Pub Date : 2024-10-01DOI: 10.1177/08850666241282294
S Lörstad, Y Wang, S Tehrani, S Shekarestan, P Åstrand, P Gille-Johnson, T Jernberg, J Persson
Introduction: The 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.
Methods: A 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.
Results: In 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).
Conclusions: The 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.
{"title":"Development of an Extended Cardiovascular SOFA Score Component Reflecting Cardiac Dysfunction with Improved Survival Prediction in Sepsis: An Exploratory Analysis in the Sepsis and Elevated Troponin (SET) Study.","authors":"S Lörstad, Y Wang, S Tehrani, S Shekarestan, P Åstrand, P Gille-Johnson, T Jernberg, J Persson","doi":"10.1177/08850666241282294","DOIUrl":"https://doi.org/10.1177/08850666241282294","url":null,"abstract":"<p><strong>Introduction: </strong>The 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.</p><p><strong>Methods: </strong>A 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.</p><p><strong>Results: </strong>In 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 <i>P </i>< .001; DeLong <i>P ≤ </i>.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 (<i>P </i>= .009) but not the DeLong test (<i>P </i>= .142).</p><p><strong>Conclusions: </strong>The 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.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142348370","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-30DOI: 10.1177/08850666241287442
Mekela M Whyte-Nesfield, Eduardo A Trujillo Rivera, Daniel Kaplan, Simon Li, Pamela S Hinds, Murray M Pollack
Objective: Develop an inpatient predictive model of parental post-traumatic stress (PTS) following their child's care in the Pediatric Intensive Care Unit (PICU). Design: Prospective observational cohort. Setting: Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICUs. Subjects: Parents of patients admitted to the PICU. Interventions: None. Measurements and Main Results: Preadmission and admission data from 169 parents of 129 children who completed follow up screening for parental post-traumatic stress symptoms at 3-9 months post PICU discharge were utilized to develop a predictive model estimating the risk of parental PTS 3-9 months after hospital discharge. The parent cohort was predominantly female (63%), partnered (75%), and working (70%). Child median age was 3 years (IQR 0.36-9.04), and more than half had chronic illnesses (56%) or previous ICU admissions (64%). Thirty-five percent (60/169) of parents met criteria for PTS (>9 on the Post-traumatic Stress Disorder Symptom Scale-Interview). The machine learning model (XGBoost) predicted subjects with parental PTS with 76.7% accuracy, had a sensitivity of 0.83 (95% CI 0.586, 0.964), a specificity of 0.72 (95% CI 0.506, 0.879), a precision of 0.682 (95% CI 0.451, 0.861) and number needed to evaluate of 1.47 (95% CI 1.16, 1.98). The area under the receiver operating curve was 0.78 (95% CI 0.64, 0.92). The most important predictive pre-admission and admission variables were determined using the Local Interpretable Model-Agnostic Explanation, which identified seven variables used 100% of the time. Composite variables of parental history of mental illness and traumatic experiences were most important. Conclusion: A machine learning model using parent risk factors predicted subsequent PTS at 3-9 months following their child's PICU discharge with an accuracy of 76.7% and number needed to evaluate of 1.47. This performance is sufficient to identify parents who are at risk during hospitalization, making inpatient and acute post admission mitigation initiatives possible.
