Journal of Intensive Care Medicine最新文献

Multisystem Inflammatory Syndrome in Children: A Comprehensive Review over the Past Five Years This review explores many facets of Multisystem Inflammatory Syndrome in Children (MIS-C) over the previous 5 years. In the time since the COVID 19 pandemic gripped our medical systems, we can now explore the data that has been collected from the previous years. The literature has allowed us to better understand the impact of COVID 19 and the post illness occurrence of a severe systemic inflammatory disease on our youngest patient populations. This paper will outline the pathophysiology of MIS-C, the treatments utilized, short and long-term patient outcomes including epidemiological factors.

The use of focused critical care echocardiography, diagnostic modality aimed to provide immediate and actionable information, represents a core competency of contemporary intensive care medicine. Resuscitative transesophageal echocardiography (TEE) is a focused, goal-directed examination performed at the point of care, for the rapid evaluation of critically ill patients in whom transthoracic images are either logistically untenable, inadequate, or unobtainable. Some of the applications of TEE in the management of critically ill patients include the evaluation of patients in shock and cardiac arrest, the assessment of trauma patients, and the guidance of several endovascular procedures. Due to the indwelling nature of the transducer, TEE can provide consistently high-quality images and allows for continuous monitoring during hemodynamic interventions, making it ideally suited for the evaluation of critically ill patients. In this article, we review the evolving landscape of resuscitative TEE, discuss the rationale, supporting evidence, safety, and training for the use of this modality in critical care settings. We address the transdisciplinary evolution of TEE and the practical aspects of its implementation in emergency and critical care settings.

BackgroundPersistent vasopressor requirements are a common reason for delayed liberation from the intensive care unit (ICU) and adjunct oral agents are sometimes used to hasten time to vasopressor discontinuation. We sought to describe the use of droxidopa for vasopressor weaning in critically ill patients with prolonged hypotension.Materials and MethodsThis retrospective, single-arm, observational study included adult patients admitted to an ICU at two academic centers between 06/2016-07/2023 who received droxidopa for vasopressor weaning. Patients who received droxidopa prior to admission or for another indication were excluded. The primary outcome was time to vasopressor discontinuation, defined as when vasopressors were stopped and remained off for at least 24 h. Secondary outcomes included rates of tachycardia and hypotension post-initiation, norepinephrine equivalents pre- and post-initiation, concomitant oral agent use, and dosing. A subgroup analysis was conducted in patients receiving droxidopa via feeding tubes.ResultsA total of 30 patients met inclusion criteria. Median age was 62 years old, 12 (40%) were female, and 73% were in a cardiac/cardiac surgical ICU. Patients were on vasopressors for a median of 16 days prior to droxidopa initiation. Median (IQR) time to vasopressor discontinuation was 70 h (23-192) and norepinephrine equivalents decreased immediately after initiation (0.08 vs 0.02 mcg/kg/min, p < 0.001). MAP increased after droxidopa initiation (68.8 vs 66.5 mm Hg, p = 0.008) while heart rates were unchanged (86 vs 84 BPM, p = 0.37) after initiation. Patients who weaned from vasopressors within 72 h versus longer than 72 h after droxidopa initiation were more likely to be on lower norepinephrine equivalents prior to initiation (0.05 vs 0.12 mcg/kg/min, p = 0.013). Feeding tube administration did not impact time to vasopressor discontinuation (p = 0.93).ConclusionsDroxidopa may be considered an adjunct therapy for vasopressor weaning. Effects were similar when analyzing patients receiving droxidopa via feeding tube.

BackgroundTo develop and validate a mortality prediction model for patients with sepsis-associated Acute Respiratory Distress Syndrome (ARDS).MethodsThis retrospective cohort study included 2466 patients diagnosed with sepsis and ARDS within 24 h of ICU admission. Demographic, clinical, and laboratory parameters were extracted from Medical Information Mart for Intensive Care III (MIMIC-III) database. Feature selection was performed using the Boruta algorithm, followed by the construction of seven ML models: logistic regression, Naive Bayes, k-nearest neighbor, support vector machine, decision tree, Random Forest, and extreme gradient boosting. Model performance was evaluated using the area under the receiver operating characteristic curve, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value.ResultsThe study identified 24 variables significantly associated with mortality. The optimal ML model, a Random Forest model, demonstrated an AUC of 0.8015 in the test set, with high accuracy and specificity. The model highlighted the importance of blood urea nitrogen, age, urine output, Simplified Acute Physiology Score II, and albumin levels in predicting mortality.ConclusionsThe model's superior predictive performance underscores the potential for integrating advanced analytics into clinical decision-making processes, potentially improving patient outcomes and resource allocation in critical care settings.

