Background: Coronavirus disease 2019 (COVID-19) has exposed critical care supply shortages worldwide. This study aimed to investigate the association between regional critical care capacity and the incidence of invasive mechanical ventilation following novel COVID-19 during the pandemic in Japan, a country with a limited intensive care unit (ICU) bed capacity of a median of 5.1 ICU beds per 100,000 individuals.
Methods: This population-based cohort study used data from the CRoss Icu Searchable Information System database and publicly available databases provided by the Japanese government and Japanese Society of Intensive Care Medicine. We identified patients recently diagnosed with COVID-19, those who received invasive mechanical ventilation, and those who received extracorporeal membrane oxygenation (ECMO) between February 2020 and March 2023. We analyzed the association between regional critical care capacity (ICU beds, high-dependency care unit (HDU) beds, resource-rich ICU beds, and intensivists) and the incidence of invasive mechanical ventilation, ECMO, and risk-adjusted mortality across 47 Japanese prefectures.
Results: Among the approximately 127 million individuals residing in Japan, 33,189,809 were recently diagnosed with COVID-19, with 12,203 and 1,426 COVID-19 patients on invasive mechanical ventilation and ECMO, respectively, during the study period. Prefecture-level linear regression analysis revealed that the addition of ICU beds, resource-rich ICU beds, and intensivists per 100,000 individuals increased the incidence of IMV by 5.37 (95% confidence interval, 1.99-8.76), 7.27 (1.61-12.9), and 13.12 (3.48-22.76), respectively. However, the number of HDU beds per 100,000 individuals was not statistically significantly associated with the incidence of invasive mechanical ventilation. None of the four indicators of regional critical care capacity was statistically significantly associated with the incidence of ECMO and risk-adjusted mortality.
Conclusions: The results of prefecture-level analyses demonstrate that increased numbers of ICU beds, resource-rich ICU beds, and intensivists are associated with the incidence of invasive mechanical ventilation among patients recently diagnosed with COVID-19 during the pandemic. These findings have important implications for healthcare policymakers, aiding in efficiently allocating critical care resources during crises, particularly in regions with limited ICU bed capacities. Registry and the registration no. of the study/trial The approval date of the registry was August 20, 2020, and the registration no. of the study was lUMIN000041450.
{"title":"Association between regional critical care capacity and the incidence of invasive mechanical ventilation for coronavirus disease 2019: a population-based cohort study.","authors":"Hiroyuki Ohbe, Satoru Hashimoto, Takayuki Ogura, Mitsuaki Nishikimi, Daisuke Kudo, Nobuaki Shime, Shigeki Kushimoto","doi":"10.1186/s40560-024-00718-2","DOIUrl":"10.1186/s40560-024-00718-2","url":null,"abstract":"<p><strong>Background: </strong>Coronavirus disease 2019 (COVID-19) has exposed critical care supply shortages worldwide. This study aimed to investigate the association between regional critical care capacity and the incidence of invasive mechanical ventilation following novel COVID-19 during the pandemic in Japan, a country with a limited intensive care unit (ICU) bed capacity of a median of 5.1 ICU beds per 100,000 individuals.</p><p><strong>Methods: </strong>This population-based cohort study used data from the CRoss Icu Searchable Information System database and publicly available databases provided by the Japanese government and Japanese Society of Intensive Care Medicine. We identified patients recently diagnosed with COVID-19, those who received invasive mechanical ventilation, and those who received extracorporeal membrane oxygenation (ECMO) between February 2020 and March 2023. We analyzed the association between regional critical care capacity (ICU beds, high-dependency care unit (HDU) beds, resource-rich ICU beds, and intensivists) and the incidence of invasive mechanical ventilation, ECMO, and risk-adjusted mortality across 47 Japanese prefectures.</p><p><strong>Results: </strong>Among the approximately 127 million individuals residing in Japan, 33,189,809 were recently diagnosed with COVID-19, with 12,203 and 1,426 COVID-19 patients on invasive mechanical ventilation and ECMO, respectively, during the study period. Prefecture-level linear regression analysis revealed that the addition of ICU beds, resource-rich ICU beds, and intensivists per 100,000 individuals increased the incidence of IMV by 5.37 (95% confidence interval, 1.99-8.76), 7.27 (1.61-12.9), and 13.12 (3.48-22.76), respectively. However, the number of HDU beds per 100,000 individuals was not statistically significantly associated with the incidence of invasive mechanical ventilation. None of the four indicators of regional critical care capacity was statistically significantly associated with the incidence of ECMO and risk-adjusted mortality.</p><p><strong>Conclusions: </strong>The results of prefecture-level analyses demonstrate that increased numbers of ICU beds, resource-rich ICU beds, and intensivists are associated with the incidence of invasive mechanical ventilation among patients recently diagnosed with COVID-19 during the pandemic. These findings have important implications for healthcare policymakers, aiding in efficiently allocating critical care resources during crises, particularly in regions with limited ICU bed capacities. Registry and the registration no. of the study/trial The approval date of the registry was August 20, 2020, and the registration no. of the study was lUMIN000041450.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"6"},"PeriodicalIF":3.8,"publicationDate":"2024-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10826037/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139575796","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Chest computed tomography findings are helpful for understanding the pathophysiology of severe acute respiratory distress syndrome (ARDS). However, there is no large, multicenter, chest computed tomography registry for patients requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). The aim of this study was to describe chest computed tomography findings at V-V ECMO initiation and to evaluate the association between the findings and outcomes in severe ARDS.
