Journal of Intensive Care Medicine最新文献

BackgroundSepsis-associated acute kidney injury (SA-AKI) is a serious condition with a high mortality rate. Whole blood-derived inflammatory markers like the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI), are emerging prognostic indicators for various diseases. This study endeavors to unravel the link of these markers to all-cause mortality(ACM) in the SA-AKI population utilizing the MIMIC-IV database.MethodsA retrospective cohort study was conducted on SA-AKI patients meeting the Sepsis-3 and KDIGO criteria. Cox regression analysis was performed to evaluate the association between inflammatory markers and mortality. Restricted cubic spline (RCS) analysis was employed to unveil the potential nonlinear relation of inflammatory markers to mortality. Survival differences across varying levels of inflammation were compared via Kaplan-Meier (KM) survival curves. Subgroup analyses were executed to examine the robustness of the relation and possible interactions between variables. The predictive performance of inflammatory markers was evaluated via receiver operating characteristic (ROC) curves, and the clinical utility of these markers was assessed through clinical decision curve analysis(DCA).Results3429 SA-AKI patients were encompassed (2785 survivors at 30 days and 644 non-survivors). Cox regression analysis revealed a significant link between risen NLR, PLR, MLR, SII, and SIRI to elevated ACM. KM survival analysis demonstrated that patients with higher levels of inflammatory markers had notably higher 30-day death rates. Subgroup analysis indicated an interaction between coronary artery disease (CHD) and inflammation in influencing mortality risk. Among the markers assessed, NLR exhibited the highest forecasting accuracy for 30-day death (AUC = 0.624). Propensity score matching (PSM) confirmed the robustness of these findings.ConclusionWhole blood-derived inflammatory markers, particularly NLR, are closely linked to mortality in patients with SA-AKI. These markers may serve as valuable prognostic tools for identifying high-risk patients and improving clinical outcomes.

During critical illness, patients experience significant and rapid onsets of muscle wasting and dysfunction with loss of strength, mass, and power. These deficits often persist long after the ICU, leading to impairments in physical function including reduced exercise capacity and increased frailty and disability. While there are numerous studies describing the epidemiology of impaired muscle and physical function in the ICU, there are significantly fewer data investigating mechanisms of prolonged and persistent impairments in ICU survivors. Additionally, while several potential clinical risk factors associated with poor physical recovery have been identified, there remains a dearth of interventions that have effectively improved outcomes long-term among survivors. In this article, we aim to provide a thorough, evidence-based review of the current state of knowledge regarding muscle dysfunction and physical function after critical illness with a focus on post-ICU and post-hospitalization phase of recovery.

BackgroundBlood lactate is commonly used in clinical medicine as a diagnostic, therapeutic and prognostic guide. Lactate's growing importance in many disciplines of clinical medicine and academic enquiry is underscored by the tenfold increase in publications over the past 10 years. Lactate monitoring is presently shifting from single to serial measurements, offering a means of assessing response to therapy and to guide treatment decisions. With the promise of wearable lactate sensors and their potential integration in electronic patient records and early warning scores, the utility of serial lactate measurement deserves closer scrutiny.MethodsArticles included in this review were identified by searching MEDLINE, PubMed and EMBASE using the term "lactate" alone and in combination with "serial", "point of care", "clearance", "prognosis" and "clinical". Authors were assigned vetting of publications according to their specialty (anesthesiology, intensive care, trauma, emergency medicine, obstetrics, pediatrics and general hospital medicine). The manuscript was assembled in multidisciplinary groups guided by underlying pathology rather than hospital area.FindingsLactate's clinical utility as a dynamic parameter is increasingly recognized. Several publications in the last year highlight the value of serial measurements in guiding therapy. Outside acute clinical areas like the emergency room, operating room or intensive care, obtaining lactate levels is often fraught with difficulty and delays.InterpretationMeasuring serial lactate and lactate clearance offers regular feedback on response to therapy and patient status. Particularly on the ward, wearable devices integrated in early warning scores via the hospital IT system are likely to identify deteriorating patients earlier than having to rely on observations by an often-overstretched nursing workforce.

