Pub Date : 2024-08-06DOI: 10.1177/08850666241268473
Nicole R Henry, Matthew A Warner, Andrew C Hanson, Phillip J Schulte, Nafisseh S Warner
Background: Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. Methods: This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. Results: Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, P < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, P < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], P < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], P < .001). Similar associations were observed across surgical and nonsurgical admissions. Conclusions: Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.
背景:住院是处方阿片类药物的主要获取点,但人们对危重病人住院前后阿片类药物暴露的模式和结果知之甚少。研究方法这是一项基于人群的观察性队列研究,研究对象是 2010 年至 2019 年期间因危重病住院的成年人(≥18 岁)。多变量模型评估住院前阿片类药物暴露(根据阿片类药物风险和趋势研究联合会进行分类)与住院后阿片类药物暴露和住院后 1 年临床结果之间的关联。结果:在 11 496 名患者中,6318 名(55%)为男性,中位年龄为 66(51,79)岁,40%(n = 4623)接受过手术治疗。入院前阿片类药物供应情况包括 8449 例(73%)无阿片类药物供应,2117 例(18%)短期阿片类药物供应,471 例(4%)偶发性阿片类药物供应和 459 例(4%)长期阿片类药物供应。39%(4144/10 708)的医院幸存者在出院时使用了阿片类药物,其中手术入院者的处方率较高(55%)。入院前阿片类药物暴露越多,1 年后阿片类药物使用率越高(长期暴露、偶发性暴露和短期暴露的几率比[95% 置信区间]分别为 24.1 [18.3-31.8]、9.42 [7.18-12.3]和 2.55 [2.08-3.12] vs none,P P P P 结论:危重症幸存者入院前的阿片类药物暴露与1年后的临床结果有关,可作为重要的预后指标。
{"title":"Patterns and Outcomes of Opioid Use Before and After Hospitalization for Critical Illness: A Population-Based Cohort Study.","authors":"Nicole R Henry, Matthew A Warner, Andrew C Hanson, Phillip J Schulte, Nafisseh S Warner","doi":"10.1177/08850666241268473","DOIUrl":"https://doi.org/10.1177/08850666241268473","url":null,"abstract":"<p><p><b>Background:</b> Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. <b>Methods:</b> This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. <b>Results:</b> Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, <i>P</i> < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, <i>P</i> < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], <i>P</i> < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], <i>P</i> < .001). Similar associations were observed across surgical and nonsurgical admissions. <b>Conclusions:</b> Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141893531","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-02DOI: 10.1177/08850666241268458
Ralph T Perry, John W Weimer, Carrie Pratt, Marci D Newcome, Gabor Bagameri, J Kyle Bohman
Objectives: To determine whether a nurse practitioner and physician assistant (NP/PA)-led rapid staffing. Model in the cardiac surgical intensive care unit (ICU) can optimize resource utilization without compromising safety or increasing hospital length of stay (LoS).
Design: Retrospective observational cohort study comparing before-and-after implementation of an NP/PA-led rapid recovery pathway.
Setting: A large tertiary referral academic cardiac surgery ICU.
Participants: There were 116 patients in the prerapid recovery cohort and 153 in the postimplementation rapid recovery phase.
Interventions: Low-risk cardiac surgery patients were selected for postoperative care by an NP/PA-led ICU staffing model.
Measurements and main results: Mean hospital LoS in the prerapid recovery cohort was 5.7 days compared to 5.2 days in the rapid recovery pathway cohort (P = .02). Thirty-day hospital readmission in the prerapid recovery pathway cohort was 7.8% compared with 2.0% in the rapid recovery cohort (P = .04). The ICU readmission rate for prerapid recovery cohort was 4.3%, while the rapid recovery percentage was 2.0% (P = .30).
Conclusions: Overall, implementation of an NP/PA-led postcardiac surgical ICU team (rapid recovery pathway) was associated with similar ICU LoS, hospital LoS, ICU readmission rates, 30-day readmission rates, and no significant signal of increased adverse events or safety concerns.