Methods: This multicenter, retrospective cohort study enrolled patients with severe ARDS on V-V ECMO, who were admitted to the intensive care units of 24 hospitals in Japan between January 1, 2012, and December 31, 2022.
Results: The primary outcome was 90-day in-hospital mortality. The secondary outcomes were the successful liberation from V-V ECMO and the values of static lung compliance. Among the 697 registry patients, of the 582 patients who underwent chest computed tomography at V-V ECMO initiation, 394 survived and 188 died. Multivariate Cox regression showed that traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality (hazard ratio [95% confidence interval] 1.77 [1.19-2.63], p = 0.005 and 1.97 [1.02-3.79], p = 0.044, respectively). The presence of traction bronchiectasis was also associated with decreased successful liberation from V-V ECMO (odds ratio: 0.27 [0.14-0.52], p < 0.001). Lower static lung compliance was associated with some chest computed tomography findings related to changes outside of pulmonary opacity, but not with the findings related to pulmonary opacity.
Conclusions: Traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality in patients with severe ARDS who required V-V ECMO.
{"title":"Chest CT findings in severe acute respiratory distress syndrome requiring V-V ECMO: J-CARVE registry.","authors":"Mitsuaki Nishikimi, Shinichiro Ohshimo, Wataru Fukumoto, Jun Hamaguchi, Kazuki Matsumura, Kenji Fujizuka, Yoshihiro Hagiwara, Ryuichi Nakayama, Naofumi Bunya, Junichi Maruyama, Toshikazu Abe, Tatsuhiko Anzai, Yoshitaka Ogata, Hiromichi Naito, Yu Amemiya, Tokuji Ikeda, Masayuki Yagi, Yutaro Furukawa, Hayato Taniguchi, Tsukasa Yagi, Ken Katsuta, Daisuke Konno, Ginga Suzuki, Yuki Kawasaki, Noriyuki Hattori, Tomoyuki Nakamura, Natsuki Kondo, Hitoshi Kikuchi, Shinichi Kai, Saaya Ichiyama, Kazuo Awai, Kunihiko Takahashi, Nobuaki Shime","doi":"10.1186/s40560-023-00715-x","DOIUrl":"10.1186/s40560-023-00715-x","url":null,"abstract":"<p><strong>Background: </strong>Chest computed tomography findings are helpful for understanding the pathophysiology of severe acute respiratory distress syndrome (ARDS). However, there is no large, multicenter, chest computed tomography registry for patients requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). The aim of this study was to describe chest computed tomography findings at V-V ECMO initiation and to evaluate the association between the findings and outcomes in severe ARDS.</p><p><strong>Methods: </strong>This multicenter, retrospective cohort study enrolled patients with severe ARDS on V-V ECMO, who were admitted to the intensive care units of 24 hospitals in Japan between January 1, 2012, and December 31, 2022.</p><p><strong>Results: </strong>The primary outcome was 90-day in-hospital mortality. The secondary outcomes were the successful liberation from V-V ECMO and the values of static lung compliance. Among the 697 registry patients, of the 582 patients who underwent chest computed tomography at V-V ECMO initiation, 394 survived and 188 died. Multivariate Cox regression showed that traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality (hazard ratio [95% confidence interval] 1.77 [1.19-2.63], p = 0.005 and 1.97 [1.02-3.79], p = 0.044, respectively). The presence of traction bronchiectasis was also associated with decreased successful liberation from V-V ECMO (odds ratio: 0.27 [0.14-0.52], p < 0.001). Lower static lung compliance was associated with some chest computed tomography findings related to changes outside of pulmonary opacity, but not with the findings related to pulmonary opacity.</p><p><strong>Conclusions: </strong>Traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality in patients with severe ARDS who required V-V ECMO.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"5"},"PeriodicalIF":3.8,"publicationDate":"2024-01-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10811928/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139564301","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-23DOI: 10.1186/s40560-024-00717-3
Han-Yang Yue, Wei Peng, Jun Zeng, Yang Zhang, Yu Wang, Hua Jiang
Background: Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).
Methods: Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.
Results: Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%).
Conclusions: Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.
