Journal of Intensive Care最新文献

Background: The optimal strategy for discontinuing arginine vasopressin and norepinephrine in patients recovering from shock remains uncertain. Although prior studies have suggested a higher risk of hypotension when arginine vasopressin is discontinued first, these findings may have been influenced by baseline imbalances and tapering practices. We conducted a retrospective study to evaluate whether the order of discontinuation between arginine vasopressin and norepinephrine was associated with the incidence of hypotension during the recovery phase of shock, with vasopressor end doses converted to norepinephrine equivalents for analysis.

Methods: This was a single-center retrospective cohort study of intensive care unit patients with shock who received both arginine vasopressin and norepinephrine from August 2017 to March 2024. Patients were categorized based on whether arginine vasopressin or norepinephrine was discontinued first. The primary outcome was the incidence of hypotension within 24 h of vasopressor cessation, defined as mean arterial pressure < 60 mmHg requiring a ≥ 25% increase in the remaining vasopressor, reinstitution of the stopped agent, or a bolus of ≥ 500 mL crystalloid or 25 g albumin. Overlap weighting using propensity scores was applied to adjust for baseline imbalances both in the overall cohort and in the septic shock subgroup. Propensity scores were estimated using logistic model, including baseline characteristics, hemodynamic parameters, and vasopressor end doses in norepinephrine equivalents.

Results: A total of 524 patients were analyzed, with 293 discontinuing AVP first and 231 discontinuing NE first. In the unadjusted cohorts, hypotension occurred in 19% of the AVP-first group and 26% of the NE-first group. After overlap weighting, all baseline covariates were balanced between the groups, and the incidence of hypotension was not significantly different (19% vs 21%, P = 0.59). In the septic shock subgroup (n = 267), the weighted analysis showed no significant difference in the incidence of hypotension between groups.

Conclusions: In patients recovering from shock who received both arginine vasopressin and norepinephrine, discontinuing arginine vasopressin first was not associated with a higher risk of hypotension.

Background: The absence of consensus criteria for diarrhea in critically ill patients poses challenges, including an uncertain prevalence and inconsistent findings regarding the impact of diarrhea on mortality. This study aimed to examine the prevalence of diarrhea, the agreement among different diagnostic criteria, and their association with mortality.

Methods: A single-center cohort study was conducted among consecutive adult patients admitted to the intensive care unit (ICU) for at least three days between January 2017 and December 2018. The six diarrhea criteria evaluated were based on frequency, quantity, and consistency. These included the European Society of Intensive Care Medicine (ESICM) criteria (≥ 3 times and > 200 g/day loose or liquid stool), the World Health Organization (WHO) criteria (≥ 3 times loose or liquid stool), the Bristol Stool Chart Scale (BSCS) score of 6 or 7, and other quantity- or frequency-based definitions. Outcomes included: (1) prevalence of diarrhea according to each definition, (2) agreement between criteria, and (3) association between diarrhea and in-hospital mortality. Associations were assessed using multivariable Cox proportional hazards models, yielding hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: Among 700 participants, 61% were men; the median age was 71 years. The prevalence of diarrhea ranged from 9 to 39%, depending on the criteria used. The WHO and ESICM criteria showed similar prevalences (18.7% and 15.1%, respectively) and high agreement (Kappa 0.87). However, both had weak agreement with the BSCS criteria (prevalence 39.3%; Kappa 0.52 and 0.43, respectively). In univariable analyses, the presence of diarrhea was associated with in-hospital mortality, regardless of the criteria used. In multivariable analyses, only the > 400 g/day loose or liquid stool, > 200 g/day loose or liquid stool, and BSCS criteria maintained this association; the adjusted HRs (95% CI) were 1.93 (1.29‒2.90), 1.78 (1.19‒2.64), and 1.73 (1.15‒2.60), respectively.

Conclusions: Diarrhea prevalence varied from 9-39% across definitions. WHO and ESICM, both frequency‑based, differed from BSCS and weight‑based criteria. Given the difficulty of accurate frequency counting in ICU patients, consistency‑ or weight‑based definitions may offer a more practical alternative for both clinical practice and research.