{"title":"Nurse Practitioner and Physician Assistant-led Cardiovascular Surgery Postoperative Intensive Care Unit Staffing Model.","authors":"Ralph T Perry, John W Weimer, Carrie Pratt, Marci D Newcome, Gabor Bagameri, J Kyle Bohman","doi":"10.1177/08850666241268458","DOIUrl":"https://doi.org/10.1177/08850666241268458","url":null,"abstract":"<p><strong>Objectives: </strong>To determine whether a nurse practitioner and physician assistant (NP/PA)-led rapid staffing. Model in the cardiac surgical intensive care unit (ICU) can optimize resource utilization without compromising safety or increasing hospital length of stay (LoS).</p><p><strong>Design: </strong>Retrospective observational cohort study comparing before-and-after implementation of an NP/PA-led rapid recovery pathway.</p><p><strong>Setting: </strong>A large tertiary referral academic cardiac surgery ICU.</p><p><strong>Participants: </strong>There were 116 patients in the prerapid recovery cohort and 153 in the postimplementation rapid recovery phase.</p><p><strong>Interventions: </strong>Low-risk cardiac surgery patients were selected for postoperative care by an NP/PA-led ICU staffing model.</p><p><strong>Measurements and main results: </strong>Mean hospital LoS in the prerapid recovery cohort was 5.7 days compared to 5.2 days in the rapid recovery pathway cohort (<i>P</i> = .02). Thirty-day hospital readmission in the prerapid recovery pathway cohort was 7.8% compared with 2.0% in the rapid recovery cohort (<i>P</i> = .04). The ICU readmission rate for prerapid recovery cohort was 4.3%, while the rapid recovery percentage was 2.0% (<i>P</i> = .30).</p><p><strong>Conclusions: </strong>Overall, implementation of an NP/PA-led postcardiac surgical ICU team (<i>rapid recovery pathway</i>) was associated with similar ICU LoS, hospital LoS, ICU readmission rates, 30-day readmission rates, and no significant signal of increased adverse events or safety concerns.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-02DOI: 10.1177/08850666241268655
Michael E Kim, Katja M Gist, Katie Brandewie, Huaiyu Zang, David Lehenbauer, David S Winlaw, David L S Morales, Jeffrey A Alten, Stuart L Goldstein, David S Cooper
Background: Elevated renin has been shown to predict poor response to standard vasoactive therapies and is associated with poor outcomes in adults. Similarly, elevated renin was associated with mortality in children with septic shock. Renin concentration profiles after pediatric cardiac surgery are unknown. The purpose of this study was to characterize renin kinetics after pediatric cardiac surgery.
Methods: Single-center retrospective study of infants who underwent cardiac surgery with cardiopulmonary bypass (CPB) utilizing serum samples obtained in the perioperative period to measure plasma renin concentrations (pg/mL). Time points included pre-bypass and 1, 4, and 24 h after initiation of CPB.
Results: Fifty patients (65% male) with a median age 5 months (interquartile range (IQR) 3.5, 6.5) were included. Renin concentrations peaked 4 h after CPB. There was a significant difference in preoperative and 4 h post-CPB renin concentration (4 h post-CPB vs preoperative: mean difference 100.6, 95% confidence interval (CI) 48.9-152.4, P < .001). Median renin concentration at 24 h after CPB was lower than the preoperative baseline.
Conclusions: We describe renin kinetics in infants after CPB. Future studies based on these data can now be performed to evaluate the associations of elevated renin concentrations with adverse outcomes.
