Critical Care Research and Practice最新文献

Background: Thrombocytopenia is a common hematologic abnormality in the intensive care unit (ICU), affecting approximately 50% of patients. It is associated with increased mortality and bleeding risk. Despite its clinical significance, epidemiological studies on ICU-related thrombocytopenia in Gulf Cooperation Council countries remain limited.

Methods: This prospective observational cohort study was conducted to investigate the prevalence, risk factors, characteristics, and clinical outcomes of thrombocytopenia in the ICU. We included ICU patients admitted for ≥ 24 h, excluding pregnant women and individuals under 18. Thrombocytopenia was defined as a platelet count < 150 × 10⁹/L after ruling out pseudothrombocytopenia. Patients were stratified by thrombocytopenia severity and followed until discharge, death, or 30 days post onset. Risk factors were analyzed using multivariable modified Poisson regression models. The Naranjo probability scale and the 4Ts score were used for causal assessment of drug-induced thrombocytopenia (DIT) and heparin-induced thrombocytopenia (HIT). Primary outcomes included three-month ICU mortality and major bleeding. Kaplan-Meier with log-rank tests assessed time-to-mortality.

Results: The study enrolled 276 patients; 38.8% had thrombocytopenia, including 23.4% with severe thrombocytopenia. The incidence of new-onset thrombocytopenia was 22.5%. DIT was suspected in 15% of cases, including five patients with potential HIT. Shock diagnosis was a significant predictor of new-onset thrombocytopenia (adjusted risk ratio = 2.26, 95% confidence interval: 1.35-3.79). Thrombocytopenic patients had higher Acute Physiology and Chronic Health Evaluation (APACHE) IV scores (p < 0.001) and experienced more major bleeding events (16.8% vs. 8.3%, p = 0.03) and higher mortality rates (27.1% vs. 5.3%, p < 0.001) with reduced time-to-mortality (log-rank p = 0.01). New-onset thrombocytopenia was independently associated with major bleeding and mortality.

Conclusion: Thrombocytopenia is prevalent in the ICU, correlating to disease severity, major bleeding, and mortality. The study's findings underscore the need for timely recognition and effective management of thrombocytopenia to improve patient outcomes.

Objective: To evaluate the effectiveness of multisensory stimulation in enhancing consciousness levels and physiological parameters among critically ill patients in the ICU.

Methods: A quasi-experimental, nonequivalent control group pretest-post-test design was employed. Seventy-one patients with Glasgow Coma scale (GCS) scores below 13 were recruited through convenience sampling. Participants were divided into an experimental group (n = 34), which received multisensory stimulation twice daily for 7 days, and a comparison group (n = 37), which received standard ICU care. Physiological indicators (heart rate, respiration rate, blood pressure, temperature, SpO₂, and glucose) and consciousness levels (GCS) were determined before and after the intervention. Data were analyzed using SPSS version 20.0, with statistical significance established at p ≤ 0.05.

Result: Experimental and comparison groups showed significant differences in consciousness from day 4 to 7 with higher GCS scores in the experimental group. Repeated measures ANOVA demonstrated improvement in GCS scores from the evening of day 2 till day 7 (p = 0.05). In contrast, the comparison group experienced a higher incidence of physiological adverse events such as tachycardia and bradycardia.

Conclusion: Multisensory stimulation is a safe and effective method to enhance consciousness in critically ill patients without inducing adverse physiological effects. Early integration of MSS into ICU protocols is recommended. Further research is needed to explore MSS's efficacy across diverse medical conditions.

Background: Persistent severe acute kidney injury (PS-AKI)-recently standardized as Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 persisting ≥ 72 h, or renal replacement therapy/death after Stage 3 diagnosis-has emerged as a trajectory-based phenotype complementing conventional KDIGO staging. Evidence in contemporary intensive care unit (ICU) cohorts remains limited.