Background: Internal jugular vein respiratory variation (IJVV) has been proposed as a dynamic predictor of fluid responsiveness. However, its utility is limited in patients with low tidal volume (Vt) ventilation in the prone position. We conducted this study to determine whether a transient increase in Vt from 6 to 8 ml kg^-1 of the predicted body weight (PBW), which is the "tidal volume challenge (TVC)", improves the feasibility of the IJVV in patients undergoing posterior lumbar surgery ventilated with a low Vt.

Methods: This was a prospective study conducted in the operating room. Patients were studied at baseline (a Vt of 6 ml kg^-1 PBW), during a 1 min increase in the Vt to 8 ml kg^-1 of the PBW, during a 1 min shift to the Trendelenburg maneuver, and after fluid administration. Baseline values of the IJVV, pulse pressure variation (PPV), and stroke volume variation (SVV) [IJVV₆, PPV₆, and SVV₆, respectively], and the changes in the IJVV during a TVC (ΔIJVV_6-8) were measured. The change in cardiac index during a Trendelenburg maneuver (ΔCI_trend) was also recorded. Volume responsiveness was defined by a ΔCI_trend ≥ 8%. The primary outcome was determination of the ΔIJVV_6-8 in predicting volume responsiveness during low Vt ventilation in the prone position. The secondary outcomes included an estimation of the IJVV₆, PPV₆, and SVV₆ diagnostic performances in predicting volume responsiveness in this surgical setting.

Results: Sixty-one patients were included in the study, 31 (50.82%) of whom were deemed volume responsive. The ΔIJVV_6-8 predicted volume responsiveness with area under the receiver operating characteristic curve (AUC) of 0.96 (95% CI 0.88-0.99; P < 0.001), with a sensitivity of 96.77% and a specificity of 86.67%. In addition, the AUC for ΔIJVV_6-8 was significantly higher than that for IJVV₆, PPV₆, and SVV₆, as confirmed by DeLong's test (P = 0.04, P < 0.001, and P = 0.01, respectively).

Conclusions: In patients undergoing posterior lumbar surgery with low Vt ventilation, changes in IJVV during a TVC effectively predict volume responsiveness and are more reliable than IJVV, PPV, and SVV in this surgical context.

Background: The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock 2024 (J-SSCG2024) were developed to improve the standardization and quality of sepsis care across various clinical settings. However, real-world adherence to these recommendations among healthcare professionals in Japan remains unclear. The objective of this study was to assess patterns of adherence to the J-SSCG2024 and identify factors associated with variation in clinical practice.

Methods: We conducted a nationwide web-based cross-sectional survey targeting healthcare professionals, administering a questionnaire that included 23 items reflecting the key J-SSCG2024 recommendations for the initial management of sepsis, along with demographic and professional background information. Cluster analysis was performed to identify the distinct adherence patterns. Subgroup analyses were conducted to explore the association between respondent characteristics and guideline compliance. Additionally, sensitivity analyses were performed to evaluate the robustness of the findings across distinct cluster numbers.

Results: A total of 734 healthcare professionals participated in the survey, most of whom were physicians (92.4%) with over 20 years of clinical experience (54.0%). High adherence was observed for recommendations, such as blood purification and the use of first-line vasopressors. However, substantial variation was detected in practices related to adjuvant therapies and initial resuscitation, particularly regarding the timing of vasopressor initiation and the use of beta-blockers. Cluster analysis revealed four distinct adherence profiles. Higher adherence was associated with expertise in emergency and critical care medicine, affiliation with intensive care units or emergency departments, and a higher number of patients with sepsis managed monthly. These findings were consistent across the sensitivity analyses.

Conclusions: This nationwide survey identified characteristic clusters based on adherence to the J-SSCG2024 among Japanese clinicians. Targeted implementation strategies are essential to enhance guideline adoption, particularly among clinicians outside specialized critical care settings.

Background: Survivors of critical illness frequently face physical, cognitive and psychological impairments after intensive care. Sensorimotor impairments potentially have a negative impact on participation. However, comprehensive understanding of sensorimotor recovery and participation in survivors of critical illness is limited. Therefore, the aims of this study were to quantify long-term sensorimotor recovery in survivors of critical illness, to examine participation in daily life 1.5 years after illness onset, and to assess the predictive capacity of sensorimotor assessments for future participation.