目标:建立一个住院病人父母创伤后应激反应(PTS)预测模型:在儿科重症监护室(PICU)对患儿进行护理后,建立一个住院患儿父母创伤后应激反应(PTS)预测模型。设计:前瞻性观察队列。地点:两家拥有内科/外科/心内科混合重症监护病房的三级儿童医院。研究对象:PICU 住院患者的家长。干预措施:无。测量和主要结果:129名患儿的169名家长在PICU出院后3-9个月完成了家长创伤后应激症状的随访筛查,我们利用这些家长的入院前和入院数据建立了一个预测模型,估计出院后3-9个月家长出现创伤后应激症状的风险。父母群体主要为女性(63%)、有伴侣(75%)和工作(70%)。孩子的中位年龄为 3 岁(IQR 0.36-9.04),半数以上患有慢性疾病(56%)或曾入住过 ICU(64%)。35%的家长(60/169)符合创伤后应激障碍标准(创伤后应激障碍症状量表-访谈>9)。机器学习模型(XGBoost)预测父母 PTS 受试者的准确率为 76.7%,灵敏度为 0.83(95% CI 0.586,0.964),特异度为 0.72(95% CI 0.506,0.879),精确度为 0.682(95% CI 0.451,0.861),评估所需人数为 1.47(95% CI 1.16,1.98)。接收者操作曲线下的面积为 0.78(95% CI 0.64,0.92)。使用 "本地可解释模型-诊断解释"(Local Interpretable Model-Agnostic Explanation)确定了最重要的入院前和入院预测变量,其中有 7 个变量被 100% 使用。父母精神病史和创伤经历这两个综合变量最为重要。结论使用父母风险因素的机器学习模型可预测孩子 PICU 出院后 3-9 个月内的 PTS,准确率为 76.7%,评估所需次数为 1.47。这一结果足以识别住院期间有风险的家长,从而使住院和急性入院后的缓解措施成为可能。
{"title":"Predicting Parental Post-Traumatic Stress Symptoms Following their Child's Stay in a Pediatric Intensive Care Unit, Prior to Discharge.","authors":"Mekela M Whyte-Nesfield, Eduardo A Trujillo Rivera, Daniel Kaplan, Simon Li, Pamela S Hinds, Murray M Pollack","doi":"10.1177/08850666241287442","DOIUrl":"https://doi.org/10.1177/08850666241287442","url":null,"abstract":"<p><p><b>Objective:</b> Develop an inpatient predictive model of parental post-traumatic stress (PTS) following their child's care in the Pediatric Intensive Care Unit (PICU). <b>Design:</b> Prospective observational cohort. <b>Setting:</b> Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICUs. <b>Subjects:</b> Parents of patients admitted to the PICU. <b>Interventions:</b> None. <b>Measurements and Main Results:</b> Preadmission and admission data from 169 parents of 129 children who completed follow up screening for parental post-traumatic stress symptoms at 3-9 months post PICU discharge were utilized to develop a predictive model estimating the risk of parental PTS 3-9 months after hospital discharge. The parent cohort was predominantly female (63%), partnered (75%), and working (70%). Child median age was 3 years (IQR 0.36-9.04), and more than half had chronic illnesses (56%) or previous ICU admissions (64%). Thirty-five percent (60/169) of parents met criteria for PTS (>9 on the Post-traumatic Stress Disorder Symptom Scale-Interview). The machine learning model (XGBoost) predicted subjects with parental PTS with 76.7% accuracy, had a sensitivity of 0.83 (95% CI 0.586, 0.964), a specificity of 0.72 (95% CI 0.506, 0.879), a precision of 0.682 (95% CI 0.451, 0.861) and number needed to evaluate of 1.47 (95% CI 1.16, 1.98). The area under the receiver operating curve was 0.78 (95% CI 0.64, 0.92). The most important predictive pre-admission and admission variables were determined using the Local Interpretable Model-Agnostic Explanation, which identified seven variables used 100% of the time. Composite variables of parental history of mental illness and traumatic experiences were most important. <b>Conclusion:</b> A machine learning model using parent risk factors predicted subsequent PTS at 3-9 months following their child's PICU discharge with an accuracy of 76.7% and number needed to evaluate of 1.47. This performance is sufficient to identify parents who are at risk during hospitalization, making inpatient and acute post admission mitigation initiatives possible.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142348273","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-30DOI: 10.1177/08850666241287154
Adriana Y Koek, Kyle A Darpel, Temenuzhka Mihaylova, Wesley T Kerr
Purpose: Myoclonus 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.
Methods: Retrospective 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.
Results: In 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).
Conclusions: Category 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.