{"title":"Kinetics of Renin Concentrations in Infants Undergoing Congenital Cardiac Surgery.","authors":"Michael E Kim, Katja M Gist, Katie Brandewie, Huaiyu Zang, David Lehenbauer, David S Winlaw, David L S Morales, Jeffrey A Alten, Stuart L Goldstein, David S Cooper","doi":"10.1177/08850666241268655","DOIUrl":"https://doi.org/10.1177/08850666241268655","url":null,"abstract":"<p><strong>Background: </strong>Elevated renin has been shown to predict poor response to standard vasoactive therapies and is associated with poor outcomes in adults. Similarly, elevated renin was associated with mortality in children with septic shock. Renin concentration profiles after pediatric cardiac surgery are unknown. The purpose of this study was to characterize renin kinetics after pediatric cardiac surgery.</p><p><strong>Methods: </strong>Single-center retrospective study of infants who underwent cardiac surgery with cardiopulmonary bypass (CPB) utilizing serum samples obtained in the perioperative period to measure plasma renin concentrations (pg/mL). Time points included pre-bypass and 1, 4, and 24 h after initiation of CPB.</p><p><strong>Results: </strong>Fifty patients (65% male) with a median age 5 months (interquartile range (IQR) 3.5, 6.5) were included. Renin concentrations peaked 4 h after CPB. There was a significant difference in preoperative and 4 h post-CPB renin concentration (4 h post-CPB vs preoperative: mean difference 100.6, 95% confidence interval (CI) 48.9-152.4, <i>P</i> < .001). Median renin concentration at 24 h after CPB was lower than the preoperative baseline.</p><p><strong>Conclusions: </strong>We describe renin kinetics in infants after CPB. Future studies based on these data can now be performed to evaluate the associations of elevated renin concentrations with adverse outcomes.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Acute kidney injury (AKI) is common in sepsis and a urine output <0.5 mL/kg/h associated with increased mortality is incorporated into AKI diagnosis. We aimed to identify the urine-output threshold associated with increased AKI incidence and hypothesized that a higher urine output than a specified threshold, which differs from the predominantly used 0.5 mL/kg/h threshold, would be associated with an increased AKI incidence.
Methods: This was a post-hoc analysis of a nationwide prospective observational study. This study included adult patients newly diagnosed with sepsis and requiring intensive care. Urine output on the day of sepsis diagnosis was categorized as low, moderate, or high (<0.5, 0.5-1.0, and >1.0 mL/kg/h, respectively), and we compared AKI incidence, renal replacement therapy (RRT) requirement, and 28-day survival by category. Estimated probabilities for these outcomes were also compared after adjusting for patient background and hourly fluid administration.
Results: Among 172 eligible patients, AKI occurred in 46.3%, 48.3%, and 53.1% of those with high, moderate, and low urine output, respectively. The probability of AKI was lower in patients with high urine output than in those with low output (43.6% vs 56.5%; P = .028), whereas RRT requirement was lower in patients with high and moderate urine output (11.7% and 12.8% vs 49.1%; P < .001). Patients with low urine output demonstrated significantly lower survival (87.7% vs 82.8% and 67.8%; P = .018). Cubic spline curves for AKI, RRT, and survival prediction indicated different urine-output thresholds, including <1.2 to 1.3 mL/kg/h for AKI and <0.6 to 0.8 mL/kg/h for RRT and mortality risk.
Conclusions: Urine output >1.0 mL/kg/h on the day of sepsis diagnosis was associated with lower AKI incidence. The urine-output threshold was higher for developing AKI than for RRT requirement or mortality.