{"title":"Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis.","authors":"Han-Yang Yue, Wei Peng, Jun Zeng, Yang Zhang, Yu Wang, Hua Jiang","doi":"10.1186/s40560-024-00717-3","DOIUrl":"10.1186/s40560-024-00717-3","url":null,"abstract":"<p><strong>Background: </strong>Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).</p><p><strong>Methods: </strong>Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.</p><p><strong>Results: </strong>Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I<sup>2</sup> = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I<sup>2</sup> = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I<sup>2</sup> = 0%).</p><p><strong>Conclusions: </strong>Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"4"},"PeriodicalIF":3.8,"publicationDate":"2024-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10804832/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139521103","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-16DOI: 10.1186/s40560-023-00714-y
Stefan Yu Bögli, Federica Stretti, Didar Utebay, Ladina Hitz, Caroline Hertler, Giovanna Brandi
Background: The limitation of life sustaining treatments (LLST) causes ethical dilemmas even in patients faced with poor prognosis, which applies to many patients admitted to a Neurocritical Care Unit (NCCU). The effects of social and cultural aspects on LLST in an NCCU population remain poorly studied.
Methods: All NCCU patients between 01.2018 and 08.2021 were included. Medical records were reviewed for: demographics, diagnosis, severity of disease, and outcome. Advance directives (AD) and LLST discussions were reviewed evaluating timing, degree, and reason for LLST. Social/cultural factors (nationality, language spoken, religion, marital status, relationship to/sex of legal representative) were noted. Associations between these factors and the patients' sex, LLST timing, and presence of AD were evaluated.
Results: Out of 2975 patients, 12% of men and 10.5% of women underwent LLST (p = 0.30). Women, compared to men, more commonly received withdrawal instead of withholding of life sustaining treatments (57.5 vs. 45.1%, p = 0.028) despite comparable disease severity. Women receiving LLST were older (73 ± 11.7 vs. 69 ± 14.9 years, p = 0.005) and often without a partner (43.8 vs. 25.8%, p = 0.001) compared to men. AD were associated with female sex and early LLST, but not with an increased in-hospital mortality (57.1 vs. 75.2% of patients with and without AD respectively).
Conclusions: In patients receiving LLST, the presence of an AD was associated with an increase of early LLST, but not with an increased in-hospital mortality. This supports the notion that the presence of an AD is primarily an expression of the patients' will but does not per se predestine the patient for an unfavorable outcome.
{"title":"Limitation of life sustaining measures in neurocritical care: sex, timing, and advance directive.","authors":"Stefan Yu Bögli, Federica Stretti, Didar Utebay, Ladina Hitz, Caroline Hertler, Giovanna Brandi","doi":"10.1186/s40560-023-00714-y","DOIUrl":"10.1186/s40560-023-00714-y","url":null,"abstract":"<p><strong>Background: </strong>The limitation of life sustaining treatments (LLST) causes ethical dilemmas even in patients faced with poor prognosis, which applies to many patients admitted to a Neurocritical Care Unit (NCCU). The effects of social and cultural aspects on LLST in an NCCU population remain poorly studied.</p><p><strong>Methods: </strong>All NCCU patients between 01.2018 and 08.2021 were included. Medical records were reviewed for: demographics, diagnosis, severity of disease, and outcome. Advance directives (AD) and LLST discussions were reviewed evaluating timing, degree, and reason for LLST. Social/cultural factors (nationality, language spoken, religion, marital status, relationship to/sex of legal representative) were noted. Associations between these factors and the patients' sex, LLST timing, and presence of AD were evaluated.</p><p><strong>Results: </strong>Out of 2975 patients, 12% of men and 10.5% of women underwent LLST (p = 0.30). Women, compared to men, more commonly received withdrawal instead of withholding of life sustaining treatments (57.5 vs. 45.1%, p = 0.028) despite comparable disease severity. Women receiving LLST were older (73 ± 11.7 vs. 69 ± 14.9 years, p = 0.005) and often without a partner (43.8 vs. 25.8%, p = 0.001) compared to men. AD were associated with female sex and early LLST, but not with an increased in-hospital mortality (57.1 vs. 75.2% of patients with and without AD respectively).</p><p><strong>Conclusions: </strong>In patients receiving LLST, the presence of an AD was associated with an increase of early LLST, but not with an increased in-hospital mortality. This supports the notion that the presence of an AD is primarily an expression of the patients' will but does not per se predestine the patient for an unfavorable outcome.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"3"},"PeriodicalIF":7.1,"publicationDate":"2024-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10790395/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139472328","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.
Main text: The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.
Conclusions: This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.
{"title":"Post-intensive care syndrome follow-up system after hospital discharge: a narrative review.","authors":"Nobuto Nakanishi, Keibun Liu, Junji Hatakeyama, Akira Kawauchi, Minoru Yoshida, Hidenori Sumita, Kyohei Miyamoto, Kensuke Nakamura","doi":"10.1186/s40560-023-00716-w","DOIUrl":"10.1186/s40560-023-00716-w","url":null,"abstract":"<p><strong>Background: </strong>Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.</p><p><strong>Main text: </strong>The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.</p><p><strong>Conclusions: </strong>This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"2"},"PeriodicalIF":7.1,"publicationDate":"2024-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10785368/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139432658","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data.
Methods: The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019.
Results: A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: "Assessment of the patient's psychological distress" and "Assessment of the patient's spiritual and cultural practices." However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members.
Conclusions: The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.
