Journal of Intensive Care Medicine最新文献

The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.

Graft versus host disease (GVHD) in acute and chronic forms is a frequent post-transplant complication and seen in 50% of patients in acute and up to 70% cases in chronic GVHD setting. Patients with multiorgan involvement and those who are steroid refractory, frequently present with complications arising from this post-transplant complication. These GVHD patients are frequently managed in the Intensive care unit for treatment of air leaks, effusions, management of hypoxemia due to lung GVHD or infections. Close coordination between hematologists and Pulmonary medicine specialists is critical for timely management of these complications to improve patient outcomes.

BackgroundThe state of prior immunosuppression in cancer enhances harmful effects (eg, sepsis). Despite advances in cancer treatment and sepsis management, the number of critically ill patients with cancer is increasing. Although the overall survival of patients with cancer experiencing septic shock has improved, the mortality observed in studies remains high.PurposeTo determine the rate mortality from septic shock in patients with cancer by analyzing variations.DesignSystematic review and meta-analysis.Data Sources and MethodsA systematic search was performed in Medline, EMBASE, SCOPUS, Web of Science, and BIREME-BVS. Articles assessing mortality in patients with cancer experiencing septic shock (aged >18 years) were included. Review articles, letters to the editor, case reports, and conference proceedings were excluded. Methodological quality was assessed with the MInCir-Prognosis Scale and the Joanna Briggs Institute checklist to assess the risk of bias in prevalence studies.ResultsOverall mortality rate from septic shock was 58% (95% confidence interval [95%CI]: 54-63). Mortality rate during 2000-2010 and 2010-2024 was 61% (95%CI: 53-68) and 58% (95%CI: 52-63), respectively. Mortality rate by continent was 50% (95%CI: 24-76) in Africa, 61% (95%CI: 53-69) in Asia, 53% (95%CI: 48-59) in Europe, 64% (95%CI: 48-78) in North America, and 61% (95%CI: 37-82) in South America. Mortality rate in the intensive care unit was 53% (95%CI: 50-57). In-hospital mortality rate was 59% (95%CI: 49-68), and 50% (95%CI: 43-57), 61% (95%CI: 40-81), 69% (95%CI: 58-80) at 28-30, 90 and 180 days, respectively.ConclusionsDespite advances in oncology and hematology, mortality among patients with cancer experiencing septic shock remains high and increases over time after discharge from the intensive care unit.Registration: PROSPERO [ID: CRD42023472191].

PurposeTo evaluate the presence of pulmonary infiltrates on admission among patients with intracranial hemorrhages, further refining on etiology and the agreement between ultrasonography and chest radiography.Materials and MethodsProspective analysis of patients with aneurysmal subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), during a 3-month period in a single center, utilizing a standardized protocol of lung ultrasonography. Clinical and ancillary testing data were also collected.Results44 patients were studied, 30 (68.18%) with ICH, and 14 (31.81%) with SAH. Among patients with ICH, 73.3% had B-lines detected in the assessment, and in the SAH group, 57.14% had presence of lung B-lines. Etiologically, 43% of patients with ICH and 7.1% with SAH had findings suggestive of neurogenic pulmonary edema. 13% of ICH patients and 28.5% in the SAH group had assessments consistent with cardiogenic pulmonary edema. Findings between chest radiography and lung ultrasonography showed poor agreement.ConclusionSonographic lung infiltrates in patients with severe brain injuries are common, reaching up to two-thirds of ICH admissions and the majority of SAH cases. The etiology varied, with presumed neurogenic pulmonary edema leading the incidence in the ICH cohort, and with cardiogenic pulmonary edema being the most common culprit within SAH patients.