目的:缺氧性脑损伤后肌阵挛是严重脑损伤的标志。心脏骤停后的体感诱发电位(SSEP)上没有皮层信号(N20),如果与严重广泛神经损伤的整体临床表现一致,则是神经系统恢复不良的可靠预测指标。我们评估了一个临床问题,即缺氧后肌阵挛患者的 SSEP 结果是否可以从其他临床和神经诊断测试结果中预测出来:方法:对所有接受脑电图(EEG)监测和 SSEP 神经诊断的心脏骤停后肌阵挛成人患者进行回顾性病历审查。肌阵挛分为 "非肌阵挛性运动"、"脑电图未捕捉到的肌阵挛"、"无脑电图相关性的肌阵挛"、"有脑电图相关性的肌阵挛 "和 "状态性肌阵挛"。SSEP 结果分为全部缺失、全部存在、N18 和 N20 双侧缺失以及仅 N20 双侧缺失。采用带删减的 Cox 比例危险度法评估肌阵挛类别、SSEP 结果和混杂因素与存活率的关系:在 56 名患者中,从心跳骤停到确诊死亡或最后一次随访的中位时间为 9 天。肌阵挛类别与 SSEP 结果或存活时间无关。无 N20 s 或 N18 s 与存活期缩短有关(N20 危险比 [HR] 4.4,p = 0.0014;N18 危险比 5.5,p 结论:肌阵挛类别与存活期无关:肌阵挛的类别并不能可靠地预测 SSEP 的结果。SSEP 结果与预后的相关性是一致的,但只有在所有存在外周电位且仅缺失 N20 s 或缺失 N18 s 和 N20 s 的患者中,护理目标才会过渡到舒适措施。
{"title":"Myoclonus After Cardiac Arrest did not Correlate with Cortical Response on Somatosensory Evoked Potentials.","authors":"Adriana Y Koek, Kyle A Darpel, Temenuzhka Mihaylova, Wesley T Kerr","doi":"10.1177/08850666241287154","DOIUrl":"https://doi.org/10.1177/08850666241287154","url":null,"abstract":"<p><strong>Purpose: </strong>Myoclonus 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.</p><p><strong>Methods: </strong>Retrospective 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.</p><p><strong>Results: </strong>In 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).</p><p><strong>Conclusions: </strong>Category 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.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142348272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-25DOI: 10.1177/08850666241285862
Eun Sang Lee, Cecilie Dahl Baltsen, William B Stubblefield, Asger Granfeldt, Asger Andersen, Karsten Stannek, David M Dudzinski, Christopher Kabrhel, Mads Dam Lyhne
Objectives: High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE.
Methods: A systematic search of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was performed. Results were screened by two independent observers. Studies reporting on intubation and positive pressure ventilation in acute PE patients were included. The primary outcome was adverse events during the peri-intubation period. Data was synthesized and an assessment of risk of bias was conducted. The review was registered on PROSPERO (CRD42023444483).
Results: 4100 unique articles were screened. Three retrospective studies comprising 104 patients with acute PE met criteria and were included. Peri-intubation, hemodynamic collapse was observed in 19%-28% of cases. Patients with hemodynamic collapse exhibited higher rates of echocardiographic RV dysfunction.
Conclusions: Peri-intubation adverse events are common in patients with acute PE. Current evidence is limited and highlights the need for further research to optimize management of respiratory failure in acute PE and patient selection for intubation to improve patient outcomes.