{"title":"Development of quality indicators for palliative care in intensive care units and pilot testing them via electronic medical record review.","authors":"Yuta Tanaka, Kento Masukawa, Hideaki Sakuramoto, Akane Kato, Yuichiro Ishigami, Junko Tatsuno, Kaori Ito, Yoshiyuki Kizawa, Mitsunori Miyashita","doi":"10.1186/s40560-023-00713-z","DOIUrl":"10.1186/s40560-023-00713-z","url":null,"abstract":"<p><strong>Background: </strong>Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data.</p><p><strong>Methods: </strong>The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019.</p><p><strong>Results: </strong>A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: \"Assessment of the patient's psychological distress\" and \"Assessment of the patient's spiritual and cultural practices.\" However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members.</p><p><strong>Conclusions: </strong>The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"1"},"PeriodicalIF":7.1,"publicationDate":"2024-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10775577/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139403187","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cardiogenic shock is a complex and diverse pathological condition characterized by reduced myocardial contractility. The goal of treatment of cardiogenic shock is to improve abnormal hemodynamics and maintain adequate tissue perfusion in organs. If hypotension and insufficient tissue perfusion persist despite initial therapy, temporary mechanical circulatory support (t-MCS) should be initiated. This decade sees the beginning of a new era of cardiogenic shock management using t-MCS through the accumulated experience with use of intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), as well as new revolutionary devices or systems such as transvalvular axial flow pump (Impella) and a combination of VA-ECMO and Impella (ECPELLA) based on the knowledge of circulatory physiology. In this transitional period, we outline the approach to the management of cardiogenic shock by t-MCS. The management strategy involves carefully selecting one or a combination of the t-MCS devices, taking into account the characteristics of each device and the specific pathological condition. This selection is guided by monitoring of hemodynamics, classification of shock stage, risk stratification, and coordinated management by the multidisciplinary shock team.
{"title":"Mechanical circulatory support in cardiogenic shock","authors":"Jun Nakata, Takeshi Yamamoto, Keita Saku, Yuki Ikeda, Takashi Unoki, Kuniya Asai","doi":"10.1186/s40560-023-00710-2","DOIUrl":"https://doi.org/10.1186/s40560-023-00710-2","url":null,"abstract":"Cardiogenic shock is a complex and diverse pathological condition characterized by reduced myocardial contractility. The goal of treatment of cardiogenic shock is to improve abnormal hemodynamics and maintain adequate tissue perfusion in organs. If hypotension and insufficient tissue perfusion persist despite initial therapy, temporary mechanical circulatory support (t-MCS) should be initiated. This decade sees the beginning of a new era of cardiogenic shock management using t-MCS through the accumulated experience with use of intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), as well as new revolutionary devices or systems such as transvalvular axial flow pump (Impella) and a combination of VA-ECMO and Impella (ECPELLA) based on the knowledge of circulatory physiology. In this transitional period, we outline the approach to the management of cardiogenic shock by t-MCS. The management strategy involves carefully selecting one or a combination of the t-MCS devices, taking into account the characteristics of each device and the specific pathological condition. This selection is guided by monitoring of hemodynamics, classification of shock stage, risk stratification, and coordinated management by the multidisciplinary shock team.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"1 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2023-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138742376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-18DOI: 10.1186/s40560-023-00712-0
Mark M. G. Mulder, Joep Schellens, Jan-Willem E. M. Sels, Frank van Rosmalen, Anne-Marije Hulshof, Femke de Vries, Ruud Segers, Casper Mihl, Walther N. K. A. van Mook, Aalt Bast, Henri M. H. Spronk, Yvonne M. C. Henskens, Iwan C. C. van der Horst, Hugo ten Cate, Leon J. Schurgers, Marjolein Drent, Bas C. T. van Bussel
Extra-hepatic vitamin K-status, measured by dephosphorylated uncarboxylated matrix Gla protein (dp-ucMGP), maintains vascular health, with high levels reflecting poor vitamin K status. The occurrence of extra-hepatic vitamin K deficiency throughout the disease of COVID-19 and possible associations with pulmonary embolism (PE), and mortality in intensive care unit (ICU) patients has not been studied. The aim of this study was to investigated the association between dp-ucMGP, at endotracheal intubation (ETI) and both ICU and six months mortality. Furthermore, we studied the associations between serially measured dp-ucMGP and both PE and mortality. We included 112 ICU patients with confirmed COVID-19. Over the course of 4 weeks after ETI, dp-ucMGP was measured serially. All patients underwent computed tomography pulmonary angiography (CTPA) to rule out PE. Results were adjusted for patient characteristics, disease severity scores, inflammation, renal function, history of coumarin use, and coronary artery calcification (CAC) scores. Per 100 pmol/L dp-ucMGP, at ETI, the odds ratio (OR) was 1.056 (95% CI: 0.977 to 1.141, p = 0.172) for ICU mortality and 1.059 (95% CI: 0.976 to 1.059, p = 0.170) for six months mortality. After adjustments for age, gender, and APACHE II score, the mean difference in plasma dp-ucMGP over time of ICU admission was 167 pmol/L (95% CI: 4 to 332, p = 0.047). After additional adjustments for c-reactive protein, creatinine, and history of coumarin use, the difference was 199 pmol/L (95% CI: 50 to 346, p = 0.010). After additional adjustment for CAC score the difference was 213 pmol/L (95% CI: 3 to 422, p = 0.051) higher in ICU non-survivors compared to the ICU survivors. The regression slope, indicating changes over time, did not differ. Moreover, dp-ucMGP was not associated with PE. ICU mortality in COVID-19 patients was associated with higher dp-ucMGP levels over 4 weeks, independent of age, gender, and APACHE II score, and not explained by inflammation, renal function, history of coumarin use, and CAC score. No association with PE was observed. At ETI, higher levels of dp-ucMGP were associated with higher OR for both ICU and six month mortality in crude and adjusted modes, although not statistically significantly.