Methods: Survivors of critical illness who were mechanically ventilated ≥ 5 days on the ICU and who were admitted with weakness to neurorehabilitation were included in this single-center prospective cohort study. Time effects on sensation, muscle strength, balance, walking and dexterity were described at admission to and at discharge from rehabilitation, and 1.5 years after critical illness onset. Participation was assessed with the Reintegration to Normal Living Index. A multiple linear regression with sensorimotor outcomes at rehabilitation admission was conducted to find predictive associations with participation. The model was compared to an extended regression model containing demographic variables and factors known to be associated with participation or quality of life.

Results: All sensorimotor outcomes among participants (n = 250, median age 63 (54-73) years) improved over time. However, in most patients some deficits remained after rehabilitation and on long-term follow-up. Good participation (≥ 75%) was achieved by 60.2% of survivors 1.5 years after critical illness onset. Concerning participation, the Mini Balance Evaluation Systems Test (Mini-BESTest) together with the Box-and-Block-Test, the Five-Times-Sit-to-Stand-Test, and the Medical Research Council score at rehabilitation admission formed a predictive model (R² = 0.157, p < 0.001). The extended regression analysis resulted in a model (R² = 0.357, p < 0.001) with the variables depression, duration of mechanical ventilation, cognitive function, Mini-BESTest, comorbidities, sex and cerebral lesion.

Conclusions: We observed significant improvements in sensorimotor function, albeit with lingering deficits in sensation, strength, balance, dexterity and participation. Sensorimotor functions at rehabilitation start have limited explanatory power in predicting participation 1.5 years after disease onset. Trial registration German Clinical Trial Register, DRKS00021753. Date of registration: September 03, 2020.

Background: Endostatin is a promising biomarker for predicting acute kidney injury (AKI) and mortality in the intensive care unit (ICU). We investigated plasma endostatin levels at ICU admission as predictors of new-onset AKI within 48 h after ICU admission, renal replacement therapy (RRT) within 7 days after ICU admission, and 30-day mortality.

Methods: A retrospective multicentre study was performed with admissions to four ICUs. Blood samples were prospectively obtained at ICU admission and retrospectively analysed. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria defined AKI. Endostatin at ICU admission was compared to and adjusted for creatinine, cystatin C, and the Simplified Acute Physiology Score 3 (SAPS-3). Regression models and mean areas under the receiver operating characteristic curves (AUCs) from repeated cross-validation were assessed.

Results: In total, 4732 admissions were included. Endostatin was associated with new-onset AKI (OR 1.7, 95% CI 1.5 $-$ 1.9), new-onset stage 3 AKI (OR 1.4, 95% CI 1.2 $-$ 1.6), and RRT (OR 1.2, 95% CI 1.05 $-$ 1.4) independently of creatinine, cystatin C, and SAPS-3. Endostatin was superior to creatinine and cystatin C in predicting new-onset AKI (mean AUC 0.67 vs. 0.63, p < 0.001). Adding endostatin to creatinine improved the prediction of new-onset AKI and new-onset stage 3 AKI, but not the need for RRT. Endostatin was not associated with 30-day mortality after adjusting for the SAPS-3 score.

Conclusions: Endostatin at ICU admission is an independent predictor of new-onset AKI and may improve early AKI risk assessment in the ICU. However, its predictive value for RRT and 30-day mortality appears limited. External validation and studies on its clinical utility are warranted.

Background: Practice and delivery of critical care in Asia varies according to healthcare structure, income setting, and cultural factors. Identifying research priorities specific to ICU patients and healthcare workers in Asia is needed to guide advancement of critical care in the region.

Methods: This was an international cross-sectional survey study with adapted methods from nominal group techniques. All members of the Asian Critical Care Clinical Trials (ACCCT) Group were invited to submit research question suggestions. Submitted research questions were combined into summarized research questions, grouped into research themes, and individually ranked by number of mentions based on the original question submission (popularity). National and Regional Representatives rated the top 15% most popular summarized research questions by pre-defined importance and feasibility criteria.

Results: Between September 20, 2024 and December 10, 2024, 160 of 228 general members of the ACCCT Group (response rate 70.2%) participated in this survey study. The participants were from 112 hospitals across 24 countries and regions within Asia. Participants submitted 408 research questions, which were categorized into 15 themes and combined into 197 summarized research questions. The top three themes, as ranked by the number of mentions, were infection/sepsis, general ICU care, and structure/training/staffing/teamwork/safety. A threshold of 4 mentions was used to identify 26 summarized research questions that represented the top 15% most popular questions. Research questions related to sepsis and acute respiratory distress syndrome were ranked most important and feasible across the region.