目的:高危急性肺栓塞(PE)死亡率高,可能需要紧急气管插管和机械通气。插管和通气被认为会加剧心肺功能的不稳定。我们的目的是进行系统性文献综述,以确定调查急性 PE 中插管周围事件的研究:方法:对 Medline、Embase、Web of Science、Cumulative Index to Nursing and Allied Health Literature 和 Cochrane Library 进行了系统检索。结果由两名独立观察员进行筛选。纳入了有关急性 PE 患者插管和正压通气的研究。主要研究结果为插管期间的不良事件。对数据进行了综合,并对偏倚风险进行了评估。该综述已在 PROSPERO(CRD42023444483)上注册:结果:共筛选出 4100 篇文章。结果:共筛选出 4100 篇文章,其中有三项回顾性研究符合标准,共纳入 104 名急性 PE 患者。19%-28%的病例在插管前出现血流动力学衰竭。血流动力学衰竭患者出现超声心动图 RV 功能障碍的比例较高:结论:急性 PE 患者发生插管周围不良事件很常见。目前的证据有限,需要进一步研究如何优化急性 PE 呼吸衰竭的管理和插管患者的选择,以改善患者的预后。
{"title":"Intubation and Mechanical Ventilation in Patients with Acute Pulmonary Embolism: A Scoping Review.","authors":"Eun Sang Lee, Cecilie Dahl Baltsen, William B Stubblefield, Asger Granfeldt, Asger Andersen, Karsten Stannek, David M Dudzinski, Christopher Kabrhel, Mads Dam Lyhne","doi":"10.1177/08850666241285862","DOIUrl":"https://doi.org/10.1177/08850666241285862","url":null,"abstract":"<p><strong>Objectives: </strong>High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE.</p><p><strong>Methods: </strong>A systematic search of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was performed. Results were screened by two independent observers. Studies reporting on intubation and positive pressure ventilation in acute PE patients were included. The primary outcome was adverse events during the peri-intubation period. Data was synthesized and an assessment of risk of bias was conducted. The review was registered on PROSPERO (CRD42023444483).</p><p><strong>Results: </strong>4100 unique articles were screened. Three retrospective studies comprising 104 patients with acute PE met criteria and were included. Peri-intubation, hemodynamic collapse was observed in 19%-28% of cases. Patients with hemodynamic collapse exhibited higher rates of echocardiographic RV dysfunction.</p><p><strong>Conclusions: </strong>Peri-intubation adverse events are common in patients with acute PE. Current evidence is limited and highlights the need for further research to optimize management of respiratory failure in acute PE and patient selection for intubation to improve patient outcomes.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142348371","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1177/08850666241279229
Nir Atlas,Xiao Zhang,Jenna N Torgeson,Joshua Hermsen,William J Gibson,Adam M Harmon,Nicholas H Von Bergen
Background: Arrhythmias, common after pediatric cardiac surgery, are associated with increased morbidity and mortality. Atrial epicardial wires (AEW) improve diagnostic accuracy but have variable pacing and sensing properties based on their location. Even so, there are no longitudinal prospective pediatric studies examining ideal placement of AEW. Methods: This multicenter study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann's Bundle (BB) and the interatrial groove near the right pulmonary veins (IGRPV) versus the surgeons' standard locations. An AtriAmp system was used to obtain an atrial ECG to calculate atrial and ventricular amplitude from atrial electrograms on the bedside monitor. Sensitivities and thresholds via a temporary pacemaker were documented. ANOVA tests with repeated measures and post-hoc pairwise comparisons were performed to compare variables within the first 24-h postoperative hours. Mixed effects linear regression models were employed to examine daily trends. Results: In the first 24-h following cardiac surgery, AEW at BB and IGRPV showed significantly larger atrial amplitudes than the surgeons' standard locations. In addition, there was a negative trend in atrial ECG amplitude in all AEW from postoperative days 0 to 1; however, subsequent days showed a positive mean change in atrial amplitude with largest increase seen at BB. Atrial sensing as measured by the temporary pacemaker had statistically greater atrial signal amplitude from the BB-IGRPV set in both polarities (ie, with the BB as the - or + electrode pair) as compared to the surgeons' standard locations. No difference in atrial thresholds (mA) were noted in the immediate postoperative period or over time, with a relatively low atrial threshold at all sites. Conclusion: Standardization of AEW at Bachmann's Bundle can yield largest atrial amplitudes by atrial ECG and highest atrial sensing parameters without compromising atrial thresholds.
