Journal of critical care最新文献

Introduction: Various Machine Learning (ML) models have been used to predict sepsis-associated mortality. We conducted a systematic review to evaluate the methodologies employed in studies to predict mortality among patients with sepsis.

Methods: Following a pre-established protocol registered at the International Prospective Register of Systematic Reviews, we performed a comprehensive search of databases from inception to February 2024. We included peer-reviewed articles reporting predicting mortality in critically ill adult patients with sepsis.

Results: Among the 1822 articles, 31 were included, involving 1,477,200 adult patients with sepsis. Nineteen studies had a high risk of bias. Among the diverse ML models, Logistic regression and eXtreme Gradient Boosting were the most frequently used, in 22 and 16 studies, respectively. Nine studies performed internal and external validation. Compared with conventional scoring systems such as SOFA, the ML models showed slightly higher performance in predicting mortality (AUROC ranges: 0.62–0.90 vs. 0.47–0.86).

Conclusions: ML models demonstrate a modest improvement in predicting sepsis-associated mortality. The certainty of these findings remains low due to the high risk of bias and significant heterogeneity. Studies should include comprehensive methodological details on calibration and hyperparameter selection, adopt a standardized definition of sepsis, and conduct multicenter prospective designs along with external validations.

Background

The results of current randomized controlled trials (RCTs) vary regarding the effectiveness of rehydration prior to anesthesia induction. Our objective was to determine the effectiveness of pre-induction rehydration in patients undergoing tracheal intubation or surgical procedures.

Methods

This meta-analysis followed PRISMA guidelines and was registered in the INPLASY database (registration number: INPLASY2022100099). Two reviewers independently searched PubMed, Embase, The Cochrane Database of Systematic Reviews, and Clinical Trials databases until October 2022, without any restrictions on date. Any randomized controlled trial investigating the administration of intravenous fluids to patients undergoing tracheal intubation or pre-surgical anesthesia induction was considered eligible. Exclusion criteria were applied to exclude certain literature. Data were analyzed using RevMan (5.4.1) software after independent extraction. The primary objective of this study was to determine if intravenous rehydration could reduce the occurrence of hypotensive events and the use of vasoactive drugs following anesthesia induction.

Results

This meta-analysis included seven studies with a total of 2850 patients, including 1430 patients who received rehydration and 1420 control patients. Patients who received early rehydration had a lower incidence of hypotensive events compared to those who did not (RR 0.78, 95% CI 0.66–0.92, P = 0.004). No heterogeneity was observed (p = 0.31, I² = 16%). However, subgroup analysis showed that rehydration before tracheal intubation did not reduce hypotensive events in critically ill patients (RR 0.99, 95% CI 0.61–1.60, P = 0.96). There were no significant differences in the use of vasoactive medications between the two study groups (RR 0.96, 95% CI 0.80–1.16, P = 0.69). No heterogeneity was observed (p = 0.26, I² = 23%). The funnel plot indicated no evidence of publication bias.

Conclusions

Pre-induction rehydration can reduce the occurrence of hypotensive events, but only in pre-surgical patients, and does not decrease the use of vasoactive medications.

Purpose

Extracorporeal cardiopulmonary resuscitation (E-CPR) may improve survival with favorable neurological outcome in patients with refractory out-of-hospital cardiac arrest (OHCA). Unfortunately, recent results from randomized controlled trials were inconclusive. We performed a meta-analysis to investigate the impact of E-CPR on neurological outcome compared to conventional cardiopulmonary resuscitation (C-CPR).

Methods

A systematic research for articles assessing outcomes of adult patients with OHCA either treated with E-CPR or C-CPR up to April 27, 2023 was performed. Primary outcome was survival with favorable neurological outcome at discharge or 30 days. Overall survival was also assessed.

Results

Eighteen studies were included. E-CPR was associated with better survival with favorable neurological status at discharge or 30 days (14% vs 7%, OR 2.35, 95% CI 1.61–3.43, I² = 80%, p < 0.001, NNT = 17) than C-CPR. Results were consistent if the analysis was restricted to RCTs. Overall survival to discharge or 30 days was also positively affected by treatment with E-CPR (OR = 1.71, 95% CI = 1.18–2.46, I² = 81%, p = 0.004, NNT = 11).

Conclusions

In this meta-analysis, E-CPR had a positive effect on survival with favorable neurological outcome and, to a smaller extent, on overall mortality in patients with refractory OHCA.

Despite advances in weaning protocols, extubation failure (EF) is associated with poor outcomes. Many predictors of EF have been proposed, including hypercapnia at the end of the spontaneous breathing test (SBT). However, performing arterial blood gases at the end of SBT is not routinely recommended, whereas end-tidal carbon dioxide (EtCO2) can be routinely monitored during SBT.

We aimed to evaluate the clinical utility of EtCO2 to predict EF. Patients undergoing planned extubation were eligible. Non-inclusion criteria were tracheostomy and patients extubated after successful T-tube SBT. We recorded clinical data and EtCO2 in 189 patients during a successful one-hour low pressure support SBT.

EtCO2 measured before successful SBT was lower in patients with EF compared to those with successful extubation (27 [24–29] vs 30 [27–47] mmHg, p = 0.02), while EtCO2 measured at five minutes and at the end of the SBT was not different between the two groups (26 [22–28] vs. 29 [28–49] mmHg, p = 0.06 and 26 [26–29] vs. 29 [27–49] mmHg, p = 0.09, respectively). Variables identified by multivariable analysis as independently associated with EF were acute respiratory failure as the cause of intubation and ineffective cough.

