Journal of Intensive Care Medicine最新文献

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.

We present the case of a patient with end-stage renal disease secondary to type 2 diabetes mellitus and hypertension who developed refractory chronic active antibody-mediated rejection following renal transplantation. Despite standard of care treatment, including intravenous immunoglobulin, therapeutic plasma exchange, and steroids, the patient exhibited persistent donor-specific antibodies and renal allograft injury. Given elevated interleukin-6 levels, tocilizumab, an IL-6 receptor monoclonal antibody, was started with marked improvement in serum creatinine, and stabilization of the allograft injury. This case highlights the potential of interleukin-6 blockade as a treatment for refractory chronic active antibody-mediated rejection, particularly in the context of interleukin-6-mediated injury.

BackgroundPulmonary embolism may cause hemodynamic instability requiring vasoactive support, but evidence on guiding agent selection is very limited.MethodsA retrospective cohort study of adult admissions to 12 Intensive Care Units in Queensland, Australia between 2015-2021. Clinical and outcome data was obtained through statewide hospital databases.ResultsOf 89,123 admissions, 460 (0.6%) patients had a primary diagnosis of pulmonary embolism. Vasoactive infusions were administered within the first 24 h of ICU admission to 182/460 patients (39.6%) and 209/460 (45.4%) patients at any time during ICU admission. Norepinephrine was the most common (175/209; 83.7%), followed by epinephrine (37/209; 17.7%). The cohort had a median ICU length of stay of 3 days (IQR; 2-5), and a 30-day mortality rate of 11.3% (52/460). Higher vasoactive requirement on day-1 was associated with significantly higher 30-day mortality (odds ratio per 1-unit increase in vasoactive-inotrope score of 3.72, 95% confidence interval 1.80-8.75, P < .001).ConclusionPrimary diagnosis of PE is uncommon among ICU presentations but 45% of patients require vasoactive support. Norepinephrine was the most used vasoactive agent. Higher vasoactive requirements reflected greater illness severity and were associated with higher 30-day mortality.

IntroductionNew-onset atrial fibrillation (AF) in sepsis is a common complication in critically ill patients and carries significant prognostic implications. Although multiple risk factors have been associated with its development, findings remain inconsistent, and data from Latin American populations are scarce. This study aimed to evaluate the association between clinical variables of sepsis and the development of new-onset atrial fibrillation (AF) in patients admitted to intensive care units (ICUs).MethodsA retrospective cohort study was conducted across three referral hospitals in Medellín, Colombia, between January 2022 and June 2023. Adult patients admitted to the ICU with a diagnosis of sepsis or septic shock, defined according to the SEPSIS-3 criteria, were included. Infection-related clinical variables were measured, and the primary outcome was the development of new-onset AF. A multivariable analysis was performed using adjusted binomial logistic regression.ResultsA total of 1356 patients were included, with a mean age of 64.3 years; 67.7% were male. The prevalence of new-onset AF was 12.6% (n = 171). In the multivariable analysis higher SOFA scores and the use of noninvasive mechanical ventilation or vasoactive drugs were associated with its development. In the multivariable analysis adjusted for confounding variables, only the use of dual vasopressor support (OR 2.7; 95% CI, 1.1-7.35) and the use of any inotrope (OR 4.02; 95% CI, 1.3-11.65) were significantly associated with the development of AF. Patients who developed AF exhibited higher ICU mortality (49% vs 34%) and in-hospital mortality (55% vs 37%).ConclusionNew-onset AF in sepsis is common among ICU patients. Use of dual vasopressor support and any inotropic agent were consistently associated with its occurrence.

BackgroundCurrent research indicated the comprehensive investigation of Annexin A3 (ANXA3) in sepsis patients remain uncertain. The aim of this research is to investigate the potential of ANXA3 as a biomarker for prediction of sepsis.MethodsWe performed a meta-analysis utilizing public datasets from Gene Expression Omnibus (GEO) and Array Express database to summarize and evaluate the expression of ANXA3 in sepsis patients. Then, we conducted a retrospective study to explore the role of plasma ANXA3 in 153 critically ill patients. Furthermore, the predictive ability of ANXA3, procalcitonin (PCT), interleukin-6 (IL-6) and Sequential Organ Failure Assessment (SOFA) score for the occurrence of sepsis were evaluated using the Area Under the Curve (AUC).ResultsTotally, the meta-analysis including 3241 sepsis and 1088 controls indicated sepsis patients were with markedly higher levels of ANXA3 mRNA expression (SMD = 2.01(1.54-2.48); P < 0.001). Meanwhile, sepsis deaths (n = 552) were with limited higher expression of ANXA3 mRNA than sepsis survivors (n = 2004) (SMD = 0.14(0.04-0.24); P < 0.01). Furthermore, our results indicated increased plasma ANXA3 on admission were significantly associated with the incidence of sepsis in critically ill patients (OR = 2.41(1.75-3.32), P < 0.001). As a predictive biomarker, plasma ANXA3 resulted in a better AUC 0.815(0.745-0.886) than PCT (0.673(0.584-0.761)) and IL-6 (0.672(0.585-0.759)) and SOFA score (0.668(0.577-0.759)). Additionally, patients with higher plasma ANXA3 had a poorer overall 28-day survival in critically ill patients (HR = 2.16(1.09-4.28); P < 0.05), but not for sepsis patients (HR = 1.63(0.65-4.06); P > 0.05).ConclusionsOur study indicated increased ANXA3 obtained a good predictive ability for sepsis. Meanwhile, plasma ANXA3 was associated with mortality of critically ill patients, but not sepsis patients. The use of ANXA3 as a biomarker in sepsis patients require further evaluation in larger studies.