通过去磷酸化非羧化基质 Gla 蛋白（dp-ucMGP）测定的肝外维生素 K 状态可维持血管健康，高水平反映了维生素 K 状态不佳。关于在 COVID-19 的整个病程中出现肝外维生素 K 缺乏以及与肺栓塞（PE）和重症监护病房（ICU）患者死亡率之间可能存在的关联，尚未进行研究。本研究旨在调查气管插管（ETI）时 dp-ucMGP 与重症监护室和六个月死亡率之间的关系。此外，我们还研究了连续测量的 dp-ucMGP 与 PE 和死亡率之间的关系。我们纳入了 112 名确诊为 COVID-19 的 ICU 患者。在 ETI 后的 4 周内，对 dp-ucMGP 进行了连续测量。所有患者均接受了计算机断层扫描肺血管造影术（CTPA）以排除 PE。结果根据患者特征、疾病严重程度评分、炎症、肾功能、香豆素使用史和冠状动脉钙化（CAC）评分进行了调整。在 ETI 时，每 100 pmol/L dp-ucMGP 与 ICU 死亡率的比值比 (OR) 为 1.056（95% CI：0.977 至 1.141，P = 0.172），与 6 个月死亡率的比值比 (OR) 为 1.059（95% CI：0.976 至 1.059，P = 0.170）。对年龄、性别和 APACHE II 评分进行调整后，血浆 dp-ucMGP 与入住 ICU 时间的平均差异为 167 pmol/L（95% CI：4 至 332，p = 0.047）。在对 c 反应蛋白、肌酐和香豆素使用史进行额外调整后，差异为 199 pmol/L（95% CI：50 至 346，p = 0.010）。在对 CAC 评分进行额外调整后，ICU 非存活者与 ICU 存活者相比，差异为 213 pmol/L（95% CI：3 至 422，p = 0.051）。表示随时间变化的回归斜率没有差异。此外，dp-ucMGP 与 PE 无关。COVID-19患者的ICU死亡率与4周内较高的dp-ucMGP水平有关，与年龄、性别和APACHE II评分无关，炎症、肾功能、香豆素使用史和CAC评分也无法解释其原因。与 PE 无关。在 ETI 时，dp-ucMGP 水平越高，ICU 和 6 个月死亡率的粗略模式和调整模式的 OR 越高，但在统计学上并不显著。
{"title":"Higher levels of circulating desphospho-uncarboxylated matrix Gla protein over time are associated with worse survival: the prospective Maastricht Intensive Care COVID cohort","authors":"Mark M. G. Mulder, Joep Schellens, Jan-Willem E. M. Sels, Frank van Rosmalen, Anne-Marije Hulshof, Femke de Vries, Ruud Segers, Casper Mihl, Walther N. K. A. van Mook, Aalt Bast, Henri M. H. Spronk, Yvonne M. C. Henskens, Iwan C. C. van der Horst, Hugo ten Cate, Leon J. Schurgers, Marjolein Drent, Bas C. T. van Bussel","doi":"10.1186/s40560-023-00712-0","DOIUrl":"https://doi.org/10.1186/s40560-023-00712-0","url":null,"abstract":"Extra-hepatic vitamin K-status, measured by dephosphorylated uncarboxylated matrix Gla protein (dp-ucMGP), maintains vascular health, with high levels reflecting poor vitamin K status. The occurrence of extra-hepatic vitamin K deficiency throughout the disease of COVID-19 and possible associations with pulmonary embolism (PE), and mortality in intensive care unit (ICU) patients has not been studied. The aim of this study was to investigated the association between dp-ucMGP, at endotracheal intubation (ETI) and both ICU and six months mortality. Furthermore, we studied the associations between serially measured dp-ucMGP and both PE and mortality. We included 112 ICU patients with confirmed COVID-19. Over the course of 4 weeks after ETI, dp-ucMGP was measured serially. All patients underwent computed tomography pulmonary angiography (CTPA) to rule out PE. Results were adjusted for patient characteristics, disease severity scores, inflammation, renal function, history of coumarin use, and coronary artery calcification (CAC) scores. Per 100 pmol/L dp-ucMGP, at ETI, the odds ratio (OR) was 1.056 (95% CI: 0.977 to 1.141, p = 0.172) for ICU mortality and 1.059 (95% CI: 0.976 to 1.059, p = 0.170) for six months mortality. After adjustments for age, gender, and APACHE II score, the mean difference in plasma dp-ucMGP over time of ICU admission was 167 pmol/L (95% CI: 4 to 332, p = 0.047). After additional adjustments for c-reactive protein, creatinine, and history of coumarin use, the difference was 199 pmol/L (95% CI: 50 to 346, p = 0.010). After additional adjustment for CAC score the difference was 213 pmol/L (95% CI: 3 to 422, p = 0.051) higher in ICU non-survivors compared to the ICU survivors. The regression slope, indicating changes over time, did not differ. Moreover, dp-ucMGP was not associated with PE. ICU mortality in COVID-19 patients was associated with higher dp-ucMGP levels over 4 weeks, independent of age, gender, and APACHE II score, and not explained by inflammation, renal function, history of coumarin use, and CAC score. No association with PE was observed. At ETI, higher levels of dp-ucMGP were associated with higher OR for both ICU and six month mortality in crude and adjusted modes, although not statistically significantly.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"29 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2023-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138715635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-13DOI: 10.1186/s40560-023-00711-1
Tuğce Dinç Dogan, Vera Guttenthaler, Alexa Zimmermann, Andrea Kunsorg, Merve Özlem Dinç, Niko Knuelle, Jens-Christian Schewe, Maria Wittmann
