Journal of Intensive Care Medicine最新文献

Necrotizing soft tissue infections (NSTIs) present a rare but devasting disease process for affected patients. Timely diagnosis and management of this condition is essential for critical care providers to obtain optimal patient outcomes. Given their rarity, NSTIs are often diagnosed late in the disease process, contributing to an increase in morbidity and mortality among these patients. In this review, we discuss how to classify these infections, their risk factors, pathophysiology, clinical presentation, diagnosis, scoring systems and treatment, with an emphasis on surgical management.

BackgroundLong-term physical dysfunction common among intensive care unit (ICU) survivors and mortality remains a concern even after hospital discharge. Although early identification of patients at risk for these outcomes is essential, few studies have investigated whether physical assessments at ICU discharge can predict physical dysfunction or death at 3, 6, and 12 months after discharge. The purpose of this study was to examine the association between physical assessment at ICU discharge and the incidence of physical functional disability or death within 12 months after discharge.MethodsThis was a multicenter prospective cohort study of 21 ICUs in Japan. Patients with sepsis admitted to the ICU for >48 h were enrolled. The primary outcome was physical dysfunction (Barthel index ≤90) or death at 3, 6, and 12 months after discharge. Physical assessments at the time of ICU discharge included the Medical Research Council (MRC) score, handgrip strength, and the Barthel index. A multiple logistic regression model and area under the curve (AUC) were used.ResultsIn total, 300 ICU patients (median age, 74 years) were included. MRC score (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.96-0.99, cut-off: 46), hand grip strength (OR: 0.95, 95%CI: 0.92-0.98, cut-off: 12.0 kg), and Barthel index (OR: 0.96, 95%CI 0.95-0.98, cut-off: 15) were independent predictors of physical dysfunction or death at 12 months after hospital discharge and at 3 and 6 months. The Barthel index at ICU discharge showed the highest AUC for physical function or death at 12 months (0.718). The Barthel index and hand grip strength were also associated with cognitive dysfunction or mental disorders.ConclusionsIn ICU patients with sepsis, clinically available physical and muscle strength assessments at ICU discharge were significantly associated with physical dysfunction incidence or death over the first year of hospital discharge.Trial registration number: UMIN000041433.

Acute kidney injury (AKI) is a frequent complication in critically ill patients and is associated with high mortality. While renal replacement therapy (RRT) remains a cornerstone of supportive care for severe AKI, the optimal circumstances for RRT initiation in critically ill patients is a longstanding subject of debate. This narrative review aims to provide an up to date summary of the evidence regarding timing of RRT initiation in the intensive care unit (ICU) and its impact on clinical outcomes. Additionally, management strategies for patients while RRT is delayed are suggested and means to identify patients who have a high probability of receiving RRT are explored.

BackgroundPregnancy-associated sepsis poses significant maternal, fetal and neonatal risks, with acute kidney injury (AKI) being a critical complication. The dynamic relationship between serum sodium trajectories and AKI in this population remains unclear.MethodsIn this retrospective cohort study, 138 pregnant patients with sepsis were analyzed using the MIMIC-IV 3.1 database. Three serum sodium trajectory groups were identified via group-based trajectory modeling (GBTM). AKI was defined per KDIGO criteria. Analyses employed logistic regression, inverse probability weighting, multivariable adjustments and cubic spline models.ResultsThree distinct trajectories emerged: Group 1 (low initial sodium that subsequently increased, n = 34), Group 2 (stable sodium levels, n = 83), and Group 3 (high sodium levels throughout, n = 21). Groups 1 and 3 exhibited higher AKI incidence (ORs: 4.04 [95%CI: 1.63-9.96] and 3.97 [95%CI: 1.33-11.87], respectively; both p < 0.05), prolonged ICU stay hours(72, 118 vs 47, p < 0.001), and elevated SOFA scores (p = 0.01) compared to Group 2. Cubic spline analysis revealed a U-shaped risk relationship, with AKI incidence rising at sodium levels >145 mmol/L (p-value for overall was 0.037 and for nonlinear was 0.021).ConclusionsDynamic sodium trajectories, particularly low initial sodium that subsequently increased, independently predict AKI and adverse outcomes in pregnancy-associated sepsis.