Severe community-acquired pneumonia (SCAP) is associated with significant morbidity and mortality, but there is a paucity of data regarding these infections in sub-Saharan Africa, especially among people living with HIV (PLWH). This study investigated the impact of HIV on clinical presentation, microbial aetiology, laboratory findings, and outcome of SCAP. This was additional analysis of data from a large, single-centre, retrospective, observational study conducted among consecutive adult patients (≥18 years) admitted to the multidisciplinary ICU at the Charlotte Maxeke Johannesburg Academic Hospital, between 1 July 2007 and 31 May 2019, with SCAP. The current study describes 718 PLWH and 131 HIV-negative cases extracted from the initial cohort. The median age was 37 [IQR 30-46] years with PLWH significantly younger than their HIV-negative counterparts (36 years [IQR 29-44] years vs 52 years [IQR 34-65] years; P < .001). PLWH were more commonly female (P = .053), while more of the HIV-negative patients were male. The median CD₄ count of the PLWH was 42 [IQR 14-108] cells/mm³ and only 15.5% were on anti-retroviral therapy (ART) prior to hospitalisation. Differences were noted in clinical, laboratory and radiological features between the groups. Overall, Mycobacterium tuberculosis was the most common microbial aetiology in both groups, followed by Streptococcus pneumoniae, which was associated with a significantly lower mortality, whereas mortality with Pneumocystis jirovecii infection, which occurred only in PLWH, was high. Overall ICU mortality was high (48.9%), and while HIV was an independent risk factor for mortality (OR 0.58, 95% CI 0.37-0.92; p = .02) on univariate analysis, this finding was not true when HIV considered within the multivariable analysis. This study describes one of the largest cohorts of PLWH with SCAP and compares their findings with HIV-negative cases. HIV was not a significant predictor of mortality when considered in the context of other covariables on multivariable analysis.

Background: Bronchiolitis is a viral respiratory illness affecting children younger than one year of age, and its accurate prognosis in the emergency department (ED) is often difficult. Lung ultrasound (LUS) has been shown to be useful in risk stratification with respect to the likelihood of being admitted to the hospital or high-intensity care units, receiving supplemental oxygen, or non-invasive ventilation (NIV). Our aim is to evaluate the predictive value of point-of-care lung ultrasound performed in a pediatric ED, especially regarding hospitalization, need for oxygen therapy and NIV. Methods: Observational prospective monocentric study including 109 patients with bronchiolitis younger than 12 months presenting to the ED. Both clinical and LUS scores were assigned at the time of medical examination, then main data regarding admission, need for oxygen supply and NIV were collected. Results: Comparing patient who required hospital care (admission, oxygen supply or NIV) or not, we found a higher median LUS score for patients requiring hospital care (4 vs 1 p < .001 for hospital admission, 4 vs 2 p < .001 for oxygen supply, 5 vs 3 p < .001 for NIV); furthermore, setting the threshold of LUS score at 3.5 as a predictive marker, the ROC AUC for hospital admission, need for oxygen supply or NIV was 0.78, 0.75 and 0.8, respectively. A logistic regression analysis evaluated the risk associated with LUS score: an increase in score affects the risk of hospital admission, need for oxygen supplementation and NIV (OR 1.4, 95%CI 1.04-1.78, p < .05; OR 1.4, 95%CI 1.10-1.78, p < .05; OR 1.6, 95%CI 1.17-2.06, p < .05, respectively). Conclusions: LUS has demonstrated to be a useful tool to help clinician in the process of risk stratification for bronchiolitis, although further (multicentric) studies would be advisable to strengthen this result.

Background: Patients with acute severe stroke requiring mechanical ventilation represent a significant clinical challenge. Identification of mortality predictors is necessary to improve outcomes. Methods: Fourteen hospitals located around Russia participated in this prospective multicenter observational clinical study. Patients admitted to ICU between November 1, 2017, and November 1, 2019 with confirmed cerebral stroke, aged 18 to 90 years, and requiring mechanical ventilation were included. The impact of various clinical factors on mortality during the 28-day period after stroke was assessed. Results: A total of 1289 patients were included in the registry, and 1144 met the study criteria. The 28-day mortality rate for stroke patients on mechanical ventilation was 64.3%. The most common indications for mechanical ventilation were impaired consciousness (75.7%) and hypoxemia (60.9%). In the cohort of strokes with NIHSS severity greater than 20 points, hypoxemia at the start of ventilation (OR 1.85 [1.21; 2.81], P = 0.004) and the use of hyperventilation mode (OR 1.46 [1.02; 2.06], P = 0.0336) were associated with increased mortality. Pressure-controlled mode as the primary ventilation method (OR 0.36 [0.21; 0.60], P < 0.001) and ICP monitoring (OR 0.23 [0.12; 0.44], P < 0.001) were associated with decreased mortality. Infectious complications were associated with longer mechanical ventilation and ICU stay (P < 0.001). The relationship between probable mortality and the severity of neurological deficit on the NIHSS scale at the start of mechanical ventilation is non-linear. A critical threshold was reached at 16 points NIHSS, where a trend of increasing probable mortality emerged. Conclusion: The identified predictors of mortality in stroke patients requiring mechanical ventilation are essential for decision-making in this cohort. They include hypoxemia, hyperventilation (used to control intracranial hypertension), volume-controlled (VC) versus pressure-controlled (PC) initial ventilation, and the use of clinical methods for monitoring ICP alone versus invasive monitoring.