Postoperative delirium is a common complication in patients after cardiac surgery, especially in older patients, and can manifest as a disturbance of attention and consciousness. It can lead to increased postoperative morbidity, prolonged need for care, and mortality. The presented study investigates whether the occurrence of postoperative delirium after cardiac surgery can be prevented by a multisensory stimulation. It was conducted as a prospective, randomized, controlled, non-pharmacological intervention study in the years 2021 and 2022 at the University Hospital Bonn in Germany. A total of 186 patients over 65 years with elective cardiac surgery were enrolled. Patients were randomized either to the intervention or control group. In both groups, postoperative delirium was assessed with the 3-min diagnostic interview for confusion assessment method on the first 5 days after surgery and pain was assessed using the Numeric Rating Scale. Multisensory stimulation was performed 20 min a day for the first three postoperative days in the intervention group. The incidence of postoperative delirium was 22.6% in the intervention group and 49.5% in the control group (p < 0.001). Duration of postoperative delirium was significantly shorter in the intervention group (p < 0.001). Stay in the intensive care unit was significantly longer in the control group (p = 0.006). In the regression model non-intervention, high pain scores, advanced age, and prolonged mechanical ventilation were associated with postoperative delirium (p = 0.007; p = 0.032; p = 0.006; p = 0.006, respectively). Results of the study imply that a multisensory stimulation done on the first 3 days after planned cardiac surgery can reduce the incidence and duration of postoperative delirium in older patients. Influence of the treatment on the incidence of delirium in other patient groups, the length of stay in the intensive care unit, and patients´ postoperative pain should be confirmed in further clinical studies. Trial registration: DRKS, DRKS00026909. Registered 28 October 2021, Retrospectively registered, https://drks.de/search/de/trial/DRKS00026909 .
{"title":"Functional intervention following cardiac surgery to prevent postoperative delirium in older patients (FEEL WELL study)","authors":"Tuğce Dinç Dogan, Vera Guttenthaler, Alexa Zimmermann, Andrea Kunsorg, Merve Özlem Dinç, Niko Knuelle, Jens-Christian Schewe, Maria Wittmann","doi":"10.1186/s40560-023-00711-1","DOIUrl":"https://doi.org/10.1186/s40560-023-00711-1","url":null,"abstract":"Postoperative delirium is a common complication in patients after cardiac surgery, especially in older patients, and can manifest as a disturbance of attention and consciousness. It can lead to increased postoperative morbidity, prolonged need for care, and mortality. The presented study investigates whether the occurrence of postoperative delirium after cardiac surgery can be prevented by a multisensory stimulation. It was conducted as a prospective, randomized, controlled, non-pharmacological intervention study in the years 2021 and 2022 at the University Hospital Bonn in Germany. A total of 186 patients over 65 years with elective cardiac surgery were enrolled. Patients were randomized either to the intervention or control group. In both groups, postoperative delirium was assessed with the 3-min diagnostic interview for confusion assessment method on the first 5 days after surgery and pain was assessed using the Numeric Rating Scale. Multisensory stimulation was performed 20 min a day for the first three postoperative days in the intervention group. The incidence of postoperative delirium was 22.6% in the intervention group and 49.5% in the control group (p < 0.001). Duration of postoperative delirium was significantly shorter in the intervention group (p < 0.001). Stay in the intensive care unit was significantly longer in the control group (p = 0.006). In the regression model non-intervention, high pain scores, advanced age, and prolonged mechanical ventilation were associated with postoperative delirium (p = 0.007; p = 0.032; p = 0.006; p = 0.006, respectively). Results of the study imply that a multisensory stimulation done on the first 3 days after planned cardiac surgery can reduce the incidence and duration of postoperative delirium in older patients. Influence of the treatment on the incidence of delirium in other patient groups, the length of stay in the intensive care unit, and patients´ postoperative pain should be confirmed in further clinical studies. Trial registration: