Journal of Intensive Care Medicine最新文献

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

IntroductionFluid overload (FO), a state of pathologic positive cumulative fluid balance (CFB), is common in Pediatric Intensive Care Units (PICU) and associated with morbidity and mortality. Because different PICUs may have unique needs, barriers, and limitations to accurately report fluid balance (FB) and reduce FO, understanding the drivers of positive FB is needed. We hypothesize CFB >5% and >10% is common on ICU days 1 and 2, but that reasons for high %CFB will vary across sites, as will barriers to accurate FB recording and opportunities to improve FB recording/management.MethodsConcurrent mixed methods study utilizing a retrospective observational cohort design and prospective interview and survey design performed at four tertiary pediatric ICUs. FB data were extracted from the electronic health record. A federated data collection framework allowed for rapid data aggregation. The primary outcome was %CFB on ICU days 1 and 2, defined as total intake minus total output divided by ICU admission weight. Chi-square test and Wilcoxon rank sum tests compared results across and within sites.ResultsAmongst 3,071 ICU encounters, day 2 CFB >5% varied from 39% to 54% (p = 0.03) and day 2 CFB >10% varied from 16% to 25% (p = 0.04) across sites. Urine occurrence recordings and patients receiving >100% Holliday-Segar fluids on Day 1 differed across sites (p < 0.001). Sites discussed overall FB and specific FB goals on rounds with differing frequency (42-73% and 19-39%, respectively), but they reported similar barriers to accurate FB reporting and achievable opportunities to improve FB measurements, including patients/families not saving urine/stool, patients not tracking oral intake, and lack of standardized charting of flushes.ConclusionDay 2 CFB >5% and >10% was common among pediatric ICU encounters but proportion of patients varied significantly across ICUs. Individual ICUs have different drivers of FO that must be targeted to improve FB management.

Background: Intravenous vitamin C has been evaluated as an adjunctive therapy in adults with septic shock, with mixed results. In pediatric patients, evidence remains limited and its role is yet to be defined. Methods: In this randomized, double-blind, placebo-controlled trial conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital from February 2022 to March 2024, children <17 years-old with septic shock were randomly assigned to receive either intravenous Vitamin C at 25 mg/kg every 6 h for 72 h or equal volumes of 5% dextrose as placebo. The primary outcome was change in pediatric sequential organ failure assessment (pSOFA) score at 72 h from baseline. Secondary outcome was shock resolution and 28-day mortality. Results: Of 262 children with septic shock, 218 were randomized [median (IQR) age: 96 months (36.5, 133); 128 male]. The adjusted mean difference for change in pSOFA score at 72 h between the Vitamin C and placebo groups was -0.51 [95% CI: (-1.76, 0.75)] (p = 0.43)] (reduction in the Vitamin C group as compared to the placebo group). The 28-day mortality was comparable [Vitamin C, 21.6% versus placebo, 22.5%, RR: 0.96 (0.58-1.58), p = 0.88]. There was no difference in shock resolution or any other outcomes. The incidence of prespecified adverse events (acute kidney injury) was similar in both groups. Conclusion Intravenous Vitamin C administration as adjunctive therapy in pediatric septic shock did not significantly impact organ dysfunction at 72 h. Our findings do not support the routine use of Vitamin C as adjunctive therapy in septic shock in children.Trial registration: Clinical trial registry India (CTRI/2020/01/022886).

