Journal of Intensive Care Medicine最新文献

BackgroundArterial catheterization serves as a cornerstone monitoring modality in septic shock management, enabling continuous hemodynamic assessment and serial blood gas analysis. Despite its widespread use, mortality benefits and optimal timing for catheter insertion remains undefined.MethodsAn analysis of clinical data from 6,485 critically ill adult patients, identified as meeting the Sepsis-3 criteria for septic shock, was conducted utilizing the MIMIC-IV database. Through entropy-balanced propensity score matching (PSM, 1:1 ratio) and doubly robust estimation with inverse probability weighting, we compared outcomes between catheterized (≤24 h post-admission) and non-catheterized groups. Restricted cubic spline (RCS) modeling characterized nonlinear temporal associations. The evaluation encompassed both primary and secondary endpoints, including 28-day mortality, mortality within the ICU and hospital settings, length of stay, CRRT requirements, and physiological resuscitation metrics.ResultsAfter PSM (1,416 patients from initial 6,485) with 1:1 ratio, arterial catheterization exhibited significantly reduced mortality across all measured outcomes compared to non-catheterized controls: 28-day mortality (26.1% vs 43.9%; aHR 0.62, 95%CI 0.51-0.75), ICU mortality (aHR 0.76, 0.61-0.94), and in-hospital mortality (HR 0.70, 0.58-0.86), all P < .05. Arterial catheterization was associated with a shorten ICU stay by 0.52 days (95%CI 0.18-0.82, P = .002) and improved physiological parameters. Restricted cubic splines identified optimal intervention timing at 204-290 min post-admission through U-shaped mortality risk association.ConclusionIn a cohort of critically ill patients with septic shock, early peripheral arterial catheterization is significantly associated with improved 28-day mortality outcomes.

PurposeThis study aimed to investigate in-patient mortality and predictors of death associated with convulsive status epilepticus (CSE) in a large nationwide cohort and create a simplified predictive score for in-hospital mortality.MethodsRetrospective data from the National Inpatient Sample (NIS) database between 2007 and 2014 were analyzed, including 123,082 adults with CSE. Univariate logistic testing identified admission variables, neurological and medical complications associated with mortality. A simplified clinical prediction score, called M³A²S²H, was generated using variables that were frequent (>1%) and had a significant impact on mortality.ResultsThe overall hospital mortality rate was 3.5%. Univariate analysis revealed that older age, female gender, past medical history, and acute hospital conditions were related to mortality. After reclassification, a final multivariable model with 27 clinical variables was constructed, and the eight strongest predictors were included in the M³A²S²H score: hypoxic-ischemic encephalopathy/cardiac arrest (2 points); age >60 years, acute symptomatic CSE, invasive mechanical ventilation, sepsis, metastases, and chronic liver failure (all 1 point); and medication nonadherence (-1 point). The mortality rate among patients with ≤0, 1, 2, 3, 4, or ≥5 of these risk factors progressively increased from 0.2%, 2.1%, 7.8%, 20.3%, 31.9%, to 50.0% (P < 0.0001). Additionally, a similar stepwise trend was observed regarding discharge to a facility versus home without services (P < 0.0001).ConclusionsThis study demonstrates that mortality in CSE cases occurs in 3.5% of adult hospital admissions. Identification of specific acute and chronic conditions using the standardized M³A²S²H score can help predict the risk of death or disability even in hospitals without advanced brain monitoring.