背景:急性肾损伤(AKI急性肾损伤(AKI)常见于败血症和尿量方法:这是对一项全国性前瞻性观察研究的事后分析。研究对象包括新诊断为败血症并需要重症监护的成年患者。脓毒症确诊当天的尿量分为低、中、高(分别为 1.0 mL/kg/h),我们按类别比较了 AKI 发病率、肾脏替代治疗(RRT)需求和 28 天存活率。在对患者背景和每小时输液量进行调整后,我们还比较了这些结果的估计概率:在 172 名符合条件的患者中,高、中、低尿量患者的 AKI 发生率分别为 46.3%、48.3% 和 53.1%。高尿量患者发生 AKI 的概率低于低尿量患者(43.6% vs 56.5%;P = .028),而高尿量和中等尿量患者的 RRT 需求较低(11.7% 和 12.8% vs 49.1%;P = .018)。AKI、RRT 和生存预测的三次样条曲线显示了不同的尿量阈值,包括结论:脓毒症确诊当天尿量>1.0 mL/kg/h与较低的AKI发生率相关。发生 AKI 的尿量阈值高于 RRT 需求或死亡率阈值。
{"title":"Urine Output and Development of Acute Kidney Injury in Sepsis: A Multicenter Observational Study.","authors":"Ryo Yamamoto, Kazuma Yamakawa, Jo Yoshizawa, Daiki Kaito, Yutaka Umemura, Koichiro Homma, Junichi Sasaki","doi":"10.1177/08850666241268390","DOIUrl":"https://doi.org/10.1177/08850666241268390","url":null,"abstract":"<p><strong>Background: </strong>Acute kidney injury (AKI) is common in sepsis and a urine output <0.5 mL/kg/h associated with increased mortality is incorporated into AKI diagnosis. We aimed to identify the urine-output threshold associated with increased AKI incidence and hypothesized that a higher urine output than a specified threshold, which differs from the predominantly used 0.5 mL/kg/h threshold, would be associated with an increased AKI incidence.</p><p><strong>Methods: </strong>This was a post-hoc analysis of a nationwide prospective observational study. This study included adult patients newly diagnosed with sepsis and requiring intensive care. Urine output on the day of sepsis diagnosis was categorized as low, moderate, or high (<0.5, 0.5-1.0, and >1.0 mL/kg/h, respectively), and we compared AKI incidence, renal replacement therapy (RRT) requirement, and 28-day survival by category. Estimated probabilities for these outcomes were also compared after adjusting for patient background and hourly fluid administration.</p><p><strong>Results: </strong>Among 172 eligible patients, AKI occurred in 46.3%, 48.3%, and 53.1% of those with high, moderate, and low urine output, respectively. The probability of AKI was lower in patients with high urine output than in those with low output (43.6% vs 56.5%; <i>P </i>= .028), whereas RRT requirement was lower in patients with high and moderate urine output (11.7% and 12.8% vs 49.1%; <i>P </i>< .001). Patients with low urine output demonstrated significantly lower survival (87.7% vs 82.8% and 67.8%; <i>P </i>= .018). Cubic spline curves for AKI, RRT, and survival prediction indicated different urine-output thresholds, including <1.2 to 1.3 mL/kg/h for AKI and <0.6 to 0.8 mL/kg/h for RRT and mortality risk.</p><p><strong>Conclusions: </strong>Urine output >1.0 mL/kg/h on the day of sepsis diagnosis was associated with lower AKI incidence. The urine-output threshold was higher for developing AKI than for RRT requirement or mortality.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-02DOI: 10.1177/08850666241267261
Jingxiao Zhang, Zhifang Zheng, Lei Ren, Chenhong Wang, Yue Li, Xidan Hu, Jie Zhang, Xiaoqing Jing, Yuzi Jin
Objectives: To investigate the diagnostic value of hepcidin for sepsis diagnosis. Methods: The relevant literature on hepcidin for sepsis diagnosis published up to October 20, 2023, was systematically searched in the Web of Science, PubMed, Embase, and China Knowledge Network databases. Two researchers screened the literature and extracted relevant data according to the inclusion and exclusion criteria. Study quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis and calculation of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were performed using State16 and Review Manager 5.3 software. Furthermore, receiver operating characteristic curve (ROC) was plotted, and the respective area under the curve (AUC) was calculated to assess the accuracy of hepcidin. Publication bias was evaluated using Deeks' funnel plot asymmetry test. Results: Overall, 1047 patients from 8 studies were included (625 patients with sepsis and 422 controls). The quality of the literature was relatively moderate. Meta-analysis demonstrated the presence of heterogeneity in the data (I2> 50%, P < .05), and a randomized model was employed to combine the diagnostic indicators. Regarding its accuracy for sepsis diagnosis, hepcidin demonstrated a pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.76-0.94) and specificity of 0.91 (95% CI: 0.76-0.97). The diagnostic odds ratio was 69.00 (95% CI: 19.00-253.00), and the ROC curve revealed an AUC of 0.95. Additionally, Deeks' funnel plot asymmetry test demonstrated absence of publication bias. Conclusions: Our meta-analysis suggested that hepcidin has a high diagnostic value in sepsis and may be a valuable diagnostic tool.
