Journal of Intensive Care Medicine最新文献

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.

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.