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States, with an incidence that has increased from 7.2 to 32.9 fatalities per 100,000 live births in the last 3 decades. This trend underscores the potential for an increase in the volume of admissions to cardiac intensive care units (CICUs) in the peripartum period. While congestive heart failure remains at the forefront of maternal morbidity, other life-threatening conditions include myocardial infarction (MI), hypertensive emergencies, fatal arrhythmias such as ventricular fibrillation, venous thromboembolism, aortopathies, valvular dysfunction, cardiac arrest, and cardiogenic shock. The lack of standardized guidelines to facilitate management of these conditions highlights the significant gap in medical knowledge while caring for acutely ill pregnant women. Through this comprehensive review, we highlight the most common cardiac pathologies encountered in the obstetric population and their diagnosis and contemporary management in the cardiac intensive care unit.

BackgroundCentral line placement is a very common inpatient procedure and the internal jugular (IJ) vein is the most commonly accessed site. Complications associated with this procedure include pneumothorax, hemothorax and pain which may be caused by accidental visceral injury with needle over-penetration.Research QuestionExtrapolating approximate needle length required to access sonographic mid-point of the internal jugular (IJ) vein.Study DesignRetrospective, non-randomized, non-blinded study.MethodRetrospective review of IJ vein images taken during central line placement to determine skin to mid-vein and skin to posterior wall depth in Trendelenburg position . Pooled data of IJ vein images taken with ultrasound probe perpendicular to skin during non-emergent/non-ICU central line placement from 12/01/2016 to 11/30/2019 (3years) was retrieved from a secure database. Images, biological sex and BMI were reviewed. Inclusion criteria: all IJ vein images. Exclusion criteria: Non- IJ vein images. Vein depth measurements were estimated using the depth marker grid accompanying the images.ResultsPrimary end point: average skin to mid-vein and skin to posterior wall depths. Secondary end point: compare the same dimensions based on biological sex and BMI. 608 images were analyzed. 375 were suitable (244 male [65%], 131 female [35%]). 233 poor quality images were discarded. Average skin to mid-vein depth for females was 1.47 cm (±0.37 SD, range 0.8-2.6 cm), for males 1.48 cm (±0.35 SD, range 0.8-2.7 cm) and for the total population 1.48 cm (±0.35 SD, range 0.8-2.7 cm). Average skin to posterior wall depth for females was 2.07 cm (±0.5 SD, range 1.2 cm-3.6 cm), for males 2.09 cm (±0.47 SD, range 1.3-3.3 cm) and for the total population 2.08 cm (+/0.48 SD, range 1.2-3.6 cm). Skin to IJ vein depths were normally distributed with similar standard deviations when compared for biological sex or total population. Adjusting for BMI, males were found to have a 0.2 cm increase in skin to mid-vein depth and a 0.12 cm increase in skin to posterior wall depth compared to females.ConclusionThe needle length required to reach the average sonographic midpoint of the IJ vein is approximately 1.48 cm with a range of 0.8 to 2.7 cm. As ultrasound does not intrinsically prevent needle over insertion, proceduralists, particularly less experienced operators, need to be mindful of needle depth to reduce complications from excessive needle tip penetration.

BackgroundNecrotizing lung infections (NLI) are rare yet severe complications of lower respiratory tract infections with high mortality. Due to their scarcity and varying severity, there are no specific guidelines on managing these entities. Incidence and outcomes of NLI in patients on VV-ECMO remains largely unknown.MethodsThis observational cohort study retrospectively analyzed data from a prospective ECMO registry at University Medical Centre Ljubljana. Consecutive adult VV-ECMO patients hospitalized between 2010 and 2023 were screened. Patients with NLI, defined as computed tomography (CT) documented necrotising pneumonia, lung abscess or necrotizing cavitation were identified and included in the analysis.ResultsOut of 125 VV-ECMO patients with severe respiratory failure due to lung infections, 38 (30.4%) had NLI. Majority of patients (71%) initially presented with viral pneumonia with secondary bacterial superinfection and most had multi-lobar involvement (73.7%). There was considerable overlap of all necrotizing entities. Duration of hospitalization prior to ECMO initiation was the only significant factor determining patient outcome (2 days in survivors vs 8 days in non-survivors, p = 0.04), while duration of mechanical ventilation prior to cannulation had no significant effect on patient outcome. Although not statistically significant, survival rates were considerably higher in patients who primarily presented with community-aquired pneumonia compared to those with hospital-aquired pneumonia (38% vs 14%). Patients with additional complications like empyema or bronchopulmonary fistula had poor outcomes, with only 5% survival. Surgical lobectomy was performed in 5 (13%) patients, all patients died. Nine (24%) patients survived to ICU and hospital discharge and were still alive at 1-year follow-up.ConclusionsIncidence of NLI in VV ECMO patients is higher than reported in non-ECMO population. Surgical interventions were not successful in this cohort. Considering the combination of severe respiratory failure and necrotising complications, overall survival rate of respiratory ECMO patients with NLI is still reasonable.

