Journal of Critical Care Medicine最新文献

The pathophysiology of sepsis is orchestrated by a delicate and dynamic interaction between pro-inflammatory and anti-inflammatory responses. Essential factors influencing this process include interleukin-7 (IL-7), the programmed cell death protein 1/programmed death ligand 1 (PD-1/PD-L1) axis, and cellular apoptosis. These elements shape the immune response in sepsis, influencing its progression and outcomes. IL-7 is an important cytokine maintaining lymphocyte function and survival. At the same time, the PD-1/PD-L1 axis acts as a modulatory checkpoint suppressing immune activation to prevent overreaction but can exacerbate immunosuppression during sepsis. Cellular apoptosis impairs the host's ability to mount an effective defence, especially against secondary infections. Despite extensive research, the precise mechanisms through which sepsis results in organ dysfunction and immune dysregulation remain incompletely understood. The global burden of sepsis emphasizes the urgent need for innovative approaches, paving the way for personalized, immune-based therapies. This review aims to delve into and synthesize the current knowledge regarding cellular apoptosis, the regulatory role of the PD-1/PD-L1 axis, and the critical functions of IL-7 in sepsis, with a focus on their underlying mechanisms, clinical relevance, and potential as targets for future immunomodulatory treatments.

Aim of the study: To determine which out-of-hospital cardiac arrest (OHCA) patients should receive advanced treatment is extremely challenging. The objective was to identify sub-phenotypes predicting the prognoses of adult OHCA patients by latent class analysis (LCA) using data up to just after admission.

Material and methods: We conducted a retrospective observational study using multicentre OHCA registry from 95 Japanese hospitals including adult non-traumatic hospitalized OHCA. The primary outcome was 30-day favourable neurological outcome. Our LCA used clinically relevant variables up to just after admission and the optimal class number was determined from clinical importance and Bayesian information criterion. The associations between subphenotypes and outcomes were analysed using univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs).

Results: Our LCA included 2,162 patients and identified four sub-phenotypes. The base excess on hospital arrival had the highest discriminative power. Thirty-day favourable neurological outcomes were observed in 526 patients (24.3%), including 284 (53.8%) in Group 1, 179 (21.2%) in Group 2, 26 (11.4%) in Group 3, and 37 (6.6%) in Group 4. Prehospital return of spontaneous circulation (ROSC) was achieved in 1,009 patients (46.7%), including 379 (81.8%) in Group 1, 340 (40.3%) in Group 2, 115 (50.4%) in Group 3, and 175 (31.1%) in Group 4. Univariate logistic regression analysis for primary outcome using Group 4 as reference revealed ORs (95% CI) of 16.5 (11.4-24.1) in Group 1, 3.83 (2.64-5.56) in Group 2, and 1.83 (1.08-3.10) in Group 3.

Conclusions: Our LCA classified OHCA into four sub-phenotypes showing significant differences for prognosis. In cases who achieved prehospital ROSC, it might be meaningful to continue advanced therapeutic interventions.

Introduction: The coronavirus disease 2019 (COVID-19) has infected millions of people worldwide resulting in high morbidity and mortality. Obesity is known to cause metabolic derangements and precipitate worse outcomes from viral pneumonia, potentially secondary to increased inflammation and/or altered respiratory mechanics.

Aim of the study: Our study's aim was to examine the relationships among BMI, systemic inflammation, and respiratory mechanics in determining clinical outcomes.

Materials and methods: This retrospective, observational cohort study included 199 adult patients with confirmed COVID-19 who were hospitalized at a quaternary-referral academic health system. Data were manually extracted from electronic medical records, including baseline demographics and clinical profiles, inflammatory markers, measures of respiratory mechanics, and clinical outcomes. We used the rank-sum test to compare the distributions of BMI and inflammatory markers between those with and without specific clinical outcomes, and the Pearson correlation to measure the correlations between BMI and inflammatory markers or respiratory mechanics.

