Journal of Intensive Care Medicine最新文献

Background: Blood 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.

Methods: Articles 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.

Findings: Lactate'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.

Interpretation: Measuring 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.

Background: Distinguishing surgical intensive care unit (ICU) patients with ongoing bleeding who require hemorrhage control interventions (HCI) can be challenging. Guidelines recommend risk-stratification with clinical variables and prediction tools, however supporting evidence remains mixed.

Methods: This retrospective study evaluated adult patients admitted to the surgical ICU with concern for ongoing hemorrhage under our institution's "Hemorrhage Watch" (HW) protocol and aimed to derive a clinical prediction model identifying those needing HCI with serial vital signs (VS) and serum biomarkers. The HW protocol included ICU admission followed by a 3-h observation period with VS monitoring every 15 min and hourly biomarkers. The primary outcome was the need for HCI (operative and endovascular interventions) within nine hours of ICU arrival. Secondary outcomes included in-hospital mortality, blood transfusions, and ICU and hospital length-of-stay. A clinical prediction model was developed by utilizing the variables most associated with HCI in a best subsets regression, which was subsequently internally validated using a Bootstrap algorithm.

Results: 305 patients were identified for inclusion and 18 (5.9%) required HCI (3 operative, 15 endovascular). The median age was 70 years (IQR 54, 83), 60% had traumatic injuries, and 73% were enrolled from the emergency department. Blood product transfusion and mortality were similar between the HCI and no-HCI groups. Our analysis demonstrated that a model based on the minimum hemoglobin (9.9 vs 8.1 g/dL), minimum diastolic (57 vs 53 mm Hg) and systolic blood pressures (105 vs 90 mm Hg), and minimum respiratory rate (15 vs 18) could predict HCI with an area under the Receiver Operating Characteristics curve (AUROC) of 0.87, outperforming the Shock Index (SI) (AUROC = 0.64).

Conclusions: In this study of surgical ICU patients with concern for ongoing bleeding, a prediction model using serial VS and biomarkers outperformed the SI and may help identify those requiring HCI.

Purpose: The onset of diaphragmatic weakness begins within hours of commencing invasive mechanical ventilation (IMV), which may contribute to the physical disability that can persist at five years after intensive care unit (ICU) discharge. Inspiratory muscle training (IMT) has the potential to alleviate the negative effects of IMV.

Methods: We conducted a systematic review and meta-analysis with an approach consistent with Cochrane methods. We registered our review a priori (PROSPERO: CRD 42023451809) and published our protocol. Randomized controlled trials (RCTs) which enrolled adults (≥18 years) admitted to ICU who required IMV for ≥24 h were eligible if they delivered an IMT intervention using an external device that provided airway resistance (eg, threshold device, tapered flow resistive device) compared to usual care. Our primary outcome was physical function. Secondary outcomes included respiratory muscle strength, mortality, length of stay, IMV weaning time, reintubation rate, dyspnea and endurance. We searched Medline, Embase, Emcare, AMED, CINAHL, CENTRAL and clinicaltrials.gov from inception and used the Covidence platform for study selection and data extraction. We reported results as standardized mean difference (SMD) if outcome measures were similar. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to assess the certainty of evidence.

Results: We screened 12 945 studies and 18 met the inclusion criteria. Three studies reported the effects of IMT on physical function. IMT may have no effect on physical function (SMD = -0.05, 95% confidence interval: -0.46 to 0.36) however results are very uncertain.

Conclusion: Our results suggest physical function is not impacted by IMT; however, our results are based on a limited number of studies with small samples sizes. High quality, appropriately powered RCTs are needed to improve the precision of the effect estimate.

Introduction: During extracorporeal membrane oxygenation (ECMO) systemic anticoagulation with unfractionated heparin (UFH) is standard-of-care. However, there is uncertainty regarding optimal anticoagulation monitoring strategies.

Methods: We retrospectively investigated venovenous and venoarterial ECMO patients at the medical ICUs at the Medical University of Graz, Austria. We analyzed the correlation and concordance of R-time in thromboelastography (TEG), activated partial thromboplastin time (aPTT), and anti-Xa activity. The proportion within target range, the association of coagulation parameters above or below target range (aPTT 54-72 s; equals 1.5-2× upper limit of normal (ULN), anti-Xa activity 0.2-0.5 U/mL, and R-time in assays without heparinase 675-900 s; equals 1.5-2× ULN) with mortality, bleeding events and thrombotic complications were investigated.

Results: We analyzed 671 clusters of simultaneously performed coagulation tests in 85 ECMO cases that fulfilled inclusion criteria. Median age of patients was 57 years and 32% were female. There were poor correlations between the three coagulation tests and the proportion of discordance was 46%. Within the target range were 21% of R-time, 15% of aPTT, and 44% of anti-Xa activity measurements. Singular and multiple bleeding events occurred in 25 and 32 patients, respectively. The most common bleeding locations were catheter and cannula insertion sites followed by pulmonary hemorrhage. In VA-ECMO, anti-Xa activity was associated (OR 1.03 [1.01-1.06], p = 0.005) and correlated with bleeding events (spearman rho 0.49, p = 0.002; point biserial 0.49, p = 0.001). aPTT level below target range was associated with reduced mortality (OR 0.98 [0.97-0.99], p = 0.024). Thrombotic events occurred in six patients with no association of coagulation tests.

