Journal of Intensive Care Medicine最新文献

Background: Blood pressure (BP) is routinely invasively monitored by an arterial catheter in the intensive care unit (ICU). However, the available data comparing the accuracy of noninvasive methods to arterial catheters for measuring BP in the ICU are limited by small numbers and diverse methodologies. Purpose: To determine agreement between invasive arterial blood pressure monitoring (IABP) and noninvasive blood pressure (NIBP) in critically ill patients. Methods: This was a single center, observational study of critical ill adults in a tertiary care facility evaluating agreement (≤10% difference) between simultaneously measured IABP and NIBP. We measured clinical features at time of BP measurement inclusive of patient demographics, laboratory data, severity of illness, specific interventions (mechanical ventilation and dialysis), and vasopressor dose to identify particular clinical scenarios in which measurement agreement is more or less likely. Results: Of the 1852 critically ill adults with simultaneous IABP and NIBP readings, there was a median difference of 6 mm Hg in mean arterial pressure (MAP), interquartile range (1-12), P < .01. A logistic regression analysis identified 5 independent predictors of measurement discrepancy: increasing doses of norepinephrine (adjusted odds ratio [aOR] 1.10 [95% confidence interval, CI 1.08-1.12] P = .03 for every change in 5 µg/min), lower MAP value (aOR 0.98 [0.98-0.99] P < .01 for every change in 1 mm Hg), higher body mass index (aOR 1.04 [1.01-1.09] P = .01 for an increase in 1), increased patient age (aOR 1.31 [1.30-1.37] P < .01 for every 10 years), and radial arterial line location (aOR 1.74 [1.16-2.47] P = .04). Conclusions: There was broad agreement between IABP and NIBP in critically ill patients over a range of BPs and severity of illness. Several variables are associated with measurement discrepancy; however, their predictive capacity is modest. This may guide future study into which patients may specifically benefit from an arterial catheter.

Background: Nontraumatic subarachnoid hemorrhage (SAH) can lead to poor neurologic outcomes, particularly when delayed cerebral ischemia (DCI) occurs. Maintenance of euvolemia following SAH is thought to reduce the risk of DCI. However, attempts at maintaining euvolemia often err on the side of hypervolemia. In this study, we assessed the relationship between fluid balance and acute kidney injury (AKI) in SAH patients, assessing hypervolemia versus euvolemia and their impact on AKI. Methods: In a quaternary care center, neuroscience intensive care unit we conducted a retrospective longitudinal analysis in adult patients who suffered a nontraumatic SAH. Results: Out of 139 patients, 15 (10.8%) patients developed an AKI while hospitalized, with 7 stage I, 3 stage II, and 5 stage III injuries. Acute kidney injury patients had higher peak sodium (150.1 mEq/L vs 142.7 mEq/L, 95% confidence interval [CI]: [2.7-12.1 mEq/L]), higher discharge chloride (109.1 mEq/L vs 104.9 mEq/L, 95% CI: [0.7-7.6 mEq/L]), and lower hemoglobin at discharge (9.3 g/dL vs 11.3 g/dL, 95% CI: [1.0-2.9 g/dL]). At 7 days, AKI patients had a fluid balance that was 1.82 L higher (P = .04), and 3.38 L higher at 14 days (P = .02), in comparison to day 3. Acute kidney injury was associated with significant mortality increases. This increase in mortality was found at 30 days from admission with a 9.52-fold increase, and at 60 days with a 6.25-fold increase. As a secondary outcome, vasospasm (19 patients, 13.7%) showed no association with AKI. Conclusions: Acute kidney injury following SAH is correlated with clinically significant hypervolemia, elevated sodium, elevated chloride, decreased urine output, and decreased hemoglobin at discharge-risk factors for all SAH patients. This study further elucidates the harm of hypervolemia and gives greater practical evidence to physicians attempting to balance the dangers of vasospasm and AKI.

Background: Published evidence indicates that mean arterial pressure (MAP) below a goal range (hypotension) is associated with worse outcomes, though MAP management failures are common. We sought to characterize hypotension occurrences in ICUs and consider the implications for MAP management. Methods: Retrospective analysis of 3 hospitals' cohorts of adult ICU patients during continuous vasopressor infusion. Two cohorts were general, mixed ICU patients and one was exclusively acute spinal cord injury patients. "Hypotension-clusters" were defined where there were ≥10 min of cumulative hypotension over a 60-min period and "constant hypotension" was ≥10 continuous minutes. Trend analysis was performed (predicting future MAP using 14 min of preceding MAP data) to understand which hypotension-clusters could likely have been predicted by clinician awareness of MAP trends. Results: In cohorts of 155, 66, and 16 ICU stays, respectively, the majority of hypotension occurred within the hypotension-clusters. Failures to keep MAP above the hypotension threshold were notable in the bottom quartiles of each cohort, with hypotension durations of 436, 167, and 468 min, respectively, occurring within hypotension-clusters per day. Mean arterial pressure trend analysis identified most hypotension-clusters before any constant hypotension occurred (81.2%-93.6% sensitivity, range). The positive predictive value of hypotension predictions ranged from 51.4% to 72.9%. Conclusions: Across 3 cohorts, most hypotension occurred in temporal clusters of hypotension that were usually predictable from extrapolation of MAP trends.

Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt^® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.

Purpose: We assessed long-term outcomes in intensive care unit (ICU) survivors with acute kidney injury (AKI) submitted to intermittent or continuous renal replacement therapy (RRT) for comparisons between groups. Methods: The multicenter prospective cohort study included 195 adult ICU survivors with an ICU stay >72 h in 10 ICUs that had at least one episode of AKI treated with intermittent RRT (IRRT) or continuous RRT (CRRT) during ICU stay. The main outcomes were mortality and health-related quality of life (HRQoL). Hospital readmissions and physical dependence were also assessed. Results: Regarding RRT, 83 (42.6%) patients received IRRT and 112 (57.4%) received CRRT. Despite the similarity regarding sociodemographic characteristics, pre-ICU state of health and type of admission between groups, the risk of death (23.5% vs 42.7%; P < .001), the prevalence of sepsis (60.7%) and acute respiratory distress syndrome (17%) were higher at ICU admission among CRRT patients. The severity of critical illness was higher among CRRT patients, regarding the need for mechanical ventilation (75.0% vs 50.6%, P = .002) and vasopressors (91.1% vs 63.9%, P < .001). One year after ICU discharge, 67 of 195 ICU survivors died (34.4%) and, after adjustment for confounders, there were no significant differences in mortality when comparing IRRT and CRTT patients (34.9% vs 33.9%; P = .590), on HRQoL in both physical (41.9% vs 42.2%; P = .926) and mental dimensions (57.6% vs 56.6%; P = .340), and on the number of hospital readmissions and physical dependence. Conclusions: Our study suggests that among ICU survivors RRT modality (IRRT vs CRRT) in the ICU does not impact long-term outcomes after ICU discharge.

Background: Timely patient and family communication is fundamental to the delivery of patient and family-centered care in the intensive care unit (ICU). However, repetitive, non-urgent communication with patients and designated patient contacts (DPCs) may lead to workflow disruptions, patient safety concerns and burnout. Implementing media-rich, educational content via a web-app could promote a more communication-friendly environment and reduce redundant communication. This may lower workflow disruptions and save time for more meaningful interactions with providers. The goal of this study was to deliver relevant, high-quality content via a web-app, assess time savings, and patient satisfaction with the web-app. Methods: A pre-implementation survey was distributed to Neurosciences intensive care unit (NSICU) staff to assess the burden of repetitive non-urgent communication and perceived duration of disruptions. Patients admitted to the NSICU from September 2022 to February 2023, n = 221 were included in the study. Patients were enrolled in the web-app. Patients and their DPC were granted access. Demographics including patient diagnosis, age, gender, and race were collected, along with data on weekly patient enrollment, number of DPCs granted access, total, frequency, and average view times of each piece of web-app content, and expected time saved due to review of web-app-based content by patient and/or DPCs to reduce repetitive communication by NSICU caregivers. The time saved for each piece of web-app content was calculated after getting feedback from providers (attendings, fellows, advanced practice providers, nurses) for how long it generally took them to convey each piece of information to patients and families. Results: Based on web-app content reviewed by patients and/or DPCs, the estimated average amount of NSICU caregiver time saved over the study period, based on application content views, was 82 min per week, and the cumulative total provider time saved for all content views was 26 h and 53 min. Twenty-one of 59 applications were rated by patients or their DPC and received five-star reviews (out of 5). Conclusion: The implementation of a web-app to facilitate and increase efficiency in communication leads to time savings for NSICU providers and patient/DPC satisfaction with the media-rich educational content.

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.