Introduction: Tracheal intubation (TI) of an obstetrical patient around the time of delivery can be an upsetting event for involved providers. It can also cause an unpredictable use of intensive care resources. Its incidence is currently poorly characterized in the literature. We analyzed the 2019 National Inpatient Sample (NIS) to assess the incidence rate and associated risk factors. Methods: Patients were identified by International Classification of Diseases, 10th edition codes for delivery of a child. Measured endpoints were the incidence of TI and factors associated. Categorical variables were compared using Chi squared or Fisher's Exact. Continuous variables were compared using the Student T-test or the Mann Whitney rank sum U-test. A logistic regression model was created to determine the odds for each variable contributing to TI. A P value of 0.05 was considered the minimum standard for significance. Results: There was a low rate of TI (0.03%). Mortality was rare (0.004%) and there was a higher rate of mortality among patients who underwent tracheal intubation (5.5% vs 0.003% among patients not intubated, P < .001). The majority of intubations occurred among patients who delivered via CD. Pneumonia, cardiomyopathy, eclampsia, and postpartum hemorrhage were all independently associated with increased odds for TI. Conclusions: There are risk factors which may increase the likelihood for tracheal intubation. The diagnosis of a cardiomyopathy was strongly associated with an increased odds for TI and may result from acute respiratory failure. PPH and eclampsia were also associated with a greater odds for intubation.

PurposeAppropriateness of care is a fundamental yet often underexamined aspect of critical care medicine. Drawing on Kant's notion of appropriateness as providing "no more and no less than the matter requires," we explore how clinicians can align medical indication with patient or surrogate consent. Misalignments in this regard may result in overtreatment or undertreatment, contributing to moral distress, burnout, and dissatisfaction among families and clinicians.MethodsWe present a case report of an elderly patient whose clinical course in the intensive care unit (ICU) traverses all four quadrants of a proposed framework-the Fourfold Table of Appropriateness. This conceptual tool classifies medical interventions according to two dimensions: medical indication (yes/no) and patient or surrogate consent (yes/no). Each quadrant is associated with ethical and clinical implications and is color-coded like a traffic light to support real-time decision-making: green (appropriate), yellow (caution), red (stop).ResultsThe case illustrates how alignment between indication and consent fosters goal-concordant care. It also demonstrates how therapeutic obstinance, paternalism, or emotionally driven demands may lead to inappropriate care. Each episode reveals different challenges-physician biases, surrogate distress, unclear prognoses-and highlights the role of communication, shared decision-making, and clinical humility.ConclusionThe Fourfold Table provides a didactic framework to guide structured reflection among ICU clinicians. By naming and examining patterns of inappropriateness, it fosters ethical awareness and better communication practices. This case-based approach highlights the necessity of early recognition of misalignments, the importance of addressing emotional and cognitive biases, and the value of interventions such as time-limited trials and family-centered care. Ultimately, this framework contributes to more compassionate, appropriate, and goal-aligned critical care.

BackgroundDelirium is a common complication of illness. Patients who experience delirium are at risk for worse outcomes during and after hospitalization. This study aims to describe rates of, and factors associated with, delirium documentation during care transitions for patients who screened positive for delirium in the pediatric intensive care unit (PICU) at transfer to the pediatric hospital medicine (PHM) service and discharge.MethodsDemographic and clinical characteristics were collected retrospectively on patients ages 0-21 years, without developmental delay, who screened positive via Cornell Assessment of Pediatric Delirium (CAPD) before transferring from PICU to PHM service of a tertiary-care children's hospital from 2016-2022. Primary outcomes were documentation of "delirium" at PICU transfer and hospital discharge. Statistical analysis included bivariate analysis and multivariate logistic regression.ResultsOf 337 encounters, 66 transfer (20%) and 62 discharge notes (18%) documented delirium. On bivariate analysis, older age, female sex, Hispanic ethnicity, prolonged and elevated CAPD scoring, longer PICU and hospital length of stay, mechanical ventilation (MV), and psychiatry consultation were associated with documentation at transfer. On logistic regression, Black race decreased odds (OR 0.275, 95% CI 0.08-0.84) while psychiatry consultation (OR 66.82, 24.45-212.25) and invasive MV (OR 6.495, 2.13-22.34) increased odds of documentation. Discharge documentation demonstrated similar associations, except sex and ethnicity were not associated, while neurology consultation was positively associated with documentation. On logistic regression, psychiatry consultation (OR 36.01, 14.51-100.71) and invasive MV (OR 2.96, 1.09-8.83) increased odds of documentation at discharge.ConclusionsDespite a validated screening tool, pediatric providers often fail to document delirium at PICU transfer and hospital discharge. Lack of documentation may leave patients and families at risk for worse outcomes.