Sepsis and septic shock (SS) represent complex, life-threatening conditions driven by a dysregulated host immune response, leading to multi-organ failure (MOF). The SEPSIS-3 guidelines have emphasized the role of immunology in defining sepsis, but therapies targeting individual mediators have largely failed. Hemoadsorption (HA), particularly with polymyxin B (PMX), presents a promising approach to modulate this immune response by non-specifically removing endotoxins and other mediators, potentially restoring physiological homeostasis. This review explores the use of PMX hemoperfusion (PMX-HA) over the last 20 years in critically ill patients, examining its role in sepsis, particularly in endotoxemic septic shock. PMX-HA works by targeting endotoxin removal, reducing inflammatory mediators, and modulating immune cell activity, including neutrophil and monocyte function. However, treatment success varies due to patient heterogeneity. Identifying optimal target populations, based on markers like endotoxin activity (EAA), SOFA scores, and lactate levels, is critical for determining the timing, dose, and duration of PMX-HA therapy. Recent studies have highlighted the importance of stratifying patients by severity and endotoxin burden, suggesting that PMX-HA is most beneficial for patients with high endotoxin activity and severe organ dysfunction. Additionally, prolonged PMX-HA sessions may improve outcomes in patients with sustained endotoxin levels. This review emphasizes the need for a personalized approach to PMX-HA, with tailored treatment protocols to optimize clinical outcomes in sepsis and septic shock patients. Future research should focus on refining patient selection criteria and determining the most effective treatment regimens.

This letter responds to the systematic review and meta-analysis by Ryota et al, which examines the safety profile of ECMO cannulation performed by intensivists. The authors report an overall complication rate of 2% per cannula and 5% per patient, with higher rates observed in VA ECMO compared to VV ECMO. We emphasized that the safety of ECMO cannulation is multifactorial, influenced by institutional infrastructure, structured training programs, adherence to protocols, credentialing standards, and quality improvement initiatives. Although procedural volume and surgical backup are important, standardization of training curricula and institutional policies play a pivotal role in optimizing safety.

This narrative review explores the implementation and impact of sepsis code protocols, an urgent intervention strategy designed to improve clinical outcomes in patients with sepsis. We examined the degree of implementation, activation criteria, areas of implementation, personnel involved, responses after activation, goals and targets, impact on clinical indicators, and challenges in implementation. The reviewed evidence suggests that sepsis codes can significantly reduce sepsis-related mortality and enhance early administration of treatments. However, variability in activation criteria and inconsistent application present ongoing challenges. The review considers the incorporation of newer scoring systems, such as NEWS and MEWS, and the potential integration of machine learning tools for early sepsis detection. It highlights the importance of tailoring implementation to specific healthcare contexts and the value of ongoing training to optimize sepsis response. Limitations include the ongoing controversy surrounding sepsis definitions and the need for standardized, feasible quality indicators. Future research should focus on standardizing activation criteria, improving protocol adherence, and exploring emerging technologies to enhance early sepsis detection and management. Despite challenges, sepsis codes show promise in improving patient outcomes when implemented thoughtfully and consistently across healthcare settings.

BackgroundThere is not a consensus in critical care medicine on when arterial catheters are indicated, nor is there evidence that ACs improve patient outcomes. There is wide variability in AC use across PICUs that is independent of illness severity.ObjectiveTo characterize arterial catheter placement practices among pediatric critical care clinicians and identify practice variability in techniques, indications, and attitudes.DesignAnonymous, cross-sectional web-based survey.Measurements and Main ResultsData were collected from 377 pediatric critical care practitioners across 93 institutions. The majority were attending physicians (n = 215, 57.0%) or fellows (n = 141, 37.4%). Ultrasound was always used for arterial catheter placement by 52.0% (196/377) of respondents, with fellows being more likely than attendings to use ultrasound (P = .005). The catheter-over-wire (Seldinger) technique was the most common insertion method (332/377, 88.1%). For site selection, the radial artery was preferred for peripheral placement (97.3%), and the femoral artery for central cannulation (81.1%). There was substantial variability in the reported indications for arterial catheter use, with 68.9% considering single vasoactive support as an indication.ConclusionsThis study demonstrates wide practice variation in arterial catheter placement among pediatric ICU clinicians, despite the existence of some practice guidelines. Future research should focus on addressing gaps in evidence, particularly around ultrasound-guided techniques and securement methods, to optimize practices and improve outcomes.