Background: This study aimed to investigate the associations between dyscapnia, ventilatory variables, and mortality. We hypothesized that the association between mechanical power or ventilatory ratio and survival is mediated by dyscapnia. Methods: Patients with moderate or severe acute respiratory distress syndrome (ARDS), who received mechanical ventilation within the first 48 h after admission to the intensive care unit for at least 48 h, were included in this retrospective single-center study. Values of arterial carbon dioxide (PaCO₂) were categorized into "hypercapnia" (PaCO₂≥ 50 mm Hg), "normocapnia" (PaCO₂ 36-49 mmHg), and "hypocapnia" (PaCO₂≤ 35 mm Hg). We used path analyses to assess the associations between ventilatory variables (mechanical power and ventilatory ratio) and mortality, where hypocapnia or hypercapnia were included as mediating variables. Results: Between December 2017 and April 2021, 435 patients were included. While there was a significant association between mechanical power and hypercapnia (B_EM= 0.24 [95% CI: 0.15; 0.34], P < .01), there was no significant association between mechanical power or hypercapnia and ICU mortality. The association between mechanical power and intensive care unit (ICU) mortality was fully mediated by hypocapnia (B_EM= -0.10 [95% CI: -0.19; 0.00], P = .05; B_MO= 0.38 [95% CI: 0.13; 0.63], P < .01). Ventilatory ratio was significantly associated with hypercapnia (B = 0.23 [95% CI: 0.14; 0.32], P < .01). There was no significant association between ventilatory ratio, hypercapnia, and mortality. There was a significant effect of ventilatory ratio on mortality, which was fully mediated by hypocapnia (B_EM= -0.14 [95% CI: -0.24; -0.05], P < .01; B_MO= 0.37 [95% CI: 0.12; 0.62], P < .01). Conclusion: In mechanically ventilated patients with moderate or severe ARDS, the association between mechanical power and mortality was fully mediated by hypocapnia. Likewise, there was a mediating effect of hypocapnia on the association between ventilatory ratio and ICU mortality. Our results indicate that the debate on dyscapnia and outcome after ARDS should consider the impact of ventilatory variables.

Purpose: Postextubation dysphagia (PED) can lead to prolonged tube feeding, but risk factors associated with prolonged tube feeding in this population are largely unknown. The purpose of this study was to identify factors independently associated with prolonged tube feeding in adult inpatients who required intubation and mechanical ventilation.

Materials and methods: Retrospective observational cohort study in a dataset of 1.3 million inpatients. Extubated adults without preventilation dysphagia or tube feeding who underwent instrumental swallowing assessment were included. To characterize factors independently associated with prolonged tube feeding, we compiled a set of potential factors, completed factor selection using a random forest algorithm, and performed logistic regression.

Results: In total, 206 of 987 (20.9%) patients had prolonged tube feeding. The regression model produced an area under the curve of 0.79. Factors with the greatest influence on prolonged tube feeding included dysphagia with thickened liquids, dysphagia with soft/solid foods, preadmission weight loss, number of intubations, admission for neurologic disorder, and hospital of admission.

Conclusions: Several factors predicted prolonged tube feeding after extubation. The strongest were some, but not all, aspects of swallowing function and clinical practice pattern variability. Clinical decision-making should consider bolus-specific data from instrumental swallowing evaluation rather than binary presence or absence of dysphagia.

Introduction: Early noninvasive respiratory support (NIRS) is correlated with a success rate of 60-75% in patients experiencing SARS-CoV-2 ARDS. We conducted a prospective case-control study to assess differences in outcomes between Helmet c-PAP (H-c-PAP) and noninvasive positive pressure ventilation (NIPPV). Methods: All patients with SARS-CoV-2 ARDS, treated with H-c-PAP or NIPPV between October 2021 and April 2022 were sampled. We recorded: demographics, comorbidities, clinical, respiratory, sepsis, NIRS parameters, and outcomes. A "NIRS team" followed the patients in respiratory support supplying them with early and timely intensive physiotherapy i-PKT as well. The Cox's proportional hazard model was applied for multivariate analyses. Results: 368 patients were admitted to our hospital medical ward. 85 patients were treated with H-c-PAP and 145 underwent NIPPV. 138 patients needing oxygen supplementation alone were excluded. The two groups were homogeneously distributed and ICU admission rates were lower in the H-c-PAP one (9.4 vs 11% P = .001) while mortality was higher in the NIPPV group (22.7 vs 9.4%, P = .001). The two multivariate models, that had overall mortality as primary outcome, identified age, H-c-PAP daily, i-PKT and ICU admission as independent variables impacting on the outcome. Age was no longer a significant independent predictor after the inclusion of elderly patients (age >80). The third model showed daily i-PKT could prevent ICU admission whereas the length of NIRS was inversely proportional to outcome. Conclusions: A "NIRS multidisciplinary team" made it possible to adopt an early and timely combination of NIRS and i-PKT resulting in the saving of both patient lives and ICU resources.