Journal of Intensive Care Medicine最新文献

Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.

Purpose: The purpose of this study was to evaluate rates of delirium or coma-free days between continuous infusion sedative-dose ketamine and continuous infusion benzodiazepines in critically ill patients. Materials and Methods: In this single-center, retrospective cohort adult patients were screened for inclusion if they received continuous infusions of either sedative-dose ketamine or benzodiazepines (lorazepam or midazolam) for at least 24 h, were mechanically ventilated for at least 48 h and admitted to the intensive care unit of a large quaternary academic center between 5/5/2018 and 12/1/2021. Results: A total of 165 patients were included with 64 patients in the ketamine group and 101 patients in the benzodiazepine group (lorazepam n = 35, midazolam n = 78). The primary outcome of median (IQR) delirium or coma-free days within the first 28 days of hospitalization was 1.2 (0.0, 3.7) for ketamine and 1.8 (0.7, 4.6) for benzodiazepines (p = 0.13). Patients in the ketamine arm spent a significantly lower proportion of time with RASS -3 to +4, received significantly higher doses and longer durations of propofol and fentanyl infusions, and had a significantly longer intensive care unit length of stay. Conclusions: The use of sedative-dose ketamine had no difference in delirium or coma-free days compared to benzodiazepines.

Background: The impact of methylene blue (MB) on critical patient outcomes, including overall mortality, hemodynamic stability, and organ function has been inconsistently described across studies. This study aims to evaluate the efficacy of MB therapy in adult patients with septic shock in the intensive care unit (ICU).

Methods: The systematic search of PubMed/MEDLINE, EMBASE and Cochrane Library databases up to February 2024 included randomized controlled trials and prospective observational studies involving adult septic shock patients who received intravenous MB therapy. The primary outcome was all-cause mortality, with secondary outcomes on hemodynamics and ICU length of stay.

Results: Fifteen studies (5 randomized, 10 non-randomized) involving a total of 441 patients, met the inclusion criteria. The meta-analysis showed statistically significant reduction in mortality rates among septic shock patients treated with MB (mortality rate 0.52; 95% CI 0.38 to 0.66; P < .001). In a sub-analysis of only randomized trials, the results remained statistically significant (risk ratio 0.66; 95% CI 0.47 to 0.94; P = .023). A significant increase in mean arterial pressure post-infusion was observed in three studies. Two studies showed no substantial difference in heart rate and two studies showed no difference in cardiac index following MB administration. Only one study showed a reduction in the length of ICU stay with MB use, while another observed a decrease in overall hospital length of stay.

Conclusions: The review and meta-analysis suggest that MB may be associated with a significant reduction in mortality in septic shock patients though findings are limited by sample size and heterogeneity. Further robust studies are needed to validate these results.

Background: Current therapies for severe COVID-19, such as steroids and immunomodulators are associated with various side effects. N-acetylcysteine (NAC) has emerged as a potential adjunctive therapy with minimal side effects for patients with cytokine storm due to COVID-19. However, evidence supporting high-dose intravenous NAC in severe COVID-19 pneumonia requiring mechanical ventilation is limited.

Methods: We conducted a retrospective analysis of consecutive patients aged ≥ 18 who were admitted for acute respiratory failure (PaO2/FiO2 ratio <300) with SARS-CoV-2 infection to the Intensive Care Unit (ICU) of Queen Elizabeth Hospital from fifth July 2020 to 31^st October 2022. Inclusion was limited to patients who required mechanical ventilation. High-dose NAC refers to a dosage of 10 g per day. The primary outcome was all-cause mortality within 28 days. Propensity-score matched analysis using logistic regression was performed.