Methods: We retrospectively studied adults admitted to a tertiary ICU (January 2024-June 2025). Acute kidney injury (AKI) was staged per KDIGO 2012, with trajectories classified as Stage 1 AKI, transient AKI (Stage 2-3 resolving within 48 h), persistent mild-moderate AKI, or PS-AKI. The primary outcome was in-hospital mortality; secondary outcomes included renal recovery. Predictors of PS-AKI were explored using logistic regression and gradient boosting with SHAP attribution.

Results: Among 139 ICU patients with AKI screened, 106 met criteria. Most AKI was community-acquired (97/106, 91.5%). PS-AKI accounted for 23% (24/106) and carried the worst outcomes, with in-hospital mortality 54% and renal recovery 17%. Within Stage 2-3, PS-AKI was associated with substantially worse outcomes than non-PS trajectories (mortality 54% vs 10.8%; adjusted HR for death 2.23, 95% CI 0.69-7.21; adjusted OR for renal recovery 0.07, 95% CI 0.01-0.24). A 72-h landmark analysis showed similar but nonsignificant trends. Inflammatory profiles distinguished PS-AKI, with higher neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), and lower platelets. The composite NLR-to-platelet ratio (NLR/PLT) was independently associated with PS-AKI (adjusted OR 2.51 per doubling, 95% CI 1.52-4.12; AUC 0.86), while the systemic immune-inflammation index (SII) showed no significant association.

Conclusions: In this predominant community-acquired ICU cohort, PS-AKI was common and strongly associated with poor in-hospital outcomes. The co-occurrence of inflammation and thrombocytopenia, summarized by NLR/PLT, may represent a simple exploratory signal for early-risk appraisal. These findings support further research into trajectory-based AKI phenotypes and the potential utility of inflammation-hematologic markers in predicting persistence.

Purpose: Neuromuscular electrical stimulation (NMES) has been increasingly used to preserve or restore neuromuscular function in critically ill patients. However, its effects on inflammatory biomarkers and its safety require to be fully elucidated. This study aimed to analyze the available evidence on the impact of NMES on biological markers in critically ill patients.

Methods: This systematic review followed a preregistered protocol (PROSPERO: CRD42023424413). A comprehensive search was conducted in PubMed, EMBASE, Web of Science, Scopus, PEDro, CENTRAL, and Google Scholar to identify randomized controlled trials (RCTs) comparing NMES with control interventions and reporting outcomes related to biological markers.

Results: Ten RCTs were included in this review. Meta-analyses revealed a significant acute increase in interleukin-10 levels (SMD: 0.60; 95% CI: 0.11 to 1.08; p = 0.02) and a delayed reduction in serum C-reactive protein levels (SMD: -0.74; 95% CI: -1.09 to -0.40; p < 0.0001) following NMES application.

Conclusions: Available evidence suggests that NMES can modulate systemic inflammation in mechanically ventilated critically ill patients, with early anti-inflammatory effects (IL-10 elevation) and subsequent attenuation of inflammation (CRP reduction). These findings support the safety of NMES during active phases of critical illness. Further high-quality RCTs are warranted to standardize stimulation protocols, characterize biomarker dynamics, and elucidate the underlying mechanisms to guide evidence-based clinical use.

Introduction: Neurocritical care patients, including those with traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage, often develop anemia, compromising brain oxygen delivery and increasing morbidity and mortality. Blood transfusion strategies, either liberal or restrictive, are commonly used to manage anemia in these patients, but the optimal approach remains unclear due to mixed results in existing studies.

Methods: A systematic search of PubMed, Cochrane Library, ScienceDirect, and Google Scholar from inception to December 2024 for randomized controlled trials (RCTs) evaluating restrictive versus liberal transfusion strategies in adult neurocritical care patients. Outcomes included mortality, Glasgow Outcome Scale (GOS), red blood cell (RBC) units transfused, sepsis, intensive care unit (ICU)/hospital length of stay, and secondary complications. The study is registered with PROSPERO (CRD42025635426).

