Journal of Intensive Care Medicine最新文献

BackgroundPulse oximeters sometimes fail to accurately reflect arterial oxygen saturation (SaO₂), particularly in darker-skinned patients resulting in undiagnosed hypoxemia, potentially delaying recognition and appropriate interventions.Research QuestionWe aimed to evaluate the prevalence and predictors of SpO₂-SaO₂ discrepancies, particularly occult hypoxemia, and to assess their association with clinical outcomes in ICU patients.Study Design and MethodsWe conducted a retrospective cohort analysis using the Blood-gas and Oximetry Linked Dataset (BOLD), analyzing critically ill patients from the eICU-CRD database (2014-2015). Patients with paired SpO₂-SaO₂ measurements within five minutes were included. We identified SpO₂-SaO₂ discrepancies as a difference of >2.99% and defined occult hypoxemia as an arterial partial pressure of oxygen (PaO₂) < 60 mm Hg or SaO₂ < 89% with an SpO₂ > 88%. The primary outcomes included ICU length of stay (LOS), Sequential Organ Failure Assessment (SOFA) score, and in-hospital mortality.ResultsAmong 36,280 ICU patients, 23.6% had SpO₂-SaO₂ discrepancies, and 4.7% had occult hypoxemia. Black patients were overrepresented in both groups, with an adjusted odds ratio (aOR) of 1.35 (95% CI: 1.25-1.47) for discrepancy and 1.22 (95% CI: 1.04-1.47) for occult hypoxemia. Higher BMI, lower pH, elevated creatinine, and higher Charlson Comorbidity Index scores were also significant predictors. Patients with discrepancies had worse clinical outcomes, including increased SOFA scores in the following 24 h (β = 0.31; p < .0001) and higher in-hospital mortality (aOR 1.15; p < .0001). Occult hypoxemia was associated with even worse outcomes, including a longer ICU LOS (IRR 1.12; p < .0001) and significantly increased mortality (aOR 1.73; p < .0001).InterpretationOne in four critically ill patient in our cohort experienced SpO₂-SaO₂ discrepancy which is associated with adverse clinical outcomes. Black race, obesity, and higher comorbidity burden were significant predictors of these discrepancies. Our findings emphasize the need for more rigorous clinician oversight in the use of this technology.

BackgroundThere is limited evidence on the epidemiology and prognostic significance of acid-base disorders in the cardiovascular intensive care unit (CICU). This study examines the association of acid-base status at admission with in-hospital mortality among CICU patients.MethodsWe conducted a retrospective analysis of adults admitted to the Mayo Clinic CICU from 2007-2018 with available blood gas data, utilizing values obtained closest to CICU admission. Arterial pH, serum bicarbonate, base excess, and partial pressure of carbon dioxide (PaCO₂) were examined as predictors of in-hospital mortality. Multivariable logistic regression was used to assess associations, with adjustment for demographics, comorbidities, illness severity, and interventions.ResultsAmong 3229 patients included for analysis, acidemia (pH < 7.35) emerged as the strongest predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI] 1.29-1.98, P < .003). Metabolic acidosis (HCO3 < 20 mEq/L, aOR 1.55, 95% CI 1.24-1.95, P < .001) and respiratory acidosis (PaCO2 > 45 mm Hg, aOR 1.44, 95% CI 1.14-1.81, P = .002) were associated with higher in-hospital mortality, whereas metabolic and respiratory alkalosis were not. After adjustment, lower pH and more negative base excess were associated with higher in-hospital mortality (both P < .001), whereas HCO3 and PaCO2 were not (P = .053 and P = .051, respectively). Patients with combined metabolic and respiratory acidosis had the highest in-hospital mortality (56.3%).ConclusionsShort-term survival in CICU patients decreases progressively with worse acidemia, especially in the context of combined metabolic and respiratory acidosis. Incorporating metabolic acid-base disorders as key therapeutic targets in randomized cardiogenic shock trials may improve outcomes in this complex population by addressing hemometabolic shock.