Conclusion: There was a high rate of discordance and poor correlation between aPTT, anti-Xa activity and R-time in TEG in ECMO patients. We found high rates of bleeding events and in VA-ECMO an association with elevated anti-Xa activity levels.

Objectives: The objective of this study was to investigate the association between the prognostic nutritional index (PNI) and the short-term outcomes in patients with community-acquired bacterial pneumonia (CABP).

Design: This study employed a retrospective design, utilizing data from the Medical Information Mart for Intensive Care (MIMIC)-IV database.

Participants: 371 individuals from the MIMIC-IV database who were diagnosed with CABP.

Primary and secondary outcomes: The primary endpoint was 28-day all-cause mortality. The secondary endpoint was the length of stay (LOS) in the intensive care unit (ICU) and in hospital.

Results: The area under the curve of PNI for predicting 28-day all-cause mortality is 0.702 (95% CI 0.630 to 0.775; p < 0.001). Patients were divided into two groups based on their PNI at admission: the low PNI (<35.75) group and the high PNI group (≥35.75). CABP patients with higher PNI presented a lower 28-day all-cause mortality rate (adjusted HR: 0.53, 95% CI 0.28-0.98, p = 0.044). Moreover, a negative linear correlation was found between the PNI and short-term mortality rates via restricted cubic splines. Eventually, there was no difference in the LOS in the ICU or hospital between the two groups.

Conclusion: These findings suggest a negative correlation between the PNI at admission and the short-term mortality rate of CABP. PNI is helpful for early identification of high-risk patients.

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.

Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.

Purpose: The respiratory rate-oxygenation (ROX) index is used to predict high-flow nasal cannula (HFNC) success in acute respiratory failure, including in Coronavirus disease 2019 (COVID-19) patients. However, no study has described its performance to predict failure of alternating sessions of noninvasive ventilation (NIV) and HFNC in severe COVID-19 patients.

Material and methods: We conducted a monocentric retrospective cohort study. COVID-19 patients admitted in the intensive care unit (ICU) for acute respiratory failure were treated by alternating sessions of HFNC and NIV. The primary endpoint was the ability for ROX index at 2 hours (h) of NIV initiation to predict HFNC/NIV failure defined by orotracheal intubation (OTI) within 7 days after noninvasive support initiation.

Results: One hundred and five patients were included in analysis, of which 47% (n = 49) required OTI by day seven. ROX index values were significantly lower in intubated group at all time points but 24 h. In multivariate analysis, a ROX index at 2 h < 4.88 was associated with a higher risk of HFNC/NIV failure (Hazard Ratio 1.90 [95% Confidence Interval 1.03-3.51], p = 0.039). The area under the receiver operating characteristic curve for ROX index at 2 h was 0.702 [0.608-0.790]. Optimal cut-off value was 5.22. Sensitivity and specificity for predicting intubation with this threshold were 71.4% and 63.3%, respectively.

Conclusions: In our study, the ROX index had a good predictive power for alternating sessions of HFNC and NIV failure in patients with acute respiratory failure due to SARS-CoV-2.

Objectives: To determine whether a nurse practitioner and physician assistant (NP/PA)-led rapid staffing. Model in the cardiac surgical intensive care unit (ICU) can optimize resource utilization without compromising safety or increasing hospital length of stay (LoS).

Design: Retrospective observational cohort study comparing before-and-after implementation of an NP/PA-led rapid recovery pathway.

Setting: A large tertiary referral academic cardiac surgery ICU.

Participants: There were 116 patients in the prerapid recovery cohort and 153 in the postimplementation rapid recovery phase.

Interventions: Low-risk cardiac surgery patients were selected for postoperative care by an NP/PA-led ICU staffing model.

Measurements and main results: Mean hospital LoS in the prerapid recovery cohort was 5.7 days compared to 5.2 days in the rapid recovery pathway cohort (P = .02). Thirty-day hospital readmission in the prerapid recovery pathway cohort was 7.8% compared with 2.0% in the rapid recovery cohort (P = .04). The ICU readmission rate for prerapid recovery cohort was 4.3%, while the rapid recovery percentage was 2.0% (P = .30).

Conclusions: Overall, implementation of an NP/PA-led postcardiac surgical ICU team (rapid recovery pathway) was associated with similar ICU LoS, hospital LoS, ICU readmission rates, 30-day readmission rates, and no significant signal of increased adverse events or safety concerns.

Trial registration: Clinicaltrials.gov NCT02270281. Registered October 16, 2014.