Results: Higher BMI was associated with worse clinical outcomes, including the need for Intensive Care Unit (ICU) admission, invasive mechanical ventilation (IMV), neuromuscular blockade, and prone positioning, particularly in male patients. Inflammation, as measured by C-reactive protein, lactate dehydrogenase (LDH), ferritin, and D-Dimer, was also increased in both male and female patients who required ICU admission, IMV, neuromuscular blockade, and prone positioning. However, only male patients had a positive correlation of LDH and D-Dimer levels with BMI. There was no correlation between BMI and respiratory mechanics, as measured by static compliance and the response to prone positioning.

Conclusions: Our findings suggest that the metabolic dysfunction and systemic inflammation seen in obesity, and not dysfunctional respiratory physiology, drive the negative clinical outcomes seen in this cohort of hospitalized COVID-19 patients.

Introduction: Determining the optimal timing for extubation in critically ill patients is essential to prevent complications. Predictive models based on Machine Learning (ML) have proven effective in anticipating weaning success, thereby improving clinical outcomes.

Aim of the study: The study aimed to evaluate the predictive capacity of five ML techniques, both supervised and unsupervised, applied to the spontaneous breathing trial (SBT), objective cough measurement (OCM), and diaphragmatic contraction velocity (DCV) to estimate a favorable outcome of SBT and extubation in critically ill patients.

Material and methods: A post hoc analysis conducted on the COBRE-US study. The study included ICU patients who underwent evaluation of SBT, OCM, and DCV. Five ML techniques were applied: unsupervised and supervised to the data in both a training group and a test group. The diagnostic performance of each method was determined using accuracy.

Results: In predicting SBT success, all supervised methods displayed the same accuracy in the training group (77.3%) and in the test group (69.6%). In predicting extubation success, decision trees demonstrated the highest diagnostic accuracy, 89.8% for the training group and 95.7% for the test group. The other supervised methods also showed a good diagnostic accuracy: 85.9% for the training group and 93.5% for the test group.

Conclusions: In predictive models using OCM, DCV, and SBT as input variables through five ML techniques, decision trees and artificial neural networks demonstrated the best diagnostic performance. This suggests that these models can effectively classify patients who are likely to succeed in SBT and extubation during the weaning process from mechanical ventilation.

Introduction: The survival benefits of treatment at high-volume hospitals (HVHs) are well-documented for several critical pediatric conditions. However, their impact on pediatric sepsis, a leading cause of mortality among children, remains understudied.

Aim of the study: To investigate the association between hospital case volume and mortality rates in pediatric sepsis.

Material and methods: We conducted a retrospective cohort study using data from the Diagnosis Procedure Combination database. The study included patients who met the following criteria: 1) aged 28 days to 17 years; 2) discharged from the hospital between April 2014 and March 2018; 3) had a sepsis diagnosis coded under the International Classification of Diseases, 10th revision; 4) underwent blood cultures on hospital admission day (day 0) or day 1; 5) received antimicrobial agents on day 0 or 1; and 6) required at least one organ support measure (e.g., mechanical ventilation or vasopressors) on day 0 or 1. Hospitals were categorized by case volume during the study period, with HVHs defined as those in the highest quartile and low-volume hospitals (LVHs) as those in the remaining quartiles. In-hospital mortality rates between HVH and LVH groups were compared using mixed-effects logistic regression analysis with propensity score (PS) matching.

Results: A total of 934 pediatric patients were included in the study, with an overall in-hospital mortality rate of 16.1%. Of them, 234 were treated at 5 HVHs (≥26 patients in 4 years), and 700 at 234 LVHs (<26 patients in 4 years). Upon PS matching, patients treated at HVHs demonstrated significantly lower odds of in-hospital mortality compared with those treated at LVHs (odds ratio, 0.42; 95% confidence interval, 0.22-0.80; P = 0.008).

Conclusions: In pediatric patients with sepsis, treatment at HVHs was associated with lower odds of in-hospital mortality.

Background: Sarcopenia, defined by a loss of skeletal muscle mass and function, has been identified as a prevalent condition associated with poor clinical outcome among critically ill patients. This study aims to evaluate the impact of pre-existing sarcopenia on outcomes in critically ill patients with acute respiratory failure (ARF) due to COVID-19.