{"title":"Diagnostic Value of Hepcidin in Sepsis: A Systematic Review and Meta-Analysis.","authors":"Jingxiao Zhang, Zhifang Zheng, Lei Ren, Chenhong Wang, Yue Li, Xidan Hu, Jie Zhang, Xiaoqing Jing, Yuzi Jin","doi":"10.1177/08850666241267261","DOIUrl":"https://doi.org/10.1177/08850666241267261","url":null,"abstract":"<p><p><b>Objectives:</b> To investigate the diagnostic value of hepcidin for sepsis diagnosis. <b>Methods:</b> The relevant literature on hepcidin for sepsis diagnosis published up to October 20, 2023, was systematically searched in the Web of Science, PubMed, Embase, and China Knowledge Network databases. Two researchers screened the literature and extracted relevant data according to the inclusion and exclusion criteria. Study quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis and calculation of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were performed using State16 and Review Manager 5.3 software. Furthermore, receiver operating characteristic curve (ROC) was plotted, and the respective area under the curve (AUC) was calculated to assess the accuracy of hepcidin. Publication bias was evaluated using Deeks' funnel plot asymmetry test. <b>Results:</b> Overall, 1047 patients from 8 studies were included (625 patients with sepsis and 422 controls). The quality of the literature was relatively moderate. Meta-analysis demonstrated the presence of heterogeneity in the data (<i>I</i><sup>2</sup><i><sup> </sup></i>> 50%, <i>P </i>< .05), and a randomized model was employed to combine the diagnostic indicators. Regarding its accuracy for sepsis diagnosis, hepcidin demonstrated a pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.76-0.94) and specificity of 0.91 (95% CI: 0.76-0.97). The diagnostic odds ratio was 69.00 (95% CI: 19.00-253.00), and the ROC curve revealed an AUC of 0.95. Additionally, Deeks' funnel plot asymmetry test demonstrated absence of publication bias. <b>Conclusions:</b> Our meta-analysis suggested that hepcidin has a high diagnostic value in sepsis and may be a valuable diagnostic tool.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878885","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-02DOI: 10.1177/08850666241267262
Nicole Cherng, Ikechukwu Achebe, Mason Winkie, Julie Thomann, Eric Then, Neil B Marya
Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.
急性胆囊炎(AC)的发病率和死亡率都很高。微创腹腔镜胆囊切除术仍是治疗的黄金标准。对于手术风险过高的患者来说,内镜治疗胆囊炎是替代经皮胆囊引流术的最佳选择。内镜治疗胆囊切除术包括经乳头和经壁支架置入术。当患者的特异性因素阻碍了手术和内镜治疗时,可选择经皮胆囊造口管(PCT)置入术。早期研究显示,与其他所有治疗 AC 的方法相比,经皮胆囊造口术的疗效更差。
{"title":"Approaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management.","authors":"Nicole Cherng, Ikechukwu Achebe, Mason Winkie, Julie Thomann, Eric Then, Neil B Marya","doi":"10.1177/08850666241267262","DOIUrl":"https://doi.org/10.1177/08850666241267262","url":null,"abstract":"<p><p>Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01Epub Date: 2024-02-11DOI: 10.1177/08850666241232362
Timothy Phillips, Abdallah Mughrabi, Levindo J Garcia, Christopher El Mouhayyar, Laith Hattar, Hocine Tighiouart, Andrew H Moraco, Claudia Nader, Bertrand L Jaber
Purpose: This study examines whether excessive adipose tissue, as measured by the body mass index (BMI), is associated with higher systemic markers of inflammation and higher risk of severe acute organ failure among patients with coronavirus disease 2019 (COVID-19). Methods: This was a multicenter retrospective cohort study of 1370 hospitalized adults (18 years or older) with COVID-19 during the first wave of the pandemic. Patient-level variables were extracted from the electronic medical record. The primary predictor variable was the BMI at time of hospital admission, in accordance with the World Health Organization classification. Multivariable logistic regression analyses examined the association of BMI with the composite of acute respiratory distress syndrome (ARDS), as defined by the use of high-flow nasal canula, non-invasive ventilation, or mechanical ventilation, severe acute kidney injury (AKI), as defined by acute dialysis requirement, or in-hospital death. Results: After adjustment for important cofounders, the BMI stratum of > 40 kg/m2 (compared to the BMI < 25 kg/m2 reference group) was associated with higher odds for the composite of ARDS, severe AKI, or in-hospital death (adjusted odds ratio [ORadj] 1.69; 95% confidence interval [CI]1.03, 2.78). As a continuous variable, BMI (per 5-kg/m2 increase) remained independently associated with the composite outcome (ORadj 1.13; 95% CI 1.03, 1.23); patients in higher BMI categories exhibited significantly higher peak levels of C-reactive protein (CRP), a systemic marker of inflammation (P = .01). In a sub-cohort of 889 patients, the association of BMI with the composite outcome was no longer significant after adjustment for the peak level of CRP. Conclusions: Among hospitalized patients with COVID-19, a higher BMI is associated with higher risk of severe organ failure or in-hospital death, which dissipates after adjustment for CRP level. This supports the hypothesis that inflammation is a downstream mediator of adipose tissue on acute organ dysfunction.
