Journal of Critical Care Medicine最新文献

Patient oxygenation significantly impacts clinical outcomes, and continuous monitoring is essential, especially in critical care settings where hypoxia is the leading cause of mortality. PFR (PaO2/FiO2 ratio or P/F ratio) is an invasive method for measuring oxygenation requiring arterial blood gas (ABG) sampling, however it carries complications making non-invasive methods more desirable. SFR (SpO2/FiO2 ratio or S/F ratio), a non-invasive tool based on pulse oximetry, provides a cost-effective and rapid way to monitor oxygenation status, especially in settings where advanced methods are unavailable. A total of 575 articles were screened from databases including Web of Science, Scopus, PubMed, and CINAHL, with 32 articles meeting the inclusion criteria for this scoping review wherein SFR was used as a surrogate for PFR and a diagnostic tool for acute lung injury and ARDS. A total of 81,637 patient records were analyzed, including ABG values, pulse oximetry readings, mechanical ventilator settings, and patient diagnoses. The study population included adults, pediatric patients, and neonates admitted to critical care units, with common diagnoses including acute hypoxemic respiratory failure, ARDS, and COVID-19. In the context of COVID-19, SFR was used to predict the need for mechanical ventilation, with a cut-off of 300 indicating a threshold for imminent ventilation requirement. The studies demonstrated statistically significant sensitivity and specificity for SFR, highlighting its utility as a non-invasive tool for assessing oxygenation status. SFR has shown potential as a reliable non-invasive surrogate for determining oxygenation status across all populations.

Background: Critical care physicians face challenges managing decompensated heart failure. This study aims to examine the volume status of patients with decompensated heart failure and evaluate the effectiveness of the renal resistive index (RRI) and renal venous flow pattern (VFP) in assessing volume status and predicting outcomes related to cardiorenal syndrome and mortality.

Patients and methods: This prospective study was conducted in the intensive care unit of Kasr Elainy Hospital at Cairo University with patients admitted for acute decompensated heart failure (ADHF). Patients were subjected to clinical screening, laboratory measurements, and echocardiographic examination, including cardiac index renal duplex.

Results: This study included 61 patients with a mean age of 64.8±9.1 years. Renal duplex parameters were 0.692±0.087 for the mean RRI, and the percentages of VFP were as follows: continuous 49.2%, biphasic 27.9%, and monophasic 23%. Elevated proBNP levels and IVC collapsibility index were significantly associated with RRI ≥0.75 and abnormal VFP patterns in assessing volume status. The ROC curve of the RRI, VFP, proBNP, SOFA score, ADHERE risk score, and GWTG-HF score for AKI occurrence showed that RRI has 68% sensitivity to detect AKI, but VFP has better results with 86.4% sensitivity. RRI has a prognostic role in predicting in-hospital mortality in acute heart failure, as RRI has 83.3% sensitivity, and VFP showed better results with 83.3% sensitivity. Also, VFP had a better predictive value for the incidence of 3 months mortality with 90.9% sensitivity, while RRI has 63.4% sensitivity.

Conclusion: Renal duplex measures, such as VFP and RRI, are highly effective prognostic tools for identifying worsening renal function. Beyond renal outcomes, these measures also serve as reliable predictors of mortality and survival in patients with acute decompensated heart failure, offering clinicians the opportunity to tailor therapeutic approaches early during treatment.

Introduction: Mechanical ventilation is fundamental for the management of critically ill patients. The mode of mechanical ventilation may impact the patient in different ways. This study aimed to assess the hemodynamic changes occurring when transitioning between Volume-Controlled Ventilation (VCV) to Variable Pressure Support (VPS) and VCV to Pressure Support (PS) by echocardiography. Also, a comparison between the spontaneous breathing modes in terms of outcomes, specifically, weaning of mechanical ventilation, days on a ventilator, hospital days, and survival, was conducted.

Methods: This prospective observational study was conducted on 40 mechanically ventilated patients who showed readiness for weaning from Mechanical ventilation. When transitioning between VCV and VPS in arm A and from VCV to PS in arm B, an echocardiographic assessment (transesophageal echocardiography and transthoracic echocardiography) was performed. Both modes were further compared in terms of weaning and the success of liberation from mechanical ventilation.

Results: By comparing both arms, there was a significant difference in velocity time integral (VTI) and stroke volume (SV) for TEE and TTE with p-values of 0.044, 0.022, and 0.05, 0.059, respectively. Also, the cardiac output (CO) showed a statistically significant difference between both arms with a p-value of 0.04. On the other side, there was no statistically significant difference between both arms in terms of ventilator days (p-value of 0.88), length of stay (p-value of 0.651), weaning trial success (p-value of 0.525), and survival rate (p-value of 0.525).