{"title":"Standardized Temporary Atrial Epicardial Wire Locations Lead to Enhanced Atrial Signal Identification.","authors":"Nir Atlas,Xiao Zhang,Jenna N Torgeson,Joshua Hermsen,William J Gibson,Adam M Harmon,Nicholas H Von Bergen","doi":"10.1177/08850666241279229","DOIUrl":"https://doi.org/10.1177/08850666241279229","url":null,"abstract":"Background: Arrhythmias, common after pediatric cardiac surgery, are associated with increased morbidity and mortality. Atrial epicardial wires (AEW) improve diagnostic accuracy but have variable pacing and sensing properties based on their location. Even so, there are no longitudinal prospective pediatric studies examining ideal placement of AEW. Methods: This multicenter study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann's Bundle (BB) and the interatrial groove near the right pulmonary veins (IGRPV) versus the surgeons' standard locations. An AtriAmp system was used to obtain an atrial ECG to calculate atrial and ventricular amplitude from atrial electrograms on the bedside monitor. Sensitivities and thresholds via a temporary pacemaker were documented. ANOVA tests with repeated measures and post-hoc pairwise comparisons were performed to compare variables within the first 24-h postoperative hours. Mixed effects linear regression models were employed to examine daily trends. Results: In the first 24-h following cardiac surgery, AEW at BB and IGRPV showed significantly larger atrial amplitudes than the surgeons' standard locations. In addition, there was a negative trend in atrial ECG amplitude in all AEW from postoperative days 0 to 1; however, subsequent days showed a positive mean change in atrial amplitude with largest increase seen at BB. Atrial sensing as measured by the temporary pacemaker had statistically greater atrial signal amplitude from the BB-IGRPV set in both polarities (ie, with the BB as the - or + electrode pair) as compared to the surgeons' standard locations. No difference in atrial thresholds (mA) were noted in the immediate postoperative period or over time, with a relatively low atrial threshold at all sites. Conclusion: Standardization of AEW at Bachmann's Bundle can yield largest atrial amplitudes by atrial ECG and highest atrial sensing parameters without compromising atrial thresholds.","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1177/08850666241285861
Daniel T Kim,Wayne Shelton,Linda Breslin,Megan K Applewhite
PURPOSEThe term 'moral distress' was coined by Andrew Jameton to name the anguish that clinicians feel when they cannot pursue what they judge to be right because of institutional constraints. We argue that moral distress in critical care should also be addressed as a function of the constraints of ethics and propose an evaluative approach to the experience considering its implications for professional identity.METHODWe build on a selective review of the literature and analyze a paradigmatic example of moral distress, namely, clinicians who feel compelled to perform procedures on patients that seem futile. Such cases are commonly cited by clinicians as among the most morally distressing.RESULTSOur analysis shows that (1) physicians' experiences of moral distress can stem not only from toxic workplace cultures and institutional constraints on their time and resources for patient care but also from the limits of ethical reasoning and (2) an emotion-based evaluative approach to analyzing moral distress is needed to address its hazards for professional identity.CONCLUSIONWe propose a new evaluative approach to moral distress with implications for professional identity and the need for institutional education and support.
