Journal of Intensive Care Medicine最新文献

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.

ObjectivesThis study endeavors to examine the relationship between lactate (LA) levels and the risk of acute kidney injury (AKI) in patients with hemorrhagic shock (HS) and septic shock (SS).Methods983 HS and 4086 SS patients from the MIMIC-IV database were included and analyzed using restricted cubic spline (RCS), Cox model, Kaplan-Meier (KM), and receiver operating characteristic (ROC) curve analysis.ResultsMultivariate Cox regression analysis revealed that elevated LA was significantly associated with higher risks of AKI and in-hospital mortality rate (IMR) (all P < .001). After adjusting for confounders, LA had a greater effect on AKI risk in SS patients (hazard ratio (HR) = 1.056 versus 1.05 in HS), whereas LA more strongly influenced IMR in HS patients (HR = 1.115 vs 1.08 in SS). The safe LA thresholds, where HR = 1, were 2.083 mmol/L for SS and 2.31 mmol/L for HS. KM analysis demonstrated significant differences in cumulative AKI incidence and IMR among different LA levels (Log-rank P < .001). In HS patients, AKI risk increased linearly with rising LA, reflecting cumulative hypoperfusion. In SS patients, AKI risk rose sharply at lower LA levels, likely due to the inflammatory cytokine storm. ROC analysis showed that LA improved the predictive performance of the Acute Physiology Score III (APSIII) and the Simplified Acute Physiology Score II (SAPSII), particularly in HS patients. The change in area under the curve (ΔAUC) of SAPSII for predicting IMR was +0.042 in HS and +0.013 in SS.ConclusionsLA is a key predictor of AKI risk and prognosis in HS or SS patients, and its impact is heterogeneous among different populations, suggesting that individualized monitoring thresholds are needed.

ObjectiveThis paper was designed to investigate the clinical efficacy of combining the Average Volume Assured Pressure Support (AVAPS) mode of non-invasive ventilation (NIV) with high-flow nasal cannula oxygenation (HFNC) oxygen therapy in managing chronic obstructive pulmonary disease (COPD) patients complicated by respiratory failure.MethodsNinety-six patients with COPD and respiratory failure were enrolled and classified into a control group and an observation group. Both groups received conventional treatment. The control group was treated with AVAPS-mode NIV, while the observation group received additional HFNC. Clinical outcomes, adverse reactions, clinical indicators, blood gas parameters, serum inflammatory markers, and pulmonary function indicators were compared between the two groups.ResultsThe observation group had a significantly higher overall clinical response rate (93.75% vs 75.00%, P < 0.05), shorter ICU stays and mechanical ventilation times, lower respiratory rates, higher PaO₂, SaO₂, FEV₁, FVC, and FEV₁/FVC values, and lower PaCO₂, IL-6, IL-8, TNF-α, and sTREM-1 levels than the control group (all P < 0.05). Heart rate did not differ significantly between the two groups (P > 0.05). The adverse reaction rate was significantly lower in the observation group relative to the control group (4.17% vs 18.75%, P < 0.05).ConclusionThis combined approach demonstrates superior efficacy in treating COPD patients with respiratory failure, improving arterial blood gas and pulmonary function, reducing inflammatory responses, and exhibiting a high safety profile.

BackgroundDelirium is a common and serious complication in critically ill and surgical patients, associated with increased morbidity, prolonged hospitalization, and long-term cognitive impairment. Ketamine and esketamine have been proposed as potential protective agents due to their anti-inflammatory, analgesic, and NMDA receptor-blocking properties.MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the use of ketamine or esketamine for the prevention of delirium in adult surgical patients, some of whom required postoperative Intensive Care Unit (ICU) level care. The primary outcome was the incidence of delirium. Secondary outcomes included pain assessment, opioid consumption, ICU and hospital length of stay, mortality, and neuropsychiatric adverse events. Risk of bias was assessed using the Cochrane RoB 2.0 tool. This review was registered in PROSPERO (CRD420251061137) and conducted according to PRISMA 2020 guidelines.ResultsEight RCTs involving a total of 1645 patients were included. Ketamine or esketamine significantly reduced the incidence of delirium compared to placebo (odds ratio [OR] = 0.50; 95% CI: 0.28-0.91; p = .02). Subgroup analysis revealed a significant benefit in older adults (mean age > 60 years), but not in younger populations. Neuropsychiatric adverse events-such as hallucinations and nightmares-were more frequent in the ketamine group (OR = 1.60; 95% CI: 1.15-2.21; p = .005). No consistent effects were observed on pain scores, opioid consumption, or length of stay.ConclusionKetamine and esketamine may reduce the incidence of delirium in surgical patients, particularly in older adults, although this benefit must be weighed against a higher incidence of neuropsychiatric symptoms.

Patients in the intensive care unit often develop anion gap metabolic acidosis most commonly from lactic acidosis. Clinicians routinely measure serum lactate levels, but it is not clear if one is able to use the measured serum lactate level to determine if there is a second cause for anion gap metabolic acidosis in these critically ill patients. In this report, 503 episodes of lactic acidosis with serum lactate levels greater than 5 mmol/L at a single institution over two years were analyzed. The average serum anion gap minus serum lactate level in these patients was 6.9 ± 0.21 mEq/L, the average corrected anion gap was -1.3 ± 0.23 mEq/L and the average strong ion gap was 5.1 ± 0.3 mEq/L. The majority of the episodes with anion gap-serum lactate concentration >8.0 mEq/L were explained by elevated serum albumin concentration, elevated serum phosphorus concentration, presence of ketones in the urine or high β-hydroxybutyrate concentrations. The above data suggest that one can use the measured serum lactate concentration and subtract from the serum anion gap to determine if there is a second reason for anion gap metabolic acidosis.

PurposeAn elevated ventilatory ratio (VR) and acute cor pulmonale (ACP) are associated with mortality in ARDS patients. The primary aim of this study was to assess the association between VR and ACP in patients with COVID-19-related ARDS (C-ARDS). The secondary objectives were to analyze the association between VR and ICU mortality, describe VR temporal behavior in survivors and non-survivors, and evaluate the association between VR and pulmonary embolism.Materials and MethodsWe studied a cohort of patients with C-ARDS. The VR was calculated using a validated formula. Echocardiography was used to diagnose ACP, and CT pulmonary angiography was performed to identify PE. To evaluate the associations between VR and ACP, mortality, and PE, a generalized logistic regression model was used.ResultsOf the 140 subjects, 60 (43%) had a VR < 2, while 80 (57%) had a VR ≥ 2. Patients with a VR ≥2 had a higher risk of developing ACP than those with a VR <2 (Odds Ratio (OR), 3.77; 95% CI: 1.30 - 8.72). The ICU mortality rate was 29%. Of the 40 patients who died, 30 (75%) had a VR ≥ 2. Mortality was significantly associated with VR ≥ 2 and driving pressure ≥ 15 cm H₂O. In non-survivor patients with a VR < 2 at ICU admission, a significant increase in VR was observed over the 7-day observation period. No significant association was observed between PE and VR (p = .118).ConclusionElevated VR was associated with ACP in patients with C-ARDS. VR ≥ 2 combined with driving pressure ≥ 15 cm H₂O significantly improved the ability to identify patients at risk for ACP. Additionally, at ICU admission, elevated VR values and initially low values that increased over the first week were associated with higher ICU mortality.

ObjectivesHigh-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.MethodsA 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).Results4100 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.ConclusionsPeri-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.