BackgroundRacial and ethnic disparities in healthcare outcomes are well-documented, but less is known about how these disparities manifest among survivors of critical illness. We examined whether Black and Hispanic ICU survivors experience different rates of 90-day and 1-year mortality and hospital readmission compared to White survivors, and whether these associations vary by age or Medicaid insurance status.MethodsWe conducted a retrospective cohort study using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. Primary outcomes were 90-day and 1-year mortality; secondary outcomes included 90-day and 1-year hospital readmissions. We used Cox proportional hazards, Accelerated Failure Time (AFT), and Fine-Gray competing risk models, adjusting for age, sex, and Medicaid status. Prespecified subgroup analyses were performed among patients aged ≥60 and those admitted to surgical ICUs.ResultsAmong 46 640 ICU survivors (mean age 63.2 years; 55.6% male; 11.8% Black; 4.6% Hispanic), Black patients had lower survival at 90 days (absolute difference (AD): -0.85% (95% CI: -1.47%, -0.23%) and 1 year (AD: -1.42% (-2.46%, -0.40%) compared to White patients. Hispanic patients had higher survival (90-day AD: 1.33% (0.39%, 2.31%); 1-year AD: 2.31% (0.67%, 4.03%). Differences were more pronounced among patients ≥60 years. Black (1-year SDHR: 1.29 (1.23, 1.34)) and Hispanic patients (SDHR: 1.22 (1.14, 1.30)) had higher readmission rates. Medicaid coverage was more common among Black (aOR: 2.26 (2.10, 2.43)) and Hispanic patients (aOR: 4.23 (3.82, 4.68)). Adjustment for Medicaid was associated with smaller survival differences between Black and White patients, with limited effect on other estimates.ConclusionsIn this cohort, Black ICU survivors had lower long-term survival, and both Black and Hispanic patients had higher readmission rates compared to White patients. Differences were more pronounced among older adults. Variation in Medicaid coverage may contribute to observed disparities and warrants further investigation.

Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.

PurposePrevious studies evaluating clonidine for dexmedetomidine weaning in critically ill patients have shown efficacy but are limited to smaller samples of adult or pediatric patients. The objective of this study was to evaluate the efficacy and safety of enteral clonidine in the transition from dexmedetomidine for agitation and sedation in the intensive care unit (ICU).Materials and MethodsThis was a single-center, retrospective cohort study of adult patients admitted to an ICU at UMass Memorial Medical Center between May 1, 2022 to April 30, 2023 who received enteral clonidine for the indication of weaning dexmedetomidine. The primary outcome was discontinuation of dexmedetomidine within 24 h of starting enteral clonidine. A priori risk factors for the primary outcome included duration of dexmedetomidine prior to clonidine initiation, clonidine total daily dose, average Richmond Agitation-Sedation Scale (RASS) and Sequential Organ Failure Assessment (SOFA) scores, history of a psychiatric disorder, intubation at time of clonidine initiation, and being on additional sedation agents at the time of clonidine initiation. Safety outcomes included the incidence of bradycardia, hypotension, and withdrawal.ResultsSeventy-three patients were included. The primary outcome of dexmedetomidine discontinuation within 24 h occurred in 38 patients (52%). Multivariable logistic regression analysis of the a priori risk factors indicated that non-intubated patients at the time of clonidine initiation were significantly more likely to achieve the primary outcome (OR 4.27, 95% CI 1.04-17.62, p = 0.04). Incidence of bradycardia (5% clonidine vs 16% dexmedetomidine, p = 0.04) and withdrawal (0% vs 49%, p < 0.0001) were higher while patients were on dexmedetomidine.ConclusionsClonidine was efficacious in weaning dexmedetomidine within 24 h in 52% of patients; however, the ideal dose and period for initiation remains unclear. Results of this study warrant further investigation to identify optimal clonidine dosing for dexmedetomidine weaning and to characterize patient populations that would benefit most from this intervention.