BackgroundIdentifying aspiration is an under-recognized component to reducing a patient's hospital length of stay, reducing hospital costs and lessening mortality risk. Given increased utilization of High Flow Nasal Oxygen (HFNO) and limited evidence identifying impacts of HFNO on swallowing and aspiration, our study contributes to determining the correlation between aspiration and HFNO.Research QuestionsDoes HFNO increase the odds of aspiration or silent aspiration? Do proportions of patients who exhibit aspiration or silent aspiration differ at different levels of oxygen support?Study Design and MethodsAn observational retrospective cohort study of a prospectively collected database of 910 adult patients from December 2020 - October 2022 treated with HFNO.ResultsMultivariable logistic regression modeling showed HFNO was not significantly associated with PAS 5-8, thin liquids (adjusted OR: 1.09, p = .702) nor significantly associated with PAS 8, thin liquids (adjusted OR: 1.04, p = .880). However, deep unsensed penetration and aspiration ranged from 48%-86% across all oxygen flow rate levels with a higher proportion of patients silently aspirating while on the 10-20L/min flow rate of oxygen.InterpretationWhile our findings did not find HFNO to be an independent risk factor, there were high rates of deep unsensed penetration and aspiration events across all oxygen flow levels. This indicates a high level of vigilance is necessary and prioritizing patient safety is recommended for critically ill patients receiving HFNO.

Purpose: To develop and validate an explainable machine learning (ML) tool to help clinicians predict the risk of propofol-associated hypertriglyceridemia in critically ill patients receiving propofol sedation. Methods: Patients from 11 intensive care units (ICUs) across five Mayo Clinic hospitals were included if they met the following criteria: a) ≥ 18 years of age, b) received propofol infusion while on invasive mechanical ventilation for ≥24 h, and c) had a triglyceride level measured. The primary outcome was hypertriglyceridemia (triglyceride >400 mg/dL) onset within 10 days of propofol initiation. Both COVID-inclusive and COVID-independent modeling pipelines were developed to ensure applicability post-pandemic. Decision thresholds were chosen to maintain model sensitivity >80%. Nested leave-one-site-out cross-validation (LOSO-CV) was used to externally evaluate pipeline performance. Model explainability was assessed using permutation importance and SHapley Additive exPlanations (SHAP). Results: Among 3922 included patients, 769 (19.6%) developed propofol-associated hypertriglyceridemia, and 879 (22.4%) had COVID-19 at ICU admission. During nested LOSO-CV, the COVID-inclusive pipeline achieved an average AUC-ROC of 0.71 (95% confidence interval [CI] 0.70-0.72), while the COVID-independent pipeline achieved an average AUC-ROC of 0.69 (95% CI 0.68-0.70). Age, initial propofol dose, and BMI were the top three most important features in both models. Conclusion: We developed an explainable ML-based tool with acceptable predictive performance for assessing the risk of propofol-associated hypertriglyceridemia in ICU patients. This tool can aid clinicians in identifying at-risk patients to guide triglyceride monitoring and optimize sedative selection.