BackgroundIntensive care unit acquired weakness (ICUAW) is a common neuromuscular complication of critical illness, impacting patients' recovery and long-term outcomes. However, limited evidence is available on pooled prevalence and risk factors of ICUAW specifically in the COVID-19-infected population.MethodsWe searched on PubMed, Embase, Cochrane Library, Web of Science, PEDro, and EBSCOhost/CINAHL up to January 31, 2024. Data synthesis was conducted using the Freeman-Tukey double-arcsine transformation model for the pooled prevalence rate and odds ratios with corresponding 95% confidence intervals was used to identify risk factors.ResultsThe pooled prevalence of ICUAW in COVID-19 patients was 55% in eight studies on 868 patients. Risk factors for developing ICUAW in these patients were: old age (WMD 4.78, 95% CI, 1.06-8.49), pre-existing hypertension (OR = 1.63, 95% CI, 1.02-2.61), medical intervention of prone position (OR = 5.21, 95% CI, 2.72-9.98), use of neuromuscular blocking agents (NMBA) (OR = 12.04, 95% CI, 6.20-23.39), needed tracheostomy (OR = 18.07, 95% CI, 5.64-57.92) and renal replacement therapy (RRT) (OR = 5.24, 95% CI = 2.36-11.63).ConclusionsThe prevalence of ICUAW in patients with COVID-19 was considered relatively high. Older age, pre-existing hypertension, medical intervention of prone position, NMBA use, needed tracheostomy and RRT were likely risk factors. In the future, interdisciplinary medical team should pay attention to high-risk groups for ICUAW prevention and early treatments.

Acute cholangitis is encountered commonly in critically ill, often elderly, patients. The most common causes of cholangitis include choledocholithiasis, biliary strictures, and infection from previous endoscopic, percutaneous, or surgical intervention of the biliary tract. Rare causes of acute cholangitis in the United States include sclerosing cholangitis and recurrent pyogenic cholangitis, the latter predominantly occurring in immigrants of Asian descent. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, gastroenterologists, endoscopists, and infectious disease physicians typically involved in the care of these patients. In this paper intended for intensivists predominantly, we will review the imaging findings and radiologic interventional management of critically ill patients with acute cholangitis, primary and secondary sclerosing cholangitis, and recurrent pyogenic cholangitis.

Objectives: To investigate the diagnostic value of hepcidin for sepsis diagnosis. Methods: The relevant literature on hepcidin for sepsis diagnosis published up to October 20, 2023, was systematically searched in the Web of Science, PubMed, Embase, and China Knowledge Network databases. Two researchers screened the literature and extracted relevant data according to the inclusion and exclusion criteria. Study quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis and calculation of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were performed using State16 and Review Manager 5.3 software. Furthermore, receiver operating characteristic curve (ROC) was plotted, and the respective area under the curve (AUC) was calculated to assess the accuracy of hepcidin. Publication bias was evaluated using Deeks' funnel plot asymmetry test. Results: Overall, 1047 patients from 8 studies were included (625 patients with sepsis and 422 controls). The quality of the literature was relatively moderate. Meta-analysis demonstrated the presence of heterogeneity in the data (I² > 50%, P < .05), and a randomized model was employed to combine the diagnostic indicators. Regarding its accuracy for sepsis diagnosis, hepcidin demonstrated a pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.76-0.94) and specificity of 0.91 (95% CI: 0.76-0.97). The diagnostic odds ratio was 69.00 (95% CI: 19.00-253.00), and the ROC curve revealed an AUC of 0.95. Additionally, Deeks' funnel plot asymmetry test demonstrated absence of publication bias. Conclusions: Our meta-analysis suggested that hepcidin has a high diagnostic value in sepsis and may be a valuable diagnostic tool.