Background: Acute Kidney Injury (AKI), a leading organ failure cause in critical patients, demands early high-risk identification to enhance outcomes. Yet comparative analyses of diagnostic and prognostic machine learning (ML) models across multiple post-admission timeframes are lacking.

Methods: Using MIMIC-IV, we carried out using the Boruta algorithm for feature selection, developing and comparing six ML models to predict AKI risk at 0-24, 24-48, 48-72, 0-48, and 0-72 h post-ICU admission. Model performance was evaluated using the Area Under the Curve (AUC) and confusion matrix. Decision Curve and calibration analyses assessed clinical applicability. We compared models with Sequential Organ Failure Assessment (SOFA) and SAPSII scores to evaluate the accuracy of the ML models. Finally, Shapley Additive Explanations (SHAP) values interpreted and visualized key features of the optimal model.

Results: Our study involved 2092 trauma Intensive Care Unit (ICU) patients. Using the 17 selected out of the 48 features among trauma patients 24 h after ICU admissions, among the six ML models and two scoring systems, all ML models outperformed SOFA and SAPS II, and the extreme gradient boosting (XGBoost) exhibited the best performance, achieving an AUC of 0.948 (95% CI [0.929-0.966]) for AKI prediction within 24 h of admission, with an AUC of 0.941 ([0.892-0.917]) and 0.878 ([0.863-0.892]) at 0-48 and 0-72 h period, respectively. However, their predictive accuracies were very limited at 24-48 h (AUC 0.602 [0.562-0.643]) and 48-72 h (AUC 0.490 [0.429-0.551]), respectively. Urine output per kilogram per hour at 6 and 12 h and age were the most important features identified through SHAP analysis.

Conclusions: Our study found ML models excel in diagnosing AKI risk in ICU trauma patients but have limited prognostic accuracy at 24-48 and 48-72 h post-admission. Further research is needed to improve this using time-series ML models with optimal windows.

Pulmonary hypertension, characterized by elevated pressures in the pulmonary arteries leading to abnormalities in right ventricular function, may lead to competing demands between the pulmonary and systemic circulation during sepsis and septic shock. As a result, management of pulmonary hypertension in sepsis, including identifying the source of infection, maintaining hemodynamic stability and continuing or transitioning pulmonary hypertension-specific therapies can often be challenging. The goal of this review is to highlight factors to consider in the evaluation and management of patients with pulmonary hypertension and sepsis.

AimTo evaluate the efficiency of combined diaphragm and intercostal muscle ultrasound assessment in predicting the extubation outcome in mechanically ventilated patients with sepsis.MethodsThis study was a prospective observational study of septic patients consecutively admitted to the hospital from October 2022 to October 2023 for mechanical ventilation. During the period when the patients passed the ventilator weaning screening and spontaneous breathing trial (SBT), ultrasound evaluation of the diaphragm and intercostal muscles was performed to measure diaphragm excursion (DE), diaphragm thickening fraction (TFD) and intercostal muscle thickening fraction (TFic). The patients were divided into the successful extubation group (89 cases) and the failed extubation group (15 cases) according to the extubation results. ROC curves were used to analyze the effects of diaphragm ultrasound and intercostal muscle ultrasound alone and in combination to predict extubation outcomes.ResultsTFic and TFic/TFD values were significantly higher in the failed extubation group than in the successful extubation group during extubation (P < 0.05). The area under the ROC curve (AUROC) of DE, TFD, and TFic to predict extubation failure in mechanically ventilated patients with sepsis before extubation were 0.689, 0.657, and 0.769, respectively, whereas the combined indexes, such as TFic/TFD and TFic &TFD_mix had AUROCs of 0.867 and 0.860, respectively. TFic/TFD with a cutoff value of >0.95, had a sensitivity of 86.7% and specificity of 75.3% in predicting extubation failure, and TFic &TFD_mix with a cutoff value of >0.13, had a sensitivity of 86.6% and specificity of 80.9% in predicting extubation failure. Conclusion: The combination of diaphragm and intercostal muscle ultrasound assessment might effectively predict the extubation outcome in mechanically ventilated patients with sepsis.