DRKS, DRKS00026909. Registered 28 October 2021, Retrospectively registered, https://drks.de/search/de/trial/DRKS00026909 .","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"105 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2023-12-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138581806","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>Dear Editor,</p><p>Battles against a critical illness never end even after survivorship, or rather the beginning of long-term hardship patients and families face to restore previous lives. The functional disabilities after ICU stay, or post-intensive care syndrome (PICS), is a physically, cognitively, and mentally devastating state that significantly reduces patient quality of life […] [1]. As prevention, evidence-based and supportive ICU care, such as the ‘ABCDEF’ bundle and nutrition therapy, is strongly recommended in daily clinical practice for all ICU patients, regardless of disease. PICS may get worse depending on the severity. Therefore, patients requiring extracorporeal membrane oxygenation (ECMO) to sustain their lives are at high risk of PICS development [2]. The benefits of ECMO have been well described and its cases have considerably increased [3]. However, the implementation of evidence-based and supportive ICU care for ECMO patients has not been adequately exposed.</p><p>We conducted a secondary analysis of previously published point prevalence studies on 3 dates (June 3, July 1, 2020, and January 27, 2021) with the aim of investigating the implementation of the ‘ABCDEF’ bundle and nutrition therapy (defined in Additional file 2: Table S1) for ECMO patients with mechanical ventilation (MV) patients as reference. A total of 60 ECMO patients and 778 MV patients were enrolled in 110 ICUs across 35 countries (Additional file 1: Figure S1 and Additional file 3: Table S2). Implementation of an entire ABCDEF bundle was extremely low in both groups. Compared to MV patients, ECMO patients, with longer ICU days, younger, and more use of renal replacement and vasopressors (Additional file 4: Table S3) demonstrated the higher implementation of Element ‘A’: pain assessments (75%), ‘C’: sedation assessments (90%), and ‘D’: delirium assessments (73%), while only one of the ten in the ECMO group received Element ‘B’: Spontaneous Awakening Trials and ‘E’: Early mobility and exercise, and one of the four received Element ‘F’: Family engagement and empowerment. More than half of both groups received 1500 kcal/day or 20 kcal/kg/day or more of energy, whereas protein provision of 1.2 g/kg/day or more was achieved for only 40%.</p><p>Large potentials to improve ICU care during ECMO were implied, though studies only captured performances on three days in the COVID-19 pandemic under high pressure on ICUs. The importance of pain, sedation, and delirium during ECMO might be relatively acknowledged, reflecting the higher requirements of analgesia and sedation than MV. However, we found an obvious opposite trend against the current recommendations of establishing whole-bundle care. Although no consensus on the optimal timings was set, light sedation, or ‘awake ECMO’, and early mobilization, which showed significant physiological benefits, were also rarely performed despite the relatively long stay in the ICU [4]. Considering high risk of new psychiatric sym
亲爱的编辑，与危重病的斗争即使在幸存者之后也不会结束，或者说，患者和家属为恢复以前的生活而面临的长期艰辛才刚刚开始。入住重症监护室后出现的功能障碍，或称重症监护后综合征（PICS），是一种在身体、认知和精神上都极具破坏性的状态，大大降低了患者的生活质量[...][1]。作为预防措施，在日常临床实践中强烈建议对所有重症监护病房患者（无论疾病）实施循证和支持性重症监护病房护理，如 "ABCDEF "捆绑疗法和营养疗法。根据严重程度，PICS 可能会恶化。因此，需要使用体外膜肺氧合（ECMO）维持生命的患者是 PICS 的高危人群[2]。ECMO 的益处已被充分描述，其病例也大幅增加 [3]。我们在 3 个日期（2020 年 6 月 3 日、7 月 1 日和 2021 年 1 月 27 日）对之前发表的点流行率研究进行了二次分析，旨在调查 ECMO 患者与机械通气（MV）患者作为参照的 "ABCDEF "捆绑和营养疗法（定义见附加文件 2：表 S1）的实施情况。35 个国家的 110 个重症监护病房共招募了 60 名 ECMO 患者和 778 名 MV 患者（附加文件 1：图 S1 和附加文件 3：表 S2）。两组患者的整个 ABCDEF 套件实施率都非常低。与 MV 患者相比，ECMO 患者的 ICU 日数更长、年龄更小、使用肾脏替代品和血管加压药的次数更多（附加文件 4： 表 S3），他们对要素 "A"：疼痛评估（75%）、"C"：镇静评估（90%）和 "D"：谵妄评估（73%）的实施率更高，而 ECMO 组的 10 名患者中只有一人接受了要素 "B"：自发苏醒试验 "和 "E"：E"：早期活动和锻炼，四人中有一人接受了要素 "F"：家庭参与和赋权。两组中均有一半以上的患者获得了 1500 千卡/天或 20 千卡/千克/天或更多的能量，而只有 40% 的患者获得了 1.2 克/千克/天或更多的蛋白质。虽然研究仅记录了在 COVID-19 大流行期间 ICU 在高压下三天的表现，但这意味着在 ECMO 期间改善 ICU 护理的巨大潜力。ECMO 期间疼痛、镇静和谵妄的重要性可能相对得到承认，这反映出镇痛和镇静的要求高于 MV。然而，我们发现，与当前建立全套护理的建议明显相反。尽管没有就最佳时间达成共识，但轻度镇静或 "清醒的 ECMO "以及早期移动（显示出显著的生理益处）也很少实施，尽管在重症监护室的住院时间相对较长[4]。考虑到 ECMO 后出现新精神症状的风险很高，家属的参与至关重要 [5]。