Results: Among the 136 patients analyzed, 42 (40.3%) patients received NAC. The unmatched NAC patients displayed a higher day-28 mortality (12 (28.6%) versus 4 (6.5%), p = 0.005) and fewer ventilator-free days (18.5 (0-23.0) versus 22.0 (18.3-24.0), p = 0.015). No significant differences were observed in ICU and hospital length of stays among survivors. In patients who were not treated with tocilizumab, those receiving NAC exhibited a trend toward a quicker reduction in C-reactive protein compared to those who did not receive NAC.After propensity score matching which included 64 patients with 33 (51.6%) receiving NAC, no significant differences were found in 28-day mortality, ventilator-free days, or ICU and hospital length of stay. After adjusting for potential confounders, logistic regression of the propensity score-matched population did not demonstrate that the use of NAC independently affected 28-day mortality.

Conclusions: In patients with COVID-19 pneumonia requiring mechanical ventilation and receiving standard COVID-19 treatment, the addition of high-dose NAC did not lead to improved clinical outcomes.

The prone position is often used for patients with adult respiratory distress syndrome and specific surgical postures. When performing venous cannulation in this position, it is important to have a structured review to introduce the available major veins and ultrasound-guided procedure. In this review, we discuss the techniques of ultrasound-guided cannulation and provide insights into various aspects, including the anatomical locations of veins, vein sizes, placement techniques, surrounding structures at risk, and reported experiences with catheter placements. Eight major veins can be accessed in the prone position: the internal jugular vein, external jugular vein, brachiocephalic vein, basilic vein, mid-thigh femoral vein, popliteal vein, posterior tibial vein, and small saphenous vein. To minimize the risk of venous thromboembolism, the ratio of catheter diameter to vessel diameter should be less than 0.67. The review also presents the minimal requirement of venous diameter for different catheters in a tabulated form. For larger veins, real-time ultrasound guidance with the long-axis view/in-plane technique is suggested, while for smaller vessels, the short-axis view/out-of-plane technique is recommended. The review includes sonographic illustrations of the two techniques and surrounding arteries and nerves for the eight major veins. The aim of this review is to help clinicians assess the eight major veins and safely insert various types of catheters for patients in the prone position.

Background: Dexmedetomidine (DEX) is a highly favored sedative agent in critically ill patients owing to its anxiolytic and analgesic properties, lower risk of delirium, and minimal respiratory depression. Additionally, DEX exhibits anti-inflammatory properties, which have prompted its use in managing COVID-19 patients to mitigate cytokine storm and multi-organ dysfunction. Thus, this study aims to evaluate the safety and effectiveness of DEX use in critically ill patients with COVID-19. Method: This multicenter, retrospective cohort study included adult patients with confirmed COVID-19 who were admitted to the ICUs and did not require invasive mechanical ventilation (MV). Patients were categorized into two groups based on receiving DEX use within 72 h of ICU admission. The primary outcome was respiratory failure requiring invasive MV; other outcomes were considered secondary. Results: A total of 155 patients were included in the study after propensity matching. DEX did not reduce respiratory failure requiring invasive MV (HR 0.66; 95% CI (0.28, 1.53), P = .33). However, the time for invasive MV was statistically significantly shorter in the DEX group compared with the control group (beta coefficient (95%CI): - 1.05 (-2.03, -0.07), P = .03). In contrast, ICU and hospital Length of stay (LOS) were not statistically significant compared to the control group (beta coefficient 0.04 (95% CI -0.29, 0.38), P = .80, and beta coefficient - 0.03 (95% CI -0.33, 0.26), P = .81, respectively). In addition, the 30-day and in-hospital mortality rates were similar between the two groups (HR 1.1; 95% CI 0.97, 1.20, P = .14, and HR 1.01; 95% CI 0.95, 1.06, P = .90, respectively). Conclusion: Dexmedetomidine did not appear to lower the risk of respiratory failure necessitating invasive mechanical ventilation in critically ill patients. However, the mean time for invasive mechanical ventilation was shorter in the DEX group. Future interventional studies are required to confirm our findings.

Objective: To assess the role of blood gas analysis as an auxiliary tool for detecting and predicting the progression of COVID-19 in patients.

Research methodology/design: A consecutive cohort study was conducted of 106 patients diagnosed with the novel coronavirus. Patients were divided into two groups based on age and the course of the disease (mild to moderate and severe). Blood gas analysis parameters were measured for all participants and results were compared between groups.

