Journal of Critical Care Medicine最新文献

Introduction: This study is part of a European survey on delivery room practices endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Romanian Association of Neonatology (ANR). The aim of our study was to evaluate the current neonatal resuscitation practices in Romanian maternity hospitals and to compare the results between level III and level II centers.

Material and methods: The questionnaire was distributed through ANR by email link to heads of neonatal departments of 53 Romanian maternity hospitals with more than one thousand of births per year between October 2019 and September 2020, having 2018 as the reference year for data collection.

Results: The overall response rate to the questionnaire was 62.26% (33/53), 83.33% (15/18) for level-III centers and 51.43% (18/35) for level-II centers. Of the responding centers, 18 (54,54%) were academic hospitals, 15 (83,33%) were level III and 3 (16,67%) level II hospitals. In 2018, responding centers reported 81.139 births representing 42.66% of all Romanian births (190.170). There were significant differences between level-III and level-II maternity hospitals regarding the number of births in 2018 (3028.73±1258.38 vs 1983.78±769.99; P=0.006), lowest GA of routinely assisted infants in delivery room (25.07±3.03 weeks vs 30.44±3.28, P<0.001), inborn infants with BW<1500 admitted to neonatal intensive care unit (NICU) in 2018 (66.86±39.14 g vs 22.87±31.50 g; P=0.002), and antenatal counseling of parents before the delivery of a very preterm infant or an infant with expected problems (60% vs 22.2%; P=0.027). There were no significant differences of thermal and umbilical cord management, positive pressure delivery, heart rate assessment between responding centers.

Conclusion: The adherence to new guidelines was high among responding centers regarding thermal and umbilical cord management, initial FiO₂, but aspects like antenatal counseling, EKG monitoring, laryngeal mask, and heated/humidified gases availability and administration, and simulation-based training require further implementation.

Introduction: Acute respiratory distress syndrome (ARDS) represents a major cause of mortality in the intensive care unit (ICU). The inflammatory response is escalated by the cytokines and chemokines released by neutrophils, therefore the search for quantifying the impact of this pathophysiological mechanism is imperative. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) are indicators of systemic inflammation, widely accessible, inexpensive, and uncomplicated parameters.

Methods: We conducted a prospective study between March 2023 and June 2023 on patients which presented Berlin criteria for the diagnosis of ARDS during the first 24 hours from admission in the ICU. We included 33 patients who were divided into two groups: one group of 11 patients with severe ARDS and the second group of 22 patients with moderate/mild ARDS. The study evaluated demographic characteristics, leukocyte, lymphocyte, neutrophil, and platelet counts, as well as NLR and PLR values from complete blood count, and severity scores (APACHE II score and SOFA score). We investigated the correlation of NLR and PLR in the two main groups (severe and moderate/mild acute respiratory distress syndrome patients).

Results: For the NLR ratio statistically significant differences between the two groups are noted: Severe ARDS 24.29(1.13-96) vs 15.67(1.69-49.71), p=0.02 For the PLR ratio, we obtained significant differences within the group presenting severe ARDS 470.3 (30.83-1427) vs. the group presenting mild/moderate ARDS 252.1 (0-1253). The difference between the two groups is statistically significant (0.049, p<0.05). The cut-off value of NLR resulted to be 23.64, with an Area Under the Curve (AUC) of 0.653 (95% CI: 0.43-0.88). The best cut-off value of PLR was performed to be 435.14, with an Area Under the Curve (AUC) of 0.645 (95% CI: 0.41-0.88).

Conclusion: Our study showed that NLR and PLR ratios 24 hours in patients with moderate/severe ARDS diagnosis can be a good predictor for severity of the disease. These biomarkers could be used in clinical practice due to their convenience, inexpensiveness, and simplicity of parameters. However, further investigations with larger populations of ARDS patients are necessary to support and validate these current findings.

Sudden respiratory and circulatory collapse during or immediately after delivery, vaginal or surgical, can have many causes that can lead to poor maternal outcomes. A pregnancy-induced amniotic fluid embolism and anaphylaxis are two distinct medical conditions that appear similar clinically but have very different underlying mechanisms and treatment approaches. Amniotic fluid embolism is a rare but life-threatening obstetric emergency that leads to a systemic inflammatory response that can be easily confounded with an anaphylactic reaction. We report the case of a patient with no comorbidities or allergies before the current pregnancy that was proposed for delivery by C-Section under spinal anesthesia. After delivery of the placenta and administering the test dose of antibiotic, the patient developed sudden circulatory collapse, altered neurological status, and critical respiratory distress. At that point, the two presumed diagnoses were amniotic fluid embolism and anaphylaxis. Concurrently with the diagnostic pathway, supportive measures (intubation, mechanical ventilation, hemodynamic support) were taken. The clinical evolution was favorable, and after day three, the patient was discharged from the hospital. Our case highlights the significance of promptly distinguishing between anaphylaxis and amniotic fluid embolism to facilitate the timely management of the critical situation.

Introduction: Pregnant women manifest an increased risk of developing coagulation disorders. Unfractionated heparin (HEP) and low-molecular-weight heparin (LMWHep) are considered as selective medication in the case of pregnancy which needs anticoagulant treatment. In addition to anticoagulant properties, HEP and its derivatives manifest other properties including anti-cancer potential. According to Globocan's latest data, colorectal cancer (CRC) is the second most encountered form of malignancy in the case of women, manifesting some special particularities, as confusion of symptoms from cancer with symptoms encountered normally in pregnant women (such as constipation or rectal bleeding), delayed diagnosis because of limitations imposed both for the fetus and for the mother, and the need for special treatment.