{"title":"When Fulfilling a Professional Obligation Causes Moral Distress: A New Evaluative Approach.","authors":"Daniel T Kim,Wayne Shelton,Linda Breslin,Megan K Applewhite","doi":"10.1177/08850666241285861","DOIUrl":"https://doi.org/10.1177/08850666241285861","url":null,"abstract":"PURPOSEThe term 'moral distress' was coined by Andrew Jameton to name the anguish that clinicians feel when they cannot pursue what they judge to be right because of institutional constraints. We argue that moral distress in critical care should also be addressed as a function of the constraints of ethics and propose an evaluative approach to the experience considering its implications for professional identity.METHODWe build on a selective review of the literature and analyze a paradigmatic example of moral distress, namely, clinicians who feel compelled to perform procedures on patients that seem futile. Such cases are commonly cited by clinicians as among the most morally distressing.RESULTSOur analysis shows that (1) physicians' experiences of moral distress can stem not only from toxic workplace cultures and institutional constraints on their time and resources for patient care but also from the limits of ethical reasoning and (2) an emotion-based evaluative approach to analyzing moral distress is needed to address its hazards for professional identity.CONCLUSIONWe propose a new evaluative approach to moral distress with implications for professional identity and the need for institutional education and support.","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1177/08850666241286484
Santiago Ferrière-Steinert,Maximiliano Acevedo de la Barra,Alexandra Neman,Tamara Vergara Cerón,Rodrigo A Cornejo,Abraham I Vn J Gajardo
The systematic review and meta-analysis performed by Kang et al about the effect of extended prone positioning in intubated COVID-19 patients with ARDS presents valuable findings on the effectiveness and safety of extended prone positioning, but also raises several concerns which require clarifications. The inclusion of observational studies without any control group, the use of crude rather than adjusted estimates in key variables from observational studies, an error in data extraction from randomized clinical trials, and the employment of odds ratios rather than risk ratios, may mislead interpretations of the aforementioned intervention.
Kang 等人就延长俯卧位对插管 COVID-19 ARDS 患者的影响所做的系统综述和荟萃分析提供了有关延长俯卧位有效性和安全性的宝贵发现,但也提出了一些需要澄清的问题。该研究纳入了没有对照组的观察性研究、使用了观察性研究中关键变量的粗略估计值而非调整估计值、随机临床试验数据提取错误以及使用了几率比而非风险比,这些都可能误导对上述干预措施的解释。
{"title":"Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome, a Revision Letter.","authors":"Santiago Ferrière-Steinert,Maximiliano Acevedo de la Barra,Alexandra Neman,Tamara Vergara Cerón,Rodrigo A Cornejo,Abraham I Vn J Gajardo","doi":"10.1177/08850666241286484","DOIUrl":"https://doi.org/10.1177/08850666241286484","url":null,"abstract":"The systematic review and meta-analysis performed by Kang et al about the effect of extended prone positioning in intubated COVID-19 patients with ARDS presents valuable findings on the effectiveness and safety of extended prone positioning, but also raises several concerns which require clarifications. The inclusion of observational studies without any control group, the use of crude rather than adjusted estimates in key variables from observational studies, an error in data extraction from randomized clinical trials, and the employment of odds ratios rather than risk ratios, may mislead interpretations of the aforementioned intervention.","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251286","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-14DOI: 10.1177/08850666241280031
Christopher Choi, Nicole De Simone, Christopher B. Webb, Peiman Lahsaei, Sean G. Yates, Jay S. Raval, Michelle S. Harkins, Donald J. Hillebrand, Antonio Belli, Nicolas A. Schlapobersky, Tina S. Ipe, Grace C. Banez-Sese, Vikramjit S. Khangoora, Steven D. Nathan, Trudy M. Demko, David C. Young, Sigalit Caron, Ravi Sarode
BackgroundEarly in the COVID-19 pandemic, patients with severe disease admitted to the intensive care unit (ICU) had a high incidence of mortality. We aimed to investigate whether plasma adsorption with the MTx.100 Column could improve survival.MethodsWe performed a prospective, single-arm, multicenter, Emergency Use Authorization (EUA) trial in patients admitted to the ICU with severe COVID-19 who were worsening despite standard therapy. The primary outcome was all-cause mortality on day 28. Outcomes were analyzed using both a pre-specified performance goal (PG), and a propensity score-matched (PSM) analysis from the highest enrolling center, in which patients treated with the standard of care (SOC) plus the MTx.100 Column (n = 70) were compared to a contemporaneous cohort treated at the same center with SOC only (n = 244).FindingsBetween May 21, 2020, and November 2, 2021, 107 patients with severe COVID-19 (mean age 58.1) at 7 US centers were enrolled and had at least one plasma adsorption treatment initiated. All-cause mortality on day 28 was 37.4% (40/107), an improvement over the prespecified PG (88.1%, p < 0.0001). There were no serious adverse events attributable to the MTx.100 Column or plasmapheresis. Improvements in most metabolic and inflammatory markers were also noted. The PSM analysis showed that survival odds were three times higher for MTx.100 Column-treated patients (95% CI: 1.56-5.88) than for those treated with SOC only.InterpretationThe MTx.100 Column treatment in severe COVID-19 resulted in a lower mortality than SOC by both pre-specified PG and PSM analysis.Trial Registrationclinicaltrials.gov (NCT04358003).