Conclusion: Twenty-six of the most popular research questions in critical care were identified by Asian ICU workers and researchers to drive research agenda in Asia for the next decade.

Background: Since the concept of post-intensive care syndrome (PICS) was proposed, numerous studies have assessed patients and their family members. However, a wide range of assessment timings has been employed across previous studies. This study aimed to clarify how assessment timings have been implemented in existing PICS research through a scoping review, and to explore expert opinions on optimal assessment timing via an online survey.

Methods: We conducted a scoping review of studies assessing PICS-related outcomes, including physical, cognitive, and psychological impairments, as well as PICS in family members. Studies were retrieved from MEDLINE, CENTRAL, and CINAHL, and screened by two independent pairs of reviewers. Eligible studies were published between January 2014 and December 2022. Studies lacking a clear description of assessment timing were excluded. We analyzed the reference point used to determine assessment schedules, the assessment time points, and their frequency. Additionally, an online questionnaire was administered to 23 members of the Japanese Society of Intensive Care Medicine PICS committee and working group members to collect expert opinions on these three aspects for clinical research.

Results: A total of 657 studies were included. In prior studies, hospital discharge was the most commonly used reference point for determining assessment schedule (240 studies, 40%). However, ICU discharge was identified by experts as the ideal reference point (16 votes, 47%). The most frequently used assessment time points were 3 months (262, 23%), 6 months (212, 19%), and 12 months (206, 18%) post-discharge. Experts most commonly selected the period between 6 and 12 months as the optimal time point for assessment. While single assessments were most common in previous studies (337, 51%), experts considered three assessments to be ideal (12, 44%).

Conclusions: This study revealed notable discrepancies between the assessment timing reported in previous studies and the opinions of experts regarding optimal timing. Standardization of assessment timing in PICS research is warranted to enhance methodological consistency and comparability.

Background: This study investigated the application of software-based data monitoring for quality control (QC) in continuous renal replacement therapy (CRRT) management.

Methods: This single-center pre-post intervention study, conducted in three ICUs of a tertiary hospital in Shanghai, compared outcomes before (Jan-Dec 2023) and after (Jan-Dec 2024) implementing the Sharesource Connect system. Data from 9 Prismaflex CRRT machines were collected retrospectively during 2023 and prospectively on a monthly basis during 2024. Alongside the software, a comprehensive quality improvement program: (1) multidisciplinary team collaboration; (2) data-driven QC; and (3) structured training. Primary outcomes-filter lifespan, downtime percentage, delivered/prescribed dose ratio, ultrafiltration volume, and vascular access alarms-were compared.

Results: A total of 798 filters from 514 patients (2023) and 717 filters from 492 patients (2024) were analyzed. Key quality metrics improved significantly following implementation (2024 vs. 2023): Filter lifespan increased significantly from 20.08 ± 4.12 h to 24.08 ± 4.27 h (P = 0.043), Kaplan-Meier analysis demonstrated improved filter survival (Log-Rank p < 0.001). Cumulative survival increased from 2023 to 2024 at key time points: 12 h (69.1%-87.2%, + 18.1%), 24 h (30.9%-34.6%, + 3.7%), and 36 h (5.6%-13.6%, + 8.0%), with consistent improvements observed. Downtime percentage decreased from 39 to 28% (P = 0.015), reducing non-effective treatment time by 11 percentage points. The delivered/prescribed dose ratio increased from 82 to 86% (P = 0.046). The mean delivered dose was 35.67 ± 4.01 mL/kg/h (prescribed: 41.33 ± 4.5 mL/kg/h). Ultrafiltration volume remained stable (3.13 ± 0.37 vs. 3.52 ± 0.44 L/treatment day, P = 0.058). There was no significant difference in vascular access alarms (3.39 ± 1.44 vs. 2.93 ± 0.73 events/day, P = 0.392).

Conclusion: The Sharesource Connect system could be used for the monitoring, collection, and analysis of CRRT data to assist in the QC management related to CRRT, so as to provide a software basis for further multi-center studies or random control trials on the intelligent management of critical patients undergoing CRRT.