{"title":"Association of Body Mass Index with Multiple Organ Failure in Hospitalized Patients with COVID-19: A Multicenter Retrospective Cohort Study.","authors":"Timothy Phillips, Abdallah Mughrabi, Levindo J Garcia, Christopher El Mouhayyar, Laith Hattar, Hocine Tighiouart, Andrew H Moraco, Claudia Nader, Bertrand L Jaber","doi":"10.1177/08850666241232362","DOIUrl":"10.1177/08850666241232362","url":null,"abstract":"<p><p><b>Purpose:</b> This study examines whether excessive adipose tissue, as measured by the body mass index (BMI), is associated with higher systemic markers of inflammation and higher risk of severe acute organ failure among patients with coronavirus disease 2019 (COVID-19). <b>Methods:</b> This was a multicenter retrospective cohort study of 1370 hospitalized adults (18 years or older) with COVID-19 during the first wave of the pandemic. Patient-level variables were extracted from the electronic medical record. The primary predictor variable was the BMI at time of hospital admission, in accordance with the World Health Organization classification. Multivariable logistic regression analyses examined the association of BMI with the composite of acute respiratory distress syndrome (ARDS), as defined by the use of high-flow nasal canula, non-invasive ventilation, or mechanical ventilation, severe acute kidney injury (AKI), as defined by acute dialysis requirement, or in-hospital death. <b>Results:</b> After adjustment for important cofounders, the BMI stratum of > 40 kg/m<sup>2</sup> (compared to the BMI < 25 kg/m<sup>2</sup> reference group) was associated with higher odds for the composite of ARDS, severe AKI, or in-hospital death (adjusted odds ratio [OR<sub>adj</sub>] 1.69; 95% confidence interval [CI]1.03, 2.78). As a continuous variable, BMI (per 5-kg/m<sup>2</sup> increase) remained independently associated with the composite outcome (OR<sub>adj</sub> 1.13; 95% CI 1.03, 1.23); patients in higher BMI categories exhibited significantly higher peak levels of C-reactive protein (CRP), a systemic marker of inflammation (<i>P</i> = .01). In a sub-cohort of 889 patients, the association of BMI with the composite outcome was no longer significant after adjustment for the peak level of CRP. <b>Conclusions:</b> Among hospitalized patients with COVID-19, a higher BMI is associated with higher risk of severe organ failure or in-hospital death, which dissipates after adjustment for CRP level. This supports the hypothesis that inflammation is a downstream mediator of adipose tissue on acute organ dysfunction.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139722996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Nirmatrelvir/Ritonavir is an orally administered anti-SARS-Cov-2 drug used in mild-to-moderate COVID-19 patients. Our retrospective cohort study aims to evaluate the efficacy and safety of Nirmatrelvir/Ritonavir in severe hospitalized patients with Omicron infection, as well as in patients at high risk for progression to critical illness in real-world settings. Methods: A total of 350 patients received Nirmatrelvir/Ritonavir while 350 matched controls did not. Patients with confirmed COVID-19 were administered Nirmatrelvir 300 mg and Ritonavir 100 mg orally twice a day for 5 days, with the medication initiated on the first day after admission. The primary endpoint of the study was a composite outcome of hospitalization or death from any cause within 28 days. Secondary endpoints included the occurrence of adverse events and the evaluation of serum levels of IL-6 and viral load. Results: We documented the mortality risk from any cause within 28 days, viral load, serum IL-6 levels, and adverse events. Nirmatrelvir/Ritonavir reduced the 28-day risk of all-cause mortality by 86% (P = .011, hazard ratio (HR) = 0.14, 95% confidence interval (CI) = 0.03, 0.64). At baseline, the serum level of IL-6 was significantly higher in the antiviral treatment group compared to the control group (P < .001), but no significant difference (P = .990) was found between the two groups at discharge. In CKD patients undergoing hemodialysis, no significant worsening of renal function was observed in the Nirmatrelvir/Ritonavir treatment group compared to the control group. Conclusion: Nirmatrelvir/Ritonavir may reduce the 28-day risk of all-cause mortality in critically ill patients with COVID-19 and in patients at high risk for critical disease progression.