Our study suggests that recording EtCO2 during successful SBT appears to have limited predictive value for EF.

Objective

Determine whether a delay in the administration of the second dose of antibiotics is associated with an increased risk of mortality for patients admitted with septic shock.

Design

Retrospective, observational evaluation.

Setting

Regional multicenter evaluation including four institutions in western Pennsylvania.

Patients

A total of 905 patients were included in this study who met the criteria for septic shock. Patients that did not receive a second dose of antibiotics, were transferred from an outside facility, or expected death within six hours of hospital admission were excluded.

Interventions

The frequency of second antibiotic dose administration delay was determined. A delay was defined as a delay greater than or equal to 25% of the antibiotic dosing interval.

Measurements and main results

A delay in second antibiotic dose administration was found in 181 (20%) of patients. Patients with a delay in the administration of second dose antibiotics had a higher mortality rate (35%) than patients without a delay (26%) (p =0.018). Patients with and without a delay in the administration of second-dose antibiotics had similar median 28-day vasopressor free days (median = 26.0, IQR = 2.0). Differences in the distribution of the 28-day vasopressor free days between groups resulted in the achievement of statistical significance (Mann-Whitney U = 57,294.5, z = −2.690, p = 0.006). There was no difference in 28-day ventilator-free days between groups. A delay in the administration of second dose antibiotics led to a longer in-hospital length of stay (9 days vs. 7 days; p = 0.022) and a longer ICU length of stay than patients without a delay (5 days vs. 3 days; p = 0.007).

Conclusions

Delays in second antibiotic dose administration in septic shock patients were present but lower than previous studies. These delays were associated with increased mortality, increased ICU and hospital length of stay.

Purpose

To assess the association between fluctuations of arterial carbon dioxide early after start of extracorporeal membrane oxygenation (ECMO) with intracranial hemorrhage (ICH) or ischemic stroke (IS).

Materials and methods

This single-center retrospective study included patients who required ECMO for circulatory or respiratory failure between January 2011 and April 2021 and for whom a cerebral computed tomography (cCT) scan was available. Multivariable logistic regression models were fitted to evaluate the association between the relative change of arterial carbon dioxide (RelΔPaCO₂) and ICH, IS or a composite of ICH, IS, and mortality.

Results

In 618 patients (venovenous ECMO: n = 295; venoarterial ECMO: n = 323) ICH occurred more frequently in patients with respiratory failure (19.0%) compared with patients with circulatory failure (6.8%). Conversely, the incidence of IS was higher in patients with circulatory failure (19.2%) compared with patients with respiratory failure (4.7%). While patients with ECMO for respiratory failure were more likely to have ICH (OR 3.683 [95% CI: 1.855;7.309], p < 0.001), they had a lower odds for IS (OR 0.360 [95%CI: 0.158;0.820], p = 0.015) compared with patients with circulatory failure. There was no significant association between RelΔPaCO₂ and ICH or IS.

Conclusions

Irrespective of the indication for ECMO, we did not find a significant association between the relative change in PaCO₂ early after ECMO initiation and acute brain injury. Aside from early PaCO₂ decline at cannulation, future studies should address fluctuations of PaCO₂ throughout the course of ECMO support and their effect on acute brain injury.

Hantaviruses, members of the Bunyaviridae family, can cause two patterns of disease in humans, hantavirus hemorrhagic fever with renal syndrome (HFRS) and cardiopulmonary syndrome (HCPS), being the latter hegemonic on the American continent. Andesvirus is one of the strains that can cause HCPS and is endemic in Chile. Its transmission occurs through direct or indirect contact with infected rodents' urine, saliva, or feces and inhalation of aerosol particles containing the virus. HCPS rapidly evolves into acute but reversible multiorgan dysfunction. The hemodynamic pattern of HCPS is not identical to that of cardiogenic or septic shock, being characterized by hypovolemia, systolic dysfunction, and pulmonary edema secondary to increased permeability. Given the lack of specific effective therapies to treat this viral infection, the focus of treatment lies in the timely provision of intensive care, specifically hemodynamic and respiratory support, which often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This narrative review aims to provide insights into specific ICU management of HCPS based on the available evidence and gathered experience in Chile and South America including perspectives of pathophysiology, organ dysfunction kinetics, timely life support provision, safe patient transportation, and key challenges for the future.

Purpose

Electrocencephalography (EEG) is a tool to assess cerebral cortical activity. We investigated the indications and results of routine EEG recordings in neurocritical care patients and corresponding changes in anti-seizure medication (ASM).

Materials and methods

This was a single-center, retrospective cohort study. We included all adult Intensive Care Unit (ICU) patients with severe acute brain injury who received a routine EEG (30–60 min). Indications, background patterns, presence of rhythmic and periodic patterns, seizures, and adjustments in ASM were documented.

Results

A total of 109 patients were included. The EEGs were performed primarily to investigate the presence of (non-convulsive) status epilepticus ((NC)SE) and/or seizures. A (slowed) continuous background pattern was present in 94%. Low voltage, burst-suppression and suppressed background patterns were found in six patients (5.5%). Seizures were diagnosed in two patients and (NC)SE was diagnosed in five patients (6.4%). Based on the EEG results, ASM was changed in 47 patients (43%). This encompassed discontinuation of ASM in 27 patients (24.8%) and initiation of ASM in 20 patients (18.3%).

Conclusions

All EEGs were performed to investigate the presence of (NC)SE or seizures. A slowed, but continuous background pattern was found in nearly all patients and (NC)SE and seizures were rarely diagnosed. Adjustments in ASM were made in approximately half of the patients.