{"title":"Plasma Adsorption with the MTx.100 Column in Critically Ill COVID-19 Patients: A Prospective Study and Propensity Score Analysis","authors":"Christopher Choi, Nicole De Simone, Christopher B. Webb, Peiman Lahsaei, Sean G. Yates, Jay S. Raval, Michelle S. Harkins, Donald J. Hillebrand, Antonio Belli, Nicolas A. Schlapobersky, Tina S. Ipe, Grace C. Banez-Sese, Vikramjit S. Khangoora, Steven D. Nathan, Trudy M. Demko, David C. Young, Sigalit Caron, Ravi Sarode","doi":"10.1177/08850666241280031","DOIUrl":"https://doi.org/10.1177/08850666241280031","url":null,"abstract":"BackgroundEarly in the COVID-19 pandemic, patients with severe disease admitted to the intensive care unit (ICU) had a high incidence of mortality. We aimed to investigate whether plasma adsorption with the MTx.100 Column could improve survival.MethodsWe performed a prospective, single-arm, multicenter, Emergency Use Authorization (EUA) trial in patients admitted to the ICU with severe COVID-19 who were worsening despite standard therapy. The primary outcome was all-cause mortality on day 28. Outcomes were analyzed using both a pre-specified performance goal (PG), and a propensity score-matched (PSM) analysis from the highest enrolling center, in which patients treated with the standard of care (SOC) plus the MTx.100 Column (n = 70) were compared to a contemporaneous cohort treated at the same center with SOC only (n = 244).FindingsBetween May 21, 2020, and November 2, 2021, 107 patients with severe COVID-19 (mean age 58.1) at 7 US centers were enrolled and had at least one plasma adsorption treatment initiated. All-cause mortality on day 28 was 37.4% (40/107), an improvement over the prespecified PG (88.1%, p < 0.0001). There were no serious adverse events attributable to the MTx.100 Column or plasmapheresis. Improvements in most metabolic and inflammatory markers were also noted. The PSM analysis showed that survival odds were three times higher for MTx.100 Column-treated patients (95% CI: 1.56-5.88) than for those treated with SOC only.InterpretationThe MTx.100 Column treatment in severe COVID-19 resulted in a lower mortality than SOC by both pre-specified PG and PSM analysis.Trial Registrationclinicaltrials.gov (NCT04358003).","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251289","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1177/08850666241280900
Bin Wang, Han Sheng Liang, Jia Wei Shen, You Zhong An, Yi Feng
ObjectiveThe purpose of this study was to investigate the risk factors associated with postoperative pulmonary complications(PPCs) in critically ill patients transferred to intensive care unit(ICU) after abdominal surgery and develop a predictive model for this disease.MethodsData for 3716 patients who were admitted to ICU after abdominal surgery in Peking University People's Hospital between January 2015 and December 2020 were retrospectively collected and analyzed to identify the risk factors and develop a nomogram prediction model. Data for patients admitted to ICU following abdominal surgery at Peking University People's Hospital from March 2021 to December 2022 were prospectively collected as a validation set to validate and assess the model.Results10 independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model was constructed for PPCs in this group patients, the area under ROC curve was 0.771[95%CI: 0.756,0.786] and 0.759[95%CI: 0.726,0.792] in the training set and validation set, respectively.ConclusionsIn this study, independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model for PPCs in critically ill surgical population was constructed using these factors, demonstrating a good predictive value.