{"title":"Efficacy and Safety of Nirmatrelvir/Ritonavir in Severe Hospitalized Patients with COVID-19 and in Patients at High Risk for Progression to Critical Illness: A Real-World Study.","authors":"Xiaohua Chen, Ying Zhu, Leer Shen, Dan Zhou, Nannan Feng, Qiang Tong","doi":"10.1177/08850666241228841","DOIUrl":"10.1177/08850666241228841","url":null,"abstract":"<p><p><b>Background:</b> Nirmatrelvir/Ritonavir is an orally administered anti-SARS-Cov-2 drug used in mild-to-moderate COVID-19 patients. Our retrospective cohort study aims to evaluate the efficacy and safety of Nirmatrelvir/Ritonavir in severe hospitalized patients with Omicron infection, as well as in patients at high risk for progression to critical illness in real-world settings. <b>Methods:</b> A total of 350 patients received Nirmatrelvir/Ritonavir while 350 matched controls did not. Patients with confirmed COVID-19 were administered Nirmatrelvir 300 mg and Ritonavir 100 mg orally twice a day for 5 days, with the medication initiated on the first day after admission. The primary endpoint of the study was a composite outcome of hospitalization or death from any cause within 28 days. Secondary endpoints included the occurrence of adverse events and the evaluation of serum levels of IL-6 and viral load. <b>Results:</b> We documented the mortality risk from any cause within 28 days, viral load, serum IL-6 levels, and adverse events. Nirmatrelvir/Ritonavir reduced the 28-day risk of all-cause mortality by 86% (<i>P</i> = .011, hazard ratio (HR) = 0.14, 95% confidence interval (CI) = 0.03, 0.64). At baseline, the serum level of IL-6 was significantly higher in the antiviral treatment group compared to the control group (<i>P</i> < .001), but no significant difference (<i>P</i> = .990) was found between the two groups at discharge. In CKD patients undergoing hemodialysis, no significant worsening of renal function was observed in the Nirmatrelvir/Ritonavir treatment group compared to the control group. <b>Conclusion:</b> Nirmatrelvir/Ritonavir may reduce the 28-day risk of all-cause mortality in critically ill patients with COVID-19 and in patients at high risk for critical disease progression.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139735449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01Epub Date: 2023-10-03DOI: 10.1177/08850666231203601
Astha Chichra, Mayanka Tickoo, Shyoko Honiden
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
{"title":"Managing the Chronically Ventilated Critically Ill Population.","authors":"Astha Chichra, Mayanka Tickoo, Shyoko Honiden","doi":"10.1177/08850666231203601","DOIUrl":"10.1177/08850666231203601","url":null,"abstract":"<p><p>Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the \"chronically critically ill\" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41135333","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1177/08850666241268470
Marianne Kruse, Philip Plettig, David Josuttis, Denis Guembel, Claas Guethoff, Bernd Hartmann, Simon Kuepper, Volker Gebhardt, Marc Dominik Schmittner