BackgroundAdherence to evidence-based care processes and patient outcomes in intensive care units (ICUs) can be influenced by staffing and resource availability. We aimed to evaluate if there is a weekend effect on adherence to evidence-based care processes, and hospitalization outcomes and whether a checklist implementation could mitigate potential differences.MethodsPost hoc analysis of the Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) study dataset collected before and after checklist implementation in 34 ICUs across 15 countries (2013-2017). Admission days were classified as 'weekend/holidays' or 'weekdays' according to local work schedules and public holidays. The primary outcome was the omission of 10 evidence-based care processes addressed in the checklist. Mortality and length of stay differences between weekend/holiday and weekday admissions were evaluated as secondary outcomes.Results4256 patients contributed 1141 weekend versus 3501 weekday observation days pre-intervention, and 2014 versus 6507 post-intervention. Pre-intervention, peptic ulcer prophylaxis was omitted more frequently on weekends/holidays than weekdays (adjusted rate ratio [aRR], 0.58 [95%-confidence interval [CI] 0.38-0.88), whereas head-of-bed elevation was omitted more often on weekdays than on weekends/holidays (aRR, 3.17 [1.14-8.86]). Post-intervention, peptic ulcer prophylaxis omission rates became similar (aRR, 1.03 [0.68-1.56], but head-of-bed elevation became omitted more often on weekends than on weekdays (aRR, 0.63 [0.45-0.88]). Post-intervention, oral care was omitted more frequently on weekends/holidays than in weekdays (aRR, 0.63 [0.45-0.9]), and central catheter removal was more frequent on weekdays than in weekends/holidays (aRR, 1.11 [1.02-1.21]). No significant differences in mortality or length of stay were found.ConclusionA weekend effect influenced adherence to some care processes. While checklist implementation improved overall adherence, some disparities diminished, while new ones emerged. Organizational, cultural, and temporal factors should be further studied to optimize care delivery across all times and settings.Clinical Trial Registration NumberNCT01973829.

Although the brain itself lacks nociceptors and cannot directly perceive pain, it can generate chronic pain following injuries such as traumatic brain injury (TBI) or ischemic stroke. This phenomenon arises from disruptions in neural connectivity that distort the interpretation of sensory input. According to Bayes' Rule, the brain combines current sensory input with prior experiences to formulate response predictions. When this process is disrupted by TBI, chronic pain may emerge. This review identified 60 relevant studies through systematic keyword searches, with inclusion based on content relevance following abstract screening. The literature underscores the brain's adaptive processes in interpreting sensory stimuli. Disruptions to this adaptability-such as those caused by neuroinflammation, cytokine activation, or cellular injury-may contribute to persistent pain states. TBI-associated chronic pain is often classified as neuropathic and may arise from peripheral or central nerve damage, inflammation-induced injury, or impaired central processing. Pain resulting from central misinterpretation, as described by Bayesian models, frequently falls outside traditional inflammatory or neuropathic patterns and may not correspond with known dermatomal distributions, complicating diagnosis and treatment.

BackgroundSeptic patients with coronary artery disease (CAD) face elevated mortality risks, potentially exacerbated by glycemic variability (GV). This study aimed to investigate the association between GV and in-hospital and 1-year mortality in septic patients with CAD.MethodsWe conducted a retrospective analysis using data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database as the discovery cohort and the Tianjin Health and Medical Database Platform (THMDP) as the validation cohort. Patients with sepsis and CAD who had at least three blood glucose measurements during their ICU stay were included. Glycemic variability was defined as the coefficient of variation of blood glucose levels, categorized into quartiles (Q1-Q4). The primary outcome was in-hospital mortality, with 1-year mortality as a secondary outcome. Cox proportional hazards models were used to assess the association between GV and mortality.ResultsHigher GV was significantly associated with increased in-hospital mortality in both cohorts (MIMIC-IV: n = 2599) adjusted Hazard Ratio (HR) 4.06, 95% CI 1.72-9.58, P = 0.001; THMDP: n = 2,797, adjusted HR 1.56, 95% CI 1.25-1.93, P = 0.001). A pooled two-cohort analysis confirmed a significant association with in-hospital mortality (adjusted HR for Q4 vs Q1: 1.65, 95% CI 1.34-2.03, P = 0.001), while the association with 1-year mortality was weaker (adjusted HR 1.24, 95% CI 0.89-1.73, P = 0.204). Restricted cubic spline (RCS) analyses revealed a nonlinear relationship between GV and in-hospital mortality (P for nonlinearity < 0.001). Kaplan-Meier (KM) survival curves showed reduced survival probability in the highest GV group.ConclusionsHigher GV is independently associated with increased in-hospital mortality among septic patients with CAD, but no significant association was found with 1-year mortality. These findings suggest that stabilizing GV may be a critical area for clinical management and warrants further investigation. Monitoring and managing GV may improve outcomes in this patient population.