Background: Sepsis-associated liver injury (SALI) occurs in about a third of septic patients, and it is often a poor prognostic factor. However, there are few studies on early SALI and its impact on the clinical course of sepsis. Here we explored the clinical characteristics, risk factors, and prognosis of early SALI. Methods: Two hundred and one patients with confirmed sepsis were divided into those with and without early SALI (on admission) based on liver function. The clinical characteristics and prognosis were compared between groups and associated factors identified by multivariable regression analysis. Results: Sepsis-related liver injury was present in 18.9% of septic patients on admission. High aspartate transaminase (AST), high direct bilirubin, and low plasma thromboplastin antecedent (PTA, factor XI) were risk factors for sepsis with SALI: the area under the AST curve was 0.825, corresponding to a sensitivity of 0.67 and a specificity of 0.93 (cutoff 91.6 U/L), the area under the direct bilirubin curve was 0.86, corresponding to a sensitivity of 0.83 and a specificity of 0.71 (cutoff 8.35 μmol/L), and the area under the PTA curve was 0.678, corresponding to a sensitivity of 0.47 and a specificity of 0.93 (cutoff 54.0). Conclusion: Septic patients with early SALI have early-onset coagulation disorders that must be recognized to instigate early intervention and halt sepsis progression. Elevated AST, PTA, and direct bilirubin may be independent risk markers of sepsis-related liver injury, and extra clinical vigilance is required when these factors are noted in patients with sepsis.

IntroductionThe cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score does not correspond with contemporary clinical practice in sepsis or identify impaired cardiac function. Our aim was to develop a modified cardiovascular SOFA component that reflects cardiac dysfunction and improves the SOFA score's 30-day mortality discrimination.MethodsA cohort of sepsis patients from a previous study was divided into a training (n = 250) and test cohort (n = 253). Nine widely available measures of cardiovascular function were screened for association with 30-day mortality using natural cubic spline. High-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP) and heart rate (HR) were transformed into ordinal variables (0-4 points). The presence of atrial fibrillation (AF) was assigned two points. The SOFA score was extended by adding the variable points in different weights and combinations. The best-performing cardiac-extended model (CE-SOFA) was evaluated in the test cohort. Improved prognostic discrimination and calibration were assessed using logistic regression, area under receiver operating characteristic curves (AUC), Net Reclassification Improvement (NRI) index, and DeLong and Hoshmer-Lemeshow tests.ResultsIn the training cohort, all differently weighted and combined models using hs-cTnT, NT-proBNP and AF points added to the SOFA score showed improved discriminative ability (AUC 0.67-0.75) compared to the SOFA score (AUC 0.62; NRI P < .001; DeLong P ≤ .001). In the test cohort, CE-SOFA demonstrated improved 30-day mortality discrimination compared to the SOFA score (AUC 0.72 vs 0.68), exhibiting good calibration and significantly improved discrimination using the NRI index (P = .009) but not the DeLong test (P = .142).ConclusionsThe CE-SOFA model reflects cardiac dysfunction and improves 30-day mortality discrimination in sepsis. External validation is the next step to further substantiate a revised cardiovascular component in a future SOFA 2.0.

Injury is both a national and international epidemic that affects people of all age, race, religion, and socioeconomic class. Injury was the fourth leading cause of death in the United States (U.S.) in 2021 and results in an incalculable emotional and financial burden on our society. Despite this, when prevention fails, trauma centers allow communities to prepare to care for the traumatically injured patient. Using lessons learned from the military, trauma care has grown more sophisticated in the last 50 years. In 1966, the first civilian trauma center was established, bringing management of injury into the new age. Now, the American College of Surgeons recognizes 4 levels of trauma centers (I-IV), with select states recognizing Level V trauma centers. The introduction of trauma centers in the U.S. has been proven to reduce morbidity and mortality for the injured patient. However, despite the proven benefits of trauma centers, the U.S. lacks a single, unified, trauma system and instead operates within a "system of systems" creating vast disparities in the level of care that can be received, especially in rural and economically disadvantaged areas. In this review we present the history of trauma system development in the U.S, define the different levels of trauma centers, present evidence that trauma systems and trauma centers improve outcomes, outline the current state of trauma system development in the U.S, and briefly mention some of the current challenges and opportunities in trauma system development in the U.S. today.