Background: Invasive pulmonary aspergillosis (IPA) is a very severe manifestation of Aspergillus disease. Besides well-known risk groups of deeply neutropenic hematologic and solid organ transplant recipients other risk groups among patients treated in ICUs have been recognized. The prevalence of IPA among ICU-patients is not known and it is not known how well IPA is recognized in ICU-settings. The diagnosis of IPA is often difficult to make and non-invasive ways to diagnose IPA reliably are needed. Objectives: In this study we studied the clinical significance of Aspergillus-positive respiratory samples in ICU-patients. Methods: We retrospectively evaluated the ICU-patients (N = 205) who provided Aspergillus-positive respiratory samples in 2007-2020 and classified patients to groups of "colonization", "putative IPA", "proven IPA ", as in AspICU algorithm. Data were collected from laboratory registry and Helsinki University Hospital medical records. Underlying conditions, reasons leading to treatment in ICU, immunosuppression, known risk factors of IA in ICU, signs of infection, results of Aspergillus-specific laboratory testing, use of antifungal treatment, survival, and reason of death were assessed. Results: Majority of the findings (63%) were colonization, 11 (5%) patients had proven IPA, and "putative IPA" 59 (29%) of the patients. All patients with proven IPA died within one year, whereas mortality in putative and colonization groups was 39% and 33% respectively. Difference in mortality during one year between "colonization" and "putative IPA" groups was not statistically significant (p = .244), but when both "proven" and "putative" IPA were included, the difference was statistically significant, p = .019. Overall hospital mortality in the study group was 38%. Mortality in all the groups is higher than overall ICU-patient mortality of non-selected patients in Finland. Conclusions: The overall incidence of Aspergillus-findings in our ICUs was low. Isolation of Aspergillus in critically ill is associated with high mortality irrespective of invasion or colonization.

BackgroundCerebral venous thrombosis (CVT) is a rare but serious complication of traumatic brain injury (TBI), yet the implications of this association remain poorly understood. This study explores the demographics, risk factors, and clinical outcomes of patients with both TBI and CVT (CVT-TBI).MethodsThe National Inpatient Sample (NIS) was queried from 2016-2020 for adult patients with a primary diagnosis of TBI and concurrent CVT. Chi-squared tests and logistic regression were used to compare demographic, clinical, and outcome variables of CVT-TBI and TBI-only patients.ResultsOf the 1,583,915 TBI patients identified between 2016-2020, 640 (0.04%) had concurrent CVT. CVT-TBI patients were younger (47.94 vs 61.81; p < 0.001), more likely to have Medicaid (30.5% vs 14.1%; p < 0.001), less likely to be female (31.3% vs 39.0%; p < 0.001), and less likely to be Caucasian (60.9% vs 68.1%; p < 0.001). Multivariate analysis demonstrated age (OR = 0.98; p < 0.001), skull fracture (OR = 3.741; p < 0.001), epidural hematoma (OR = 1.407; p = 0.012), subdural hematoma (OR = 2.395; p < 0.001), and subarachnoid hemorrhage (OR = 1.415; p < 0.001) as CVT risk factors. CVT-TBI patients experienced more severe clinical courses involving mechanical ventilation (21.9% vs 10.4%; p < 0.001), cerebral herniation (6.3% vs 3.7%; p = 0.001), and being comatose (45.3% vs 30.7%; p < 0.001) and were more likely to undergo decompressive hemicraniectomy (4.7% vs 1.1%; p < 0.001), tracheostomy or percutaneous endoscopic gastrostomy tube placement (3.9% vs 1.5%; p < 0.001), and develop long-term sequelae, including seizures (10.9% vs 4.2%; p < 0.001) and hydrocephalus (7.0% vs 1.7%; p < 0.001). After matching, there was a significant difference in discharge home (OR = 1.806; p = 0.018), but no significant difference in discharge to a skilled nursing home (OR = 1.068; p = 0.449), short term rehabilitation facility (OR = 0.850; p = 0.500), or inpatient mortality (OR = 1.134; p = 0.500).ConclusionsThis population-based retrospective analysis unveils distinctive demographic and clinical features of CVT-TBI patients, emphasizing the need for tailored risk assessment and management strategies to improve outcomes for this subset of TBI patients.