BackgroundPost-critical illness cognitive dysfunction (PCICD) is a frequent and debilitating outcome among survivors of critical illness. Although sepsis has been associated with poor cognitive outcomes, its independent contribution remains unclear due to overlapping clinical factors. This study sought to characterize cognitive recovery trajectories over 12 months after intensive care.MethodsIn this single-center prospective cohort study, adult ICU survivors were assessed at 1, 3, 6 and 12 months post-discharge using telephone-administered Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA-Blind). Total scores were standardized within instrument (z-scores). Linear mixed-effects models evaluated change in z-scores over time. Domain-specific analyses examined whether any cognitive domain was disproportionately impaired. Logistic regression estimated odds of cognitive impairment adjusting for time, sepsis status, test type, age, Charlson index, peak SOFA, and benzodiazepine exposure; complete-case analyses were used.ResultsOf 185 eligible patients, 84 (45%) completed at least one cognitive assessment. Standardized scores improved from 1 to 3 months (+0.40 SD; 95% CI 0.02-0.78; p = 0.04) and 6 months (+0.54 SD; 95% CI 0.10-0.98; p = 0.02), with a similar but non-significant rise by 12 months (+0.49 SD; 95% CI -0.05 to 0.95; p = 0.10). Adjusted odds of impairment declined at 6 (OR 0.25, 95% CI 0.12-0.55) and 12 months (OR 0.34, 95% CI 0.14-0.85) versus 1 month; the 3-month reduction did not reach significance (OR 0.48, 95% CI 0.23-1.04). Sepsis was not associated with impairment (OR 1.49, 95% CI 0.63-3.56). No single cognitive domain showed a significant longitudinal slope.ConclusionsICU survivors show measurable cognitive recovery over the first year-most prominently by 3-6 months-with reduced odds of impairment by 6 and 12 months. Sepsis did not independently alter recovery. These findings support early post-ICU cognitive follow-up and rehabilitation within the first six months after discharge.

Intravenous crystalloid solutions are among the most common medical interventions applied and have supplanted colloid-based solutions as the standard of care for volume resuscitation in most settings. Despite their widespread use, debate has existed over the optimal composition of these solutions and their differential effects on patient outcomes. In this review, we will describe the pre-clinical studies that identified physiological differences when 'balanced crystalloids' and 'normal saline' are administered, the experimental studies that confirmed these differences in humans, the observational studies that indicated the level of concern, and the subsequent clinical trials that provide evidence to guide therapy in current practice.

ObjectiveThis study aimed to investigate associations between early diuretic administration following neonatal cardiac surgery and clinical outcomes.MethodsThis was a retrospective cohort study including neonates who underwent cardiac surgery within the first 30 postnatal days between September 2015 and January 2018 at 22 centers participating in the Pediatric Cardiac Critical Care Consortium (PC⁴) and Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) registries. Multivariable logistic and ordinal regression models were used to assess associations between early diuretic administration [defined as receipt of furosemide in the operating room and/or any diuretic on postoperative day 0 (POD0)] and outcomes. Outcomes: peak cumulative fluid balance, delay in achieving first negative daily fluid balance, duration of mechanical ventilation, hospital length of stay (LOS), and severe persistent acute kidney injury (AKI). An additional exploratory analysis was performed to assess for association between receiving enteral diuretic within the study period (POD0-6) and hospital LOS.ResultsOf 2240 neonates, 63% (n = 1405) had early diuretic administration and 15% (n = 344) received enteral diuretics. After adjusting for covariates and center effect, early diuretic administration was associated with shorter duration of mechanical ventilation [Odds Ratio (OR) = 0.59, 95% confidence interval (95%CI) 0.42-0.82] and a lower odds of delay in negative daily fluid balance (OR = 0.44, 95%CI 0.26-0.75), but not severe persistent AKI. Receiving enteral diuretic by POD6 was associated with decreased hospital LOS (OR = 0.3, 95%CI 0.23-0.41).ConclusionsEarly diuretic administration is associated with earlier time to negative daily fluid balance and shorter duration of mechanical ventilation. Efforts to standardize early diuretic administration have the potential to decrease resource utilization and warrants further study.

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.