Purpose of Research: The objective of this study was to determine if protocolized music intervention paired with spontaneous awakening trial (SAT) is a feasible intervention for mechanically ventilated and sedated intensive care unit (ICU) patients to reduce overall sedation exposure. Major Findings: Patients were admitted to the medical ICU (MICU) or surgical ICU (SICU), mechanically ventilated for at least 24 h with anticipated duration of at least 72 h, and with hearing optimized to baseline disposition. Patients were excluded if they had a specified prior to admission diagnosis, traumatic or medical encephalopathy, or need for deep sedation. Eligible patients were randomized to music intervention or usual care during SAT. Patients in the music intervention group underwent a second randomization to Commercial Music Intervention (CMI) or Preference Music Intervention (PMI).The primary outcome was sedation exposure via sedation intensity score (SIS), an aggregate of the frequency and intensity of sedatives from disparate drug classes such as opioids, anxiolytics, antipsychotics, and others, which was summed for exposure comparison. The usual care group had significantly higher median SIS compared to the music intervention group (4 [IQR 4.9-6.4] vs 3 [IQR 3.1-4.2], P = .0006). Patients who received PMI had significantly higher mean SIS compared to the CMI group (5 ± 2.4 vs 2.3 ± 1.7, P = .0002). Compared to usual care, the music intervention group had a higher percentage of delirium-free ICU days (37% vs 22%, P = .009) and a higher percentage of CPOT scores at goal (69% vs 52%, P = .002), but no difference in percentage of goal sedation scores (64% vs 67%, P = .7). Conclusions: Protocolized music intervention paired with daily spontaneous awakening trial is a feasible routine intervention for mechanically ventilated patients. Future studies are needed to confirm if this intervention may reduce overall sedation requirements.

IntroductionLudwig's angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal infections are the most common causes, arising from poor dentition, oral procedures, alcoholism, diabetes or vascular disease, immunocompromised states such as malignancy, or malnutrition. Treatment involves securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid.CaseA 22-year-old transgender woman with a history of pre-diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder reported poor dentition with dysphagia, drooling, and pain in ears and throat for about 1 week. She was taking amoxicillin after being seen at an urgent care 4 days prior for cough, fever, chills, and suspected pharyngitis and tonsillitis. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration in the submandibular area with tenderness to palpation, and limited neck range of motion. She was placed on mechanical ventilation and broad spectrum antibiotics. She was then taken for an incision and drainage (I & D) of submental and submandibular abscesses followed by removal of 5 teeth with dental carry debridement. Subsequent chest tube insertions into the pleura and mediastinum were performed for fluid collection as well as repeated I & D procedures. We found bilateral otomastoiditis with an abscess on the right extending to the sternocleidomastoid, drained abscesses on the right mastoid, and performed a tympanostomy on the left. Infection spread to the cerebellum necessitated initiation of high dose ceftriaxone. Her condition improved after a 45-day stay and she was sent to a long-term acute care hospital.ConclusionThis Ludwig angina case illustrates the tendency of S. constellatus to form abscesses elsewhere. The steroid hormone treatments, elevated cortisol state of Cushing's Syndrome, and severe metabolic syndrome provided ample opportunity for this infection to persist and spread to the mediastinum, pleura, and central nervous system. Source control is critical, as well as early and frequent evaluations by Otolaryngology and Oromaxillofacial surgery to provide extraction, drainage, and additional measures if needed.

BackgroundAcute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation.MethodsA systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses.Results39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I²= 92%, p < 0.01), GCS 9-15 (1.0%, I²= 0%, p = 0.91), and mixed GCS (11.0%, I²= 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I²= 84%, p < 0.01), GCS 9-15 (4.0%, I²= 78%, p < 0.01), and mixed group (5.0%, I²= 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I²= 0%, p = 0.62), GCS 9-15 (1.0%, I²= 0%, p = 0.99), and mixed group (2.0%, I²= 68%, p < 0.01).ConclusionThe conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.

The use of focused critical care echocardiography, diagnostic modality aimed to provide immediate and actionable information, represents a core competency of contemporary intensive care medicine. Resuscitative transesophageal echocardiography (TEE) is a focused, goal-directed examination performed at the point of care, for the rapid evaluation of critically ill patients in whom transthoracic images are either logistically untenable, inadequate, or unobtainable. Some of the applications of TEE in the management of critically ill patients include the evaluation of patients in shock and cardiac arrest, the assessment of trauma patients, and the guidance of several endovascular procedures. Due to the indwelling nature of the transducer, TEE can provide consistently high-quality images and allows for continuous monitoring during hemodynamic interventions, making it ideally suited for the evaluation of critically ill patients. In this article, we review the evolving landscape of resuscitative TEE, discuss the rationale, supporting evidence, safety, and training for the use of this modality in critical care settings. We address the transdisciplinary evolution of TEE and the practical aspects of its implementation in emergency and critical care settings.