Adequate fluid therapy is crucial to maintain organ function after burn trauma. Major burns lead to a systemic response with fluid loss and cardiac dysfunction. To guide fluid therapy, measurement of cardiac pre- and afterload is helpful. Whereas cardiac function is usually measured after admission to intensive care unit (ICU), in this study, hemodynamic monitoring was performed directly after arrival at hospital. We conducted a prospective cohort study with inclusion of 19 patients (male/female 13/6, 55 ± 18 years, mean total body surface area 36 ± 19%). Arterial waveform analysis (PulsioFlexProAqt®, Getinge) was implemented immediately after admission to hospital to measure cardiac pre- and afterload and to guide resuscitation therapy. Cardiac parameters 3.75 (2.67-6.0) h after trauma were normal regarding cardiac index (3.45 ± 0.82) L/min/m², systemic vascular resistance index (1749 ± 533) dyn sec/cm5 m2, and stroke volume (SV; 80 ± 20) mL. Stroke volume variation (SVV) was increased (21 ± 7) % and associated with mortality (mean SVV survivors vs nonsurvivors 18.92 (±6.37) % vs 27.6 (±5.68) %, P = .017). Stroke volume was associated with mortality at the time of ICU-admission (mean SV survivors vs nonsurvivors 90 (±20) mL vs 50 (±0) mL, P = .004). Changes after volume challenge were significant for SVV (24 ± 9 vs19 ± 8%, P = .01) and SV (68 ± 24 vs 76 ± 26 mL, P = .03). We described association of SVV and SV with survival of severely burned patients in an observational study. This indicates high valence of those parameters in the early postburn period. The use of an autocalibrated device enables a very early monitoring of parameters relevant to burn shock survival.
{"title":"Stroke Volume and Stroke Volume Variation, but not Cardiac Index Is Associated With Survival of Majorly Burned Patients in Early Burn Shock.","authors":"Marianne Kruse, Philip Plettig, David Josuttis, Denis Guembel, Claas Guethoff, Bernd Hartmann, Simon Kuepper, Volker Gebhardt, Marc Dominik Schmittner","doi":"10.1177/08850666241268470","DOIUrl":"https://doi.org/10.1177/08850666241268470","url":null,"abstract":"<p><p>Adequate fluid therapy is crucial to maintain organ function after burn trauma. Major burns lead to a systemic response with fluid loss and cardiac dysfunction. To guide fluid therapy, measurement of cardiac pre- and afterload is helpful. Whereas cardiac function is usually measured after admission to intensive care unit (ICU), in this study, hemodynamic monitoring was performed directly after arrival at hospital. We conducted a prospective cohort study with inclusion of 19 patients (male/female 13/6, 55 ± 18 years, mean total body surface area 36 ± 19%). Arterial waveform analysis (PulsioFlexProAqt<sup>®</sup>, Getinge) was implemented immediately after admission to hospital to measure cardiac pre- and afterload and to guide resuscitation therapy. Cardiac parameters 3.75 (2.67-6.0) h after trauma were normal regarding cardiac index (3.45 ± 0.82) L/min/m², systemic vascular resistance index (1749 ± 533) dyn sec/cm<sup>5</sup> m<sup>2</sup>, and stroke volume (SV; 80 ± 20) mL. Stroke volume variation (SVV) was increased (21 ± 7) % and associated with mortality (mean SVV survivors vs nonsurvivors 18.92 (±6.37) % vs 27.6 (±5.68) %, <i>P</i> = .017). Stroke volume was associated with mortality at the time of ICU-admission (mean SV survivors vs nonsurvivors 90 (±20) mL vs 50 (±0) mL, <i>P</i> = .004). Changes after volume challenge were significant for SVV (24 ± 9 vs19 ± 8%, <i>P</i> = .01) and SV (68 ± 24 vs 76 ± 26 mL, <i>P</i> = .03). We described association of SVV and SV with survival of severely burned patients in an observational study. This indicates high valence of those parameters in the early postburn period. The use of an autocalibrated device enables a very early monitoring of parameters relevant to burn shock survival.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141875107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}