economic impact.