ObjectiveObservational studies suggest links between inflammatory factors, metabolites, and sepsis, yet their causality is uncertain. This study employs Mendelian Randomization (MR) to investigate the causality between these factors and sepsis, aiming to uncover the precise relationship and identify novel treatment approaches.MethodsWe used summary data from genome-wide association studies (GWAS) involving 91 inflammatory factors, 1400 metabolites as exposure, and STREPTO SEPSIS as outcome. Inverse variance weighting (IVW) and MR-Egger were used to evaluate the causal effect between exposure and outcome. Sensitivity analyses were performed using Cochrane's Q test, MR-Egger intercept method, MR-PRESSO method and leave-one-out method.ResultsThymic stromal lymphopoietin levels (TSLP) (OR = 1.269; 95%CI = 1.016-1.585; P = .036) and Interleukin 15 receptor subunit alpha levels (IL-15Rα) (OR = 0.894; 95%CI = 0.801-0.998; P = .046) had a significant causal relationship with sepsis. Forty-four metabolites were associated with sepsis, including Spermidine to choline ratio (OR = 1.447; 95%CI = 1.104-1.977; P = .009), 4-hydroxyhippurate levels (OR = 1.448; 95%CI = 1.117-1.877; P = .005), and Sphingomyelin (d18:1/20:1, d18:2/20:0) levels (OR = 1.371; 95%CI = 1.139-1.651; P < .001). TSLP was associated with 19 metabolites, and IL-15Rα was associated with 30 metabolites.ConclusionsThis study uncovers the causal link between sepsis and two inflammatory factors, TSLP and IL-15Rα, and suggests metabolites' potential in intervention. It also identifies 44 metabolites associated with sepsis, indicating possible biomarkers or therapeutic targets. The findings offer new perspectives on sepsis pathogenesis and could inform future treatment strategies.

PurposeMyoclonus after anoxic brain injury is a marker of significant cerebral injury. Absent cortical signal (N20) on somatosensory evoked potentials (SSEPs) after cardiac arrest is a reliable predictor of poor neurological recovery when combined with an overall clinical picture consistent with severe widespread neurological injury. We evaluated a clinical question of if SSEP result could be predicted from other clinical and neurodiagnostic testing results in patients with post-anoxic myoclonus.MethodsRetrospective chart review of all adult patients with post-cardiac arrest myoclonus who underwent both electroencephalographic (EEG) monitoring and SSEPs for neuroprognostication. Myoclonus was categorized as "non-myoclonic movements," "myoclonus not captured on EEG," "myoclonus without EEG correlate," "myoclonus with EEG correlate," and "status myoclonus." SSEP results were categorized as all absent, all present, N18 and N20 absent bilaterally, and N20 only absent bilaterally. Cox proportional hazards with censoring was used to evaluate the association of myoclonus category, SSEP results, and confounding factors with survival.ResultsIn 56 patients, median time from arrest to either confirmed death or last follow up was 9 days. The category of myoclonus was not associated with SSEP result or length of survival. Absence of N20 s or N18 s was associated with shorter survival (N20 hazard ratio [HR] 4.4, p = 0.0014; N18 HR 5.5, p < 0.00001).ConclusionsCategory of myoclonus did not reliably predict SSEP result. SSEP result was correlated with outcome consistently, but goals of care transitioned to comfort measures only in all patients with present peripheral potentials and either absent N20 s only or absence of N18 s and N20 s. Our results suggest that SSEPs may retain prognostic value in patients with post-anoxic myoclonus.

Background: Hyperbaric Oxygen Therapy (HBOT) is a medical treatment that involves administering 100% oxygen at increased atmospheric pressure to enhance oxygen delivery to tissues. Initially developed for decompression sickness, HBOT has since been utilized for a wide range of medical conditions, including severe infections, non-healing wounds, and, more recently, COVID-19. Objective: This review explores the historical development of HBOT, its principles, its emerging role in the management of and its outcome as treatment in COVID-19, particularly in mitigating inflammation, hypoxemia, and oxidative stress. Methods: A comprehensive review of the literature was conducted, analyzing case reports and case series that examined the effectiveness of HBOT in various clinical scenarios, with a focus on COVID-19. Results: HBOT has been shown to enhance tissue oxygenation, reduce inflammation, and modulate oxidative stress, thereby improving clinical outcomes in patients with severe COVID-19. The therapy's ability to increase dissolved oxygen levels in blood and tissues, independent of hemoglobin, makes it particularly beneficial in conditions like COVID-19, where hypoxemia and inflammation are prominent. Conclusion: HBOT offers a promising adjunctive treatment for severe COVID-19, with the potential to reduce mortality and improve recovery by targeting key pathophysiological processes such as hypoxemia, inflammation, and oxidative stress. Further research is warranted to optimize treatment protocols and confirm long-term benefits.