Conclusion: The study showed that VPS is a promising modality that can be used in place of PS as a weaning mode. It provides better patient comfort and a more physiological way of breath delivery. The study also concluded that TTE and TEE will show similar results in most patients and that both can be used interchangeably.

Introduction: Hemoptysis is a commonly encountered diagnosis caused by blood originating from the respiratory tract. Current pharmacological guideline recommendations for treatment do not exist. Tranexamic acid is a synthetic anti-fibrinolytic used in the management of various bleeding complications. Tranexamic acid has gained popularity for the treatment of hemoptysis with limited side effect knowledge. Our aim is to describe the clinical characteristics of patients receiving nebulized tranexamic acid for hemoptysis and compare clinical outcomes to those of patients receiving supportive care.

Materials and methods: This is a retrospective descriptive analysis performed in medical and ICU units at three tertiary hospitals. All patients were hospitalized with hemoptysis between January 1st, 2018 - December 31st, 2021. Demographic information, severity variables, and clinical outcomes were collected from medical records. For statistical analysis, we used t-test for continuous variables, chi-square or fishers' exact test for categorical variables, and propensity analysis to adjust for disease severity and underlying medical conditions.

Results: 488 patients were identified; 96 received tranexamic acid. There were slightly more smokers in the no TXA group (p = 0.04) but otherwise the two groups were similar in terms of demographic characteristics. The average length of hospital and ICU stay, need for mechanical ventilation or bronchoscopy, and mortality were significantly higher in the tranexamic acid group (p<0.01). The propensity analysis showed higher odds of death with nebulized tranexamic acid use, OR 2.51 (1.56-4.02).

Conclusions: There appears to be an indication bias for tranexamic acid based on disease severity without an obvious improvement in clinical outcomes. Our analysis suggests that nebulized tranexamic acid for hemoptysis may be potentially harmful, and further larger prospective research is warranted.

Introduction: Holmium Laser Enucleation of the Prostate (HoLEP) is a widely used minimally invasive surgical technique for benign prostatic hyperplasia (BPH), offering advantages such as reduced bleeding, shorter hospitalization, and elimination of TURP syndrome. However, complications related to fluid absorption and capsular perforation can still occur. We report a rare case of severe refractory metabolic acidosis and acute abdominal compartment syndrome (ACS) following HoLEP.

Case presentation: A 74-year-old male with diabetes and hypertension underwent HoLEP for a 180-ml prostate, during which 106 liters of normal saline irrigation were used over three hours. Intraoperatively, the patient developed sudden respiratory distress and hypotension, with arterial blood gas analysis revealing severe metabolic acidosis (pH 7.141, HCO₃ 11 mEq/L, Cl 115 mEq/L), primarily due to excessive saline absorption and hyperchloremia. The patient required intubation, vasopressor support, and emergency dialysis due to worsening hemodynamic instability. Postoperative imaging revealed intra-abdominal fluid collection, which was drained percutaneously. After two days of intensive ICU management, the acidosis resolved, and the patient was successfully extubated.

Conclusion: This is the first case highlighting the potential risks of normal saline absorption and the effect of capsular perforation, which caused ACS and refractory acidosis, and required CRRT due to the prolonged duration of HoLEP.

Introduction: Angioedema has potential for rapid airway decompensation requiring intervention. Patients are often admitted to an ICU for "airway watch." There is a lack of evidence to support which patients require this.

Aim: We aimed to characterize admission patterns and outcomes of angioedema patients at our institution to assess resource utilization and necessity of ICU use. We hypothesized that patients not requiring intubation upon presentation are safe to manage outside the ICU.

Materials and methods: Retrospective chart review of patients admitted to our urban academic quaternary referral institution with angioedema ICD-10 codes between 2017 and 2020. Charts reviewed for demographics, etiology, admission location, level of care, length of stay (LOS), intubation information, discharge destination, and specific treatment administered. Statistical analysis included a t-test for continuous variables (LOS).

Results: Of 135 encounters for angioedema, 117 patients were admitted. 50 were admitted to an ICU. Patients were evenly split based on sex, majority black, and the most common etiology was ACE-inhibitor use. 20 required airway intervention with intubations primarily outside the ICU setting and only 2 in the ICU. 1 surgical airway performed in the ED. The mean time from presentation to intubation was 2.7 hours (Min 0h; Max 7.5h). The average ICU LOS for non-intubated patients was 1.1 days, with hospital LOS 1.5 days compared to 0.25 days for those not admitted to an ICU (p<0.001). For intubated patients, average ICU LOS was 4.3 days, with hospital LOS 6.2 days. All intubated patients were successfully liberated from the ventilator. No deaths occurred.