Material and methods: A retrospective study was carried out on COVID-19 patients admitted to intensive care. Pre-existing sarcopenia was assessed using early CT scans. Clinical outcomes, including duration of high-flow oxygenation (HFO), mechanical ventilation (MV), length of hospital stay (LOS) and ICU mortality, were evaluated according to sarcopenia status.

Results: Among the studied population, we found a high prevalence (75 patients, 50%) of pre-existing sarcopenia, predominantly in older male patients. Pre-existing sarcopenia significantly impacted HFO duration (6.8 (+/-4.4) vs. 5 (+/-2.9) days; p=0.005) but did not significantly affect MV requirement (21 (28%) vs. 23 (37.3%); p=185), MV duration (7 vs. 10 days; p=0.233), ICU mortality (12 (16%) vs. 10 (13.3 %); p=0.644) or hospital LOS (27 vs. 25 days; p=0.509). No differences in outcomes were observed between sarcopenic and non-sarcopenic obese patients.

Conclusions: Pre-existing sarcopenia in critically ill COVID-19 patients is associated with longer HFO duration but not with other adverse outcomes. Further research is needed to elucidate the mechanisms and broader impact of sarcopenia on septic critically ill patient outcomes.

Objective: Systematically examine the literature describing midodrine to treat shock and to summarize current administration and dosing strategies.

Data sources: Structured literature search conducted in MEDLINE (PubMed) from inception through May 10, 2023.

Study selection and data extraction: Abstracts and full texts were assessed for inclusion by two blinded, independent reviewers. English-language publications describing use of midodrine in adult patients with shock were included. Data were extracted by two blinded, independent abstractors using a standardized extraction tool. Quality assessments were completed by paired reviewers using JBI methodology.

Data synthesis: Fifteen of 698 (2%) screened manuscripts were included with 1,714 patients with a variety of shock types. Seven studies (47%) were retrospective, two (13%) prospective observational, and six (40%) randomized controlled studies. Midodrine was initiated to facilitate intravenous vasopressor (IVP) weaning in most (11, 73%) studies; only two (13%) reported IVP weaning protocol use. Starting doses were 10 mg every 8 hours (4, 27%) or three times a day (3, 20%), 20 mg every 8 hours (2, 13%); six studies (40%) did not report initial midodrine dosing. A midodrine titration protocol was reported in 6 (40%) studies. Thirteen (87%) studies evaluated for bradycardia, identified in 6 (46%) studies among 204 patients; only one (0.5%) patient required midodrine discontinuation. Three (20%) studies reported on hypertension with an incidence of 7-11%. Four (27%) studies assessed for ischemia; 5/1128 (0.4%) patients experienced mesenteric ischemia requiring midodrine discontinuation.

Relevance to patient care and clinical practice: This review explores the pragmatic details involved in initiating, titrating, and weaning midodrine for the bedside clinician and identifies rates of adverse events and complications.

Conclusions: Published literature describing midodrine use for shock is heterogeneous and comprised primarily of low or very low quality data. Future controlled trials addressing the shortcomings identified in this systematic review are warranted.

Introduction: Mechanically ventilated patients have disturbed sleep.

Aim of the study: To explore whether there is a relationship between successful or unsuccessful weaning of patients and their sleep quality and circadian rhythm.

Materials and methods: A scoping review. The search process involved four online databases: CINAHL, MEDLINE, ProQuest, and ScienceDirect. Original studies published between January 2020 and October 2022 were included in the review.

Results: Six studies met the inclusion criteria. These studies showed that patients with difficult weaning were more likely to have atypical sleep, shorter REM sleep, and reduced melatonin metabolite excretion. Muscle weakness was an independent factor associated with prolonged weaning from mechanical ventilation and was significantly more frequent in patients with atypical sleep. Heterogeneous patient samples and the methodology of the studies hamper a clear interpretation of the results.

Conclusions: A relationship was found between abnormal sleep patterns, reduced melatonin metabolite (6-sulfa-toxymelatonin) excretion, and unsuccessful weaning. However, the causality is not clear from the existing research.