Journal of Intensive Care Medicine最新文献

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.

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.