Aim: The aim of the present work is to follow the incidence and safety of consumption of HEP and LMWHep in the case of pregnant women and to analyze their potential on the HCT 116 colorectal carcinoma cells.

Results: Analyzing the consumption of heparins in case of pregnant women hospitalized from 01.01.2022 to 31.12.2022 at the Pius Brînzeu" Emergency Clinical Hospital from Timisoara, Obstetrics and Gynecology Clinic I, it was observed that 44,6% of the patients were administered the following medication and no administration risks were observed. When tested on HCT 116 cells, heparins manifested a significant anti-migratory effect (with wound healing rates of 2,6%, when tested with HEP 100 UI concentration and 14.52% wound healing rates in case of fraxiparine 100 UI). In addition, different signs of apoptosis were observed, suggesting the pro-apoptotic potential of the tested substances.

Conclusions: Heparins remain the preferred medication to be administered to pregnant women with the potential for coagulation disorders, showing a high safety profile. Testing on the cancerous line of colorectal carcinoma highlights important properties that stimulate future studies, to establish the anti-tumor potential and the exact mechanism of action.

Introduction: Proper management of sepsis poses a challenge even today, with early diagnosis and targeted treatment being the most important steps. Easy, cost-effective bedside tools are needed in order to pinpoint towards the outcome of sepsis or septic shock.

Aim of study: This study aims to find a correlation between Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) severity scores, the Neutrophil-Lymphocytes Ratio (NLR) and carboxyhaemoglobin (COHb) levels in septic or septic shock patients with the scope of establishing a bed side cost-effective prognostic tool.

Materials and methods: A pilot, prospective, observational, and ongoing study was conducted on 61 patients admitted with sepsis or septic shock according to the SEPSIS 3 Consensus definition. We followed clinical and paraclinical parameters on day 1 (D1) and day 5 (D5) after meeting the inclusion criteria.

Results: On D1 we found a statistically significant positive correlation between each severity score (p <0.0001), r = 0.7287 for SOFA vs. APACHE II with CI: 0.5841-0.8285, r = 0.6862 for SOFA vs. SAPS II with CI: 0.5251-0.7998 and r = 0.8534 for APACHE II vs. SAPS II with CI: 0.7663 to 0.9097. On D5 we observed similar results: a significant positive correlation between each severity score (p <0.0001), with r = 0.7877 for SOFA vs. APACHE II with CI: 0.6283 to 0.8836, r = 0.8210 for SOFA vs. SAPS II with CI: 0.6822 to 0.9027 and r = 0.8880 for APACHE II vs. SAPS II., CI: 0.7952 to 0.9401. Nil correlation was found between the severity scores, NLR and COHb on D1 and D5.

Conclusion: Cost-effective bedside tools to pinpoint towards the outcome of sepsis are yet to be found, however the positive correlation between the severity scores point out to a combination of such tools for prognosis prediction of septic or septic shock patients.

Introduction: Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.

Aim of the study: To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU.

Material and methods: We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.

Results: NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).

Conclusions: Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Introduction: Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.

Aim of the study: This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period.

Material and methods: This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients' demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.

Results: Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3-210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.

Conclusion: Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.

Introduction: Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited. Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.

Material and methods: We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.

Results: Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8-14.3 days) and 23 days (interquartile range: 15.5-41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11-18.5 days) and 30 days (interquartile range: 16-45.5 days), respectively, in the reintubation group.

Conclusions: The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.

Background: Though laboratory tests have been shown to predict mortality in COVID-19, there is still a dearth of information regarding the role of biochemical parameters in predicting the type of ventilatory support that these patients may require.

Methods: The purpose of our retrospective observational study was to investigate the relationship between biochemical parameters and the type of ventilatory support needed for the intensive care of severely ill COVID-19 patients. We comprehensively recorded history, physical examination, vital signs from point-of-care testing (POCT) devices, clinical diagnosis, details of the ventilatory support required in intensive care and the results of the biochemical analysis at the time of admission. Appropriate statistical methods were used and P-values < 0.05 were considered significant. Receiver operating characteristics (ROC) analysis was performed and Area Under the Curve (AUC) of 0.6 to 0.7, 0.7 to 0.8, 0.8 to 0.9, and >0.9, respectively, were regarded as acceptable, fair, good, and exceptional for discrimination.

Results: Statistically significant differences (p<0.05) in Urea (p = 0.0351), Sodium (p = 0.0142), Indirect Bilirubin (p = 0.0251), Albumin (p = 0.0272), Aspartate Transaminase (AST) (p = 0.0060) and Procalcitonin (PCT) (p = 0.0420) were observed between the patients who were maintained on non-invasive ventilations as compared to those who required invasive ventilation. In patients who required invasive ventilation, the levels of Urea, Sodium, Indirect bilirubin, AST and PCT were higher while Albumin was lower. On ROC analysis, higher levels of Albumin was found to be acceptable indicator of maintenance on non-invasive ventilation while higher levels of Sodium and PCT were found to be fair predictor of requirement of invasive ventilation.

Conclusion: Our study emphasizes the role of biochemical parameters in predicting the type of ventilatory support that is needed in order to properly manage severely ill COVID-19 patients.