Conclusion: Most angioedema encounters did not require airway intervention within the first hours of presentation. Airway decompensation and intervention mostly occurred prior to the ICU setting. ICU resources should be carefully allocated and may be unnecessary for patients presenting with angioedema who are not intubated on initial evaluation.

Background: Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbidity and mortality in the United States. The efficacy of early antiseizure medication (ASM) is debated. Recent literature reports seizure rates ranging from 7.8% to 15.2% following spontaneous aSAH. Current guidelines recommend use of early ASM in patients with "high-risk features," but whether early ASM use decreases the rate of death associated with aSAH remains unclear. This study assessed whether early administration of early ASM impacts mortality rates after spontaneous aSAH.

Methods: We conducted a retrospective cohort study using a publicly available dataset from the Massachusetts Institute of Technology, Medical Information Mart for Intensive Care-III (MIMIC) database of all patients over the age of 18 with spontaneous aSAH resulting in an intensive care unit (ICU) admission to a major United States trauma center from 2001 to 2012. The primary exposure was receiving early ASM and primary outcome of death within 7 days. Different regression models were created to explore the association between early ASM administration within 24 hours of admission and a composite outcome of seizure and/or death within 7 days of admission. Secondary outcomes included 30-day and one-year mortality.

Results: Of 253 patients with spontaneous aSAH, 148 received early ASM within 24 hours. Patients who did receive early ASM were less likely to die within 7 days of admission (adjusted odd ratio, [aOR]: 0.26 95% CI 0.10 to 0.68; P=0.006) but were more likely to have a seizure (aOR: 7.63 95% CI 2.07 to 28.17; P=0.002).

Conclusion: Early ASM administration was associated with lower rates of death and composite death/seizure within 7 days of admission among patients who presented to an ICU with spontaneous aSAH. These findings suggest broader use of early ASM in patients who present with spontaneous aSAH may improve early mortality.

Introduction: In the fast-paced environment of Emergency Departments (EDs), biomarkers are essential for the rapid diagnosis and management of critical conditions.

Aim of the study: This study evaluates the current clinical practice on key biomarkers in Romanian EDs, addressing the needs of emergency medicine physicians, and the challenges associated with biomarker testing.

Material and methods: An online survey was sent to physicians working in ED to explore their perceptions, needs, and barriers regarding biomarkers, including Point-of-care (POC). Data was collected anonymously through an online platform and subsequently analyzed.

Results: This survey analyzed data from 168 completed responses, with 95.2% of respondents being specialists in emergency medicine. Procalcitonin and presepsin were most preferred for PoCT, while troponin and D-dimer were highly rated regardless of the testing method, reflecting their utility in sepsis and cardiovascular emergencies. Neuron-specific enolase, interleukin-6, and procalcitonin were the biomarkers considered needed.

Conclusions: The most frequently used biomarkers in ED were troponin, D-dimer, BNP/NT-proBNP, and procalcitonin. NSE, IL-6, and procalcitonin were the most recommended for future integration. High costs, limited availability, and false-positive concerns remain significant challenges in biomarker use.

Introduction: Total hip arthroplasty (THA) is a standard orthopedic procedure. Deep vein thrombosis (DVT) and pulmonary embolism are potential life-threatening postoperative complications.

Aim of the study: This study aimed to assess the prognostic value of systemic inflammatory indices [monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelets-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI)] and their potential association with acute postoperative DVT.

Materials and methods: We designed a multicentric, retrospective, observational cohort study, including adult patients undergoing elective HTA. Patients were divided into two groups, the DVT and non-DVT groups. We investigated the development of acute DVT early, and at 4 weeks after surgery and also registered length of hospital stay and mortality. All demographic data and laboratory data, hematological indices were extracted from patients files.

Results: 199 patients were included. Of those, 12 (6.03%) developed DVT and 187 (93.97%) did not. There was no statistically significant difference between patient age, gender, BMI, smoking status or comorbidities. No difference was founds between the two groups regarding median values of MLR (0.31 vs 0.27, p=0.12), NLR (3.16 vs 2.42, p=0.27), PLR (163.39 vs 123.01, p=0.27), SII (660.26 vs 568.52, p=0.33), SIRI (67.5 vs 65.26, p=0.89) and AISI (302.35 vs 290.48, p=0.85). Length of hospital stay was not significantly different (median 9 days in the DVT group vs 7 days in the non-DVT group, p=0.38), but mortality was significantly higher in the DVT group (3 deaths vs none in the non-DVT group, p<0.001).

Conclusion: MLR, NLR, PRL, SII, SIRI and AISI were not associated with the development of acute DVT following HTA in our study population.