Setting: This study was conducted in the Department of Laboratory Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China.

Main outcome measures: Arterial/alveolar oxygen partial pressure ratio, reduced hemoglobin fraction, sodium ion, lactic acid, oxygen saturation, oxygen partial pressure, and oxyhemoglobin fraction.

Results: Findings indicated statistically significant differences between the two groups in the measured parameters.

Conclusion: Blood gas analysis has the potential to more accurately assess the progression of COVID-19 in elderly patients, specifically related to respiratory and acid-base balance issues.

Implications for clinical practice: This study underscores the importance for bedside nurses to pay close attention to acid-base balance, lung ventilation/ventilation function, and hypoxia status in elderly critically ill patients with COVID-19, in order to more effectively diagnose and predict the progression of the disease.

Background: There is a considerable gap in the current evidence concerning the prevalence of superinfections among critically ill patients with SARS-CoV-2 infection in Saudi Arabia.

Objectives: We sought to determine the prevalence of bacterial superinfections following the initiation of antibiotic therapy in critically ill patients with SARS-CoV-2 infection.

Methods: A retrospective observational study that included patients with SARS-CoV-2 infection admitted to the intensive care unit (ICU) for at least 24 hours and received empirical antibiotic therapy. The primary outcome was the rate of bacterial superinfections occurring at least 48 hours after the initiation of antibiotics. ICU-related outcomes and complications were compared between subgroups with and without superinfections and amongst the two most frequently used antibiotic regimens.

Results: A total of 230 patients were included in our study. Superinfections developed in 40 (17.4%) patients, with the median time from the first dose of antibiotic to the emergence of superinfection of 17.6 days (IQR 9.8-29.2). Patients with superinfections had longer median ICU stays [ 27.1 days(IQR 15.2-43.3) versus 7.1 days(IQR 3.8-11.8); P < 0.001], developed more complications [92.5% versus 52.6%; P < 0.001], and had higher ICU mortality [45.0% versus 22.1%; P = 0.0034] compared to patients without superinfections. The two most frequently prescribed antibiotic regimens were piperacillin/tazobactam plus levofloxacin (53.9%) and meropenem plus levofloxacin (19.7%). Although there was no significant difference in the rate of superinfections [15.3% versus 26.7%; P = 0.09] between the two groups, patients in the superinfections group who received piperacillin/tazobactam plus levofloxacin developed more complications [94.7% versus 91.7%; P < 0.001] and had a higher ICU mortality [57.9% versus 50%; P < 0.001].

Conclusion: Superinfections occurred at a higher rate in critically ill patients with SARS-CoV-2 infection post empirical antibiotics initiation. The use of piperacillin/tazobactam plus levofloxacin was associated with an increase in the rate of complications and higher ICU mortality. Larger multicenter studies are needed to confirm these results.

Venous obstructions and thrombosis can present diagnostic challenges due to their varied presentations and potential for significant complications if untreated. Pulse wave doppler ultrasound via identification of damping or loss of cardiac pulsatility and/ or respiratory phasicity of venous waveforms serves as a practical, noninvasive, fast, and efficient diagnostic tool for identifying venous obstructions in the presence of compressible veins beyond the point of evaluation.We present two cases demonstrating the effectiveness of pulse wave doppler ultrasound in identifying significant and life-threatening venous obstructions. The first case involves a 68-year-old male with an incidental finding of a compressible left subclavian vein showing a monophasic waveform. Further investigation revealed significant compression of the left brachiocephalic vein by an aortic arch aneurysm. The second case describes a 65-year-old male with a compressible right femoral vein but a monophasic waveform, leading to the discovery of extensive thrombosis from the iliac veins to the inferior vena cava. This series proposes to always assess cardiac pulsatility and respiratory phasicity during doppler ultrasound procedure such as thyroid ultrasounds, deep vein thrombosis (DVT) evaluations, and pre-central vein catheterizations for identifying any venous obstructions, whether they are intrinsic or extrinsic, and for reducing the risk of thromboembolic complications.

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.