{"title":"A Nomogram for Predicting Postoperative Pulmonary Complications in Critical Patients Transferred to ICU After Abdominal Surgery","authors":"Bin Wang, Han Sheng Liang, Jia Wei Shen, You Zhong An, Yi Feng","doi":"10.1177/08850666241280900","DOIUrl":"https://doi.org/10.1177/08850666241280900","url":null,"abstract":"ObjectiveThe purpose of this study was to investigate the risk factors associated with postoperative pulmonary complications(PPCs) in critically ill patients transferred to intensive care unit(ICU) after abdominal surgery and develop a predictive model for this disease.MethodsData for 3716 patients who were admitted to ICU after abdominal surgery in Peking University People's Hospital between January 2015 and December 2020 were retrospectively collected and analyzed to identify the risk factors and develop a nomogram prediction model. Data for patients admitted to ICU following abdominal surgery at Peking University People's Hospital from March 2021 to December 2022 were prospectively collected as a validation set to validate and assess the model.Results10 independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model was constructed for PPCs in this group patients, the area under ROC curve was 0.771[95%CI: 0.756,0.786] and 0.759[95%CI: 0.726,0.792] in the training set and validation set, respectively.ConclusionsIn this study, independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model for PPCs in critically ill surgical population was constructed using these factors, demonstrating a good predictive value.","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142190119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-11DOI: 10.1177/08850666241281281
Diego González-Guzmán,Carlos A Andrade-Castellanos,Marco A Ponce-Gallegos,Ignacio Mesina-Estarrón,José G Mora-Almanza,Hugo E Ruelas-Moreno,Daniel Rodríguez-González,Omar Eguia-Ortega,Luis Enrique Colunga-Lozano
PURPOSEWe assessed the potential association between N-acetyl-cysteine (NAC) and clinical outcomes in critically ill subjects with COVID-19-related ARDS.MATERIAL AND METHODSWe included subjects with confirmed COVID-19 who were admitted to our ICU between March 1, 2020, and January 31, 2021, due to ARDS and necessitating invasive mechanical ventilation (IMV). Subjects who received standard of care (SOC) were compared with subjects who additionally received NAC 600 mg bid orally.RESULTSA total of 243 subjects were included in this study. The results indicate significantly improved survival rates in the NAC plus SOC group, both in the unadjusted analysis and after adjusting for confounding factors such as ARDS severity (HR 0.48, 95% CI 0.32-0.70).CONCLUSIONSWe found that oral administration of NAC was associated with reduced mortality in critically ill patients with COVID-19 related ARDS.
{"title":"N-acetyl-cysteine in Intensive Care Unit Patients with Acute Respiratory Distress Syndrome due to COVID-19: A Retrospective Cohort Study.","authors":"Diego González-Guzmán,Carlos A Andrade-Castellanos,Marco A Ponce-Gallegos,Ignacio Mesina-Estarrón,José G Mora-Almanza,Hugo E Ruelas-Moreno,Daniel Rodríguez-González,Omar Eguia-Ortega,Luis Enrique Colunga-Lozano","doi":"10.1177/08850666241281281","DOIUrl":"https://doi.org/10.1177/08850666241281281","url":null,"abstract":"PURPOSEWe assessed the potential association between N-acetyl-cysteine (NAC) and clinical outcomes in critically ill subjects with COVID-19-related ARDS.MATERIAL AND METHODSWe included subjects with confirmed COVID-19 who were admitted to our ICU between March 1, 2020, and January 31, 2021, due to ARDS and necessitating invasive mechanical ventilation (IMV). Subjects who received standard of care (SOC) were compared with subjects who additionally received NAC 600 mg bid orally.RESULTSA total of 243 subjects were included in this study. The results indicate significantly improved survival rates in the NAC plus SOC group, both in the unadjusted analysis and after adjusting for confounding factors such as ARDS severity (HR 0.48, 95% CI 0.32-0.70).CONCLUSIONSWe found that oral administration of NAC was associated with reduced mortality in critically ill patients with COVID-19 related ARDS.","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.1,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142190120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}