The unprimed right ventricle is exquisitely sensitive to acute elevations in afterload. High pulmonary vascular tone incurred with acute pulmonary embolism has the potential to induce obstructive shock and circulatory collapse. While emergent pulmonary reperfusion is essential in severe circumstances, an important subset of pulmonary embolism patients may exhibit a less extreme presentation posing a management dilemma. As intensive care therapies have the potential to both salvage and harm the failing right ventricle, a keen understanding of the pathophysiology is requisite in the care of the contemporary patient with hemodynamically significant pulmonary embolism. Here, we review right ventricular pathophysiology, an approach to risk stratification, and offer guidance on the medical and mechanical supportive and therapeutic strategies for the critically ill patient with acute pulmonary embolism.

Acute variceal bleeding (AVB) is a known complication of decompensated cirrhosis and carries with it a high mortality rate. Understanding the basic underlying pathophysiologic processes that lead to the development of varices and how to prevent progression of this disease is crucial for an intensivist. Once bleeding occurs, intensivists must be able to navigate a complex presentation of impending respiratory failure and hemorrhagic shock. A multidisciplinary approach to AVB including medical therapies combined with procedural interventions such as endoscopy, balloon tamponade, and emergency surgery must all be considered in severe cases. In this narrative review, we aim to provide an updated and comprehensive overview of the prevention and management of variceal bleeding in patients with cirrhosis.

BackgroundThe impact of methylene blue (MB) on critical patient outcomes, including overall mortality, hemodynamic stability, and organ function has been inconsistently described across studies. This study aims to evaluate the efficacy of MB therapy in adult patients with septic shock in the intensive care unit (ICU).MethodsThe systematic search of PubMed/MEDLINE, EMBASE and Cochrane Library databases up to February 2024 included randomized controlled trials and prospective observational studies involving adult septic shock patients who received intravenous MB therapy. The primary outcome was all-cause mortality, with secondary outcomes on hemodynamics and ICU length of stay.ResultsFifteen studies (5 randomized, 10 non-randomized) involving a total of 441 patients, met the inclusion criteria. The meta-analysis showed statistically significant reduction in mortality rates among septic shock patients treated with MB (mortality rate 0.52; 95% CI 0.38 to 0.66; P < .001). In a sub-analysis of only randomized trials, the results remained statistically significant (risk ratio 0.66; 95% CI 0.47 to 0.94; P = .023). A significant increase in mean arterial pressure post-infusion was observed in three studies. Two studies showed no substantial difference in heart rate and two studies showed no difference in cardiac index following MB administration. Only one study showed a reduction in the length of ICU stay with MB use, while another observed a decrease in overall hospital length of stay.ConclusionsThe review and meta-analysis suggest that MB may be associated with a significant reduction in mortality in septic shock patients though findings are limited by sample size and heterogeneity. Further robust studies are needed to validate these results.

We appreciate the insightful remarks by Sin et al regarding our systematic review and meta-analysis on extracorporeal membrane oxygenation (ECMO) cannulation by intensivists. Their comments highlight important considerations for contextualizing our findings. Our analysis confirmed that intensivist-performed cannulation is generally safe and feasible when supported by structured training, credentialing, and immediate surgical backup for complications such as vascular injury. Venovenous cannulation was associated with relatively low complication rates, whereas venoarterial cannulation carried higher risks, underscoring the need for additional caution. Importantly, extracorporeal cardiopulmonary resuscitation (ECPR) is characterized by substantially higher complication rates, likely driven by technical and environmental challenges rather than operator specialty. Equipment selection, including the use of smaller arterial cannulas in venoarterial ECMO, may further reduce vascular complications, though survival remains adversely affected when such complications occur. Beyond operator expertise, institutional infrastructure, standardized training, adherence to protocols, and availability of surgical support are pivotal to ensuring safe practice. We concur that future development of standardized guidelines addressing intensivist-led cannulation, including preparation for high-risk scenarios such as ECPR, will be essential to optimize outcomes.