尽管营养治疗与捆绑治疗有协同作用，尤其是早期移动，但只有约一半的 ECMO 或以下患者获得了充足的蛋白质供应。这为所有重症监护室工作人员敲响了紧急警钟，以提高重症监护室对需要 ECMO 的患者（最严重和最脆弱的患者）的护理质量，从而实现未来成功的功能性结果（图 1）。该图显示了在调查日期入住 ICU 的未进行体外膜肺氧合或进行体外膜肺氧合的机械通气患者的 ABCDEF 套件和营养疗法的实施率。重症监护的长期并发症。Crit Care Med.2011;39:371-9.Article PubMed Google Scholar Chommeloux J, Valentin S, Winiszewski H, Adda M, Pinetonde Chambrun M, Moyon Q, et al. COVID-19 相关 ARDS ECMO 后幸存者一年身心健康评估。Am J Respir Crit Care Med.2023;207:150-9.Article PubMed Google Scholar Combes A, Peek GJ, Hajage D, Hardy P, Abrams D, Schmidt M, et al. ECMO 治疗严重 ARDS：系统综述和个体患者数据荟萃分析。重症监护医学》。2020; 46:2048-57.Article CAS PubMed PubMed Central Google Scholar Langer T, Santini A, Bottino N, Crotti S, Batchinsky AI, Pesenti A, et al. "Awake" extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering.Crit Care.2016;20:1-10.
{"title":"Light and dark sides of evidence-based and supportive ICU care for patients undergoing extracorporeal membrane oxygenation","authors":"Keibun Liu, Mohan Gurjar, Ricardo Kenji Nawa, Chi Ryang Chung, Kensuke Nakamura","doi":"10.1186/s40560-023-00704-0","DOIUrl":"https://doi.org/10.1186/s40560-023-00704-0","url":null,"abstract":"<p>Dear Editor,</p><p>Battles against a critical illness never end even after survivorship, or rather the beginning of long-term hardship patients and families face to restore previous lives. The functional disabilities after ICU stay, or post-intensive care syndrome (PICS), is a physically, cognitively, and mentally devastating state that significantly reduces patient quality of life […] [1]. As prevention, evidence-based and supportive ICU care, such as the ‘ABCDEF’ bundle and nutrition therapy, is strongly recommended in daily clinical practice for all ICU patients, regardless of disease. PICS may get worse depending on the severity. Therefore, patients requiring extracorporeal membrane oxygenation (ECMO) to sustain their lives are at high risk of PICS development [2]. The benefits of ECMO have been well described and its cases have considerably increased [3]. However, the implementation of evidence-based and supportive ICU care for ECMO patients has not been adequately exposed.</p><p>We conducted a secondary analysis of previously published point prevalence studies on 3 dates (June 3, July 1, 2020, and January 27, 2021) with the aim of investigating the implementation of the ‘ABCDEF’ bundle and nutrition therapy (defined in Additional file 2: Table S1) for ECMO patients with mechanical ventilation (MV) patients as reference. A total of 60 ECMO patients and 778 MV patients were enrolled in 110 ICUs across 35 countries (Additional file 1: Figure S1 and Additional file 3: Table S2). Implementation of an entire ABCDEF bundle was extremely low in both groups. Compared to MV patients, ECMO patients, with longer ICU days, younger, and more use of renal replacement and vasopressors (Additional file 4: Table S3) demonstrated the higher implementation of Element ‘A’: pain assessments (75%), ‘C’: sedation assessments (90%), and ‘D’: delirium assessments (73%), while only one of the ten in the ECMO group received Element ‘B’: Spontaneous Awakening Trials and ‘E’: Early mobility and exercise, and one of the four received Element ‘F’: Family engagement and empowerment. More than half of both groups received 1500 kcal/day or 20 kcal/kg/day or more of energy, whereas protein provision of 1.2 g/kg/day or more was achieved for only 40%.</p><p>Large potentials to improve ICU care during ECMO were implied, though studies only captured performances on three days in the COVID-19 pandemic under high pressure on ICUs. The importance of pain, sedation, and delirium during ECMO might be relatively acknowledged, reflecting the higher requirements of analgesia and sedation than MV. However, we found an obvious opposite trend against the current recommendations of establishing whole-bundle care. Although no consensus on the optimal timings was set, light sedation, or ‘awake ECMO’, and early mobilization, which showed significant physiological benefits, were also rarely performed despite the relatively long stay in the ICU [4]. Considering high risk of new psychiatric sym","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"81 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2023-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138546023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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