Journal of Intensive Care Medicine最新文献

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.

PurposeCritical Care Echocardiography (CCE) is now a major tool in assessments of ICU patients. We aimed to evaluate its clinical impact in patients admitted to the intensive care unit for acute respiratory failure (ARF) or shock.MethodsWe conducted a single-center retrospective observational study of all patients admitted between January 1th and December 31st 2019 for ARF or shock, who received CCE in the first 12 h of admission. The primary outcome was the therapeutic impact associated with CCE. Secondary outcomes included differences in therapeutic impact between ARF and shock patients, and between trans-thoracic (TTE) and trans-esophageal (TEE) CCE.Results486 patients were potentially eligible, 109 were excluded because CCE was performed after 12 h or because of missing CCE report. 329 patients were analyzed, 31% with shock, 44% with ARF, 25% with both. TTE was performed in 71%, TEE in 29%. All TEE patients were invasively mechanically ventilated and 65% of invasively ventilated patients underwent TEE. No TEE-related complications were observed. CCE was followed with 363 therapeutic interventions in 231 (70%) patients within 2 h. The most common involved hemodynamic optimization in 193 patients (59%), including fluid expansion (129 patients, 39%), vasopressor initiation (39 patients, 12%), vasopressor dose adjustment (79 patients, 24%), inotrope initiation (15 patients, 4.5%), inotrope dose adjustment (5 patients), and others like cardioversion (4 patients) and veno-arterial ECMO implantation (3 patients). TEE patients were more likely to receive therapeutic changes, notably significantly more fluids (53% vs 34% p = 0.0014) and had more frequent vasopressor dose adjustments (64% vs 24% p < 0.001).ConclusionsCCE was followed with therapeutic interventions in nearly 70% of patients admitted for ARF or shock, emphasizing its diagnostic value. Hemodynamic optimization was the primary intervention. We have not found any complications or adverse events of TEE in our cohort.

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

Objectives: Early rehabilitation of critically ill patients has been reported to have benefits such as recovery of physical function at the time of discharge and increasing ventilator-free days, but there is also a risk of increasing the mortality rate. Whether early rehabilitation for patients with septic shock is associated with mobilization during their intensive care unit (ICU) stay without worsening the survival rate was investigated. Design: The Best Available Treatment for septic SHOCK (BEAT-SHOCK) registry was a multicenter, prospective, cohort study. Setting: Twenty ICUs in Japan. Patients: Patients with septic shock requiring high-dose norepinephrine (≥0.2 µg/kg/min) who were admitted to participating ICUs for more than 5 days from 2020 to 2022. Interventions: Early rehabilitation within 48 h after ICU admission for patients with septic shock. Measurements: The primary outcomes were sitting on the edge of the bed and standing within 14 days during the ICU stay, with secondary outcomes including 28-day mortality and 90-day mortality. Main Results: Of 268 patients, 156 underwent early rehabilitation. The early rehabilitation and no early rehabilitation groups had similar median ages (72 vs 73 years) and Acute Physiology And Chronic Health Evaluation II scores (28 vs 26). Early rehabilitation had a significant effect on sitting on the edge of the bed within 14 days after ICU admission (adjusted hazard ratio [aHR] 1.66; 95% confidence interval [CI] 1.15-2.39). It also had a significant effect on standing within 14 days after ICU admission (aHR 2.20; 95%CI 1.29-3.77). The 90-day mortality rate was similar between the groups (early rehabilitation group: 28%, no early rehabilitation group: 23%, P=0.51), with an aHR of 1.27 (95%CI 0.78-2.08). Conclusion: Early rehabilitation for patients with septic shock was associated with mobilization during their ICU stay without worsening the survival rate.[Trial registration: UMIN clinical trial registry, UMIN000038302. Registered November 1, 2019, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000043641].

ObjectiveTo evaluate the implementation of a blood culture algorithm in a mixed medical-surgical ICU at a community hospital, and examine the association with blood culture utilization rate and patient outcomes. Design: A quasi-experimental study examining pre- and post-implementation periods. Setting: A 22-bed mixed medical-surgical ICU at a community hospital. Patients: Adult ICU patients were admitted between February 2022 and October 2024, excluding those with neutropenia (<500 cells/μL) or solid organ transplants. Intervention: Introduction of a multidisciplinary-developed blood culture algorithm designed to standardize ordering practices for new clinical events and clearance of bacteremia. Measurements and Main Results: Primary outcomes included blood culture event rates. Secondary outcomes were antibiotic days of therapy, mortality, and readmissions. Interrupted time series analysis using Poisson regression models were used to examine associations between the intervention and clinical outcomes. The intervention reduced blood culture event rates by 39% (IRR 0.61, 95% 0.49, 0.75) without significantly decreasing adverse events such as 90-day death incidence (5.7% vs 7.2%, p-value 0.44) and 30-day hospital readmission (11.0% vs 8.0%, p-value 0.11). Inappropriate blood culture rates also decreased. Conclusions: Implementation of a blood culture algorithm in a community ICU setting was associated with reduced blood culture utilization without compromising patient safety. The intervention may substantially reduce unnecessary blood cultures, addressing a key gap in diagnostic stewardship in non-academic settings.