Findings: The analysis included seven RCTs with 1941 patients. The restrictive strategy significantly reduced the number of RBC units transfused per patient (MD: 2.36; 95% CI: 1.08-3.64; p = 0.0003) and was associated with a lower incidence of sepsis (RR: 0.73; 95% CI: 0.56-0.96; p = 0.02). There were no significant differences between restrictive and liberal strategies for ICU (RR 0.74; 95% CI 0.28-1.91; p = 0.53), in-hospital (RR 0.77; 95% CI 0.35-1.68), 30-day (RR 0.91; 95% CI 0.70-1.18), 6-month (RR 0.98; 95% CI 0.67-1.44), or long-term mortality (RR 1.00; 95% CI 0.80-1.24). GOS scores at 6 months showed no significant difference (RR 0.94; 95% CI 0.83-1.07). ICU and hospital length of stay were also comparable between strategies. Secondary outcomes, including stroke, brain hypoxia, intracranial hypertension, and other non-neurological complications, showed no significant differences between the two strategies.

Conclusion: Restrictive transfusion strategies are as effective as liberal strategies in terms of mortality and neurological complications, with additional benefits such as fewer RBC transfusions and lower sepsis rates. These findings support restrictive strategies as a safer approach to managing anemia in neurocritical care, though further research on long-term outcomes is needed.

Aim: To evaluate the current status and explore influencing factors of junior intensive care unit (ICU) nurses' recognition and response capabilities to clinical deterioration.

Design: This cross-sectional study followed the STROBE statement.

Methods: From November 2024 to January 2025, 260 junior ICU nurses from five tertiary hospitals in China were recruited. Data were collected using a validated 25-item questionnaire spanning six dimensions to assess their recognition and response abilities. SPSS was used for statistical analyses, including descriptive statistics, Kruskal-Wallis H/Mann-Whitney U tests, and multiple linear regression to examine differences under sociodemographic and occupational factors.

Results: The total score for recognition and response abilities among 250 junior ICU nurses was 99 (95, 103), with an average item score of 3.96 ± 0.83. Dimension scores ranked from lowest to highest: emergency handling, evaluation, teamwork, disease information analysis, disease information acquisition, and clinical decision-making. Education level, work experience, and participation in disease observation training were identified as significant influencing factors.

Conclusions: Junior ICU nurses in China demonstrate relatively strong overall observation skills but insufficient clinical decision-making abilities. Nursing managers and educators should integrate these factors into training to enhance young nurses' capabilities in recognizing and responding to clinical deterioration, which is crucial for improving critical care outcomes.

Patient or public contribution: Patients and the public were not directly involved in the design, implementation, or reporting of this study. However, the results of the study emphasize the importance of improving primary ICU nurses' clinical decision-making skills and emergency response skills, which may have an impact on patient care.

Background: Prolonged use of intravenous (IV) vasopressors in critically ill patients is associated with significant complications. Droxidopa, a norepinephrine precursor approved for neurogenic orthostatic hypotension, has gained interest as an off-label agent for facilitating vasopressor weaning in ICU settings. This systematic review aimed to evaluate the efficacy and safety of droxidopa for vasopressor weaning in ICU patients.

Methods: A systematic review was conducted following PRISMA guidelines. Databases searched included PubMed, Embase, Cochrane, and Web of Science through April 2025. Eligible studies reporting primary clinical data on droxidopa use in ICU patients were included. Outcomes included time to IV vasopressor discontinuation, duration of droxidopa use, ICU length of stay (LOS), and ICU mortality, and results were narratively synthesized. The risk of bias was assessed using the ROBINS-I and the JBI checklists.

Results: Seven studies involving 161 ICU patients were included. Five studies reported time to vasopressor discontinuation, ranging from 29 to 120 h. The duration of droxidopa use ranged from 87 to 192 h. Two studies reported ICU LOS, ranging from 18 to 44 days. ICU mortality was inconsistently reported. These findings are primarily drawn from small, retrospective studies and should be interpreted cautiously.

Discussion: Findings suggest that droxidopa may effectively facilitate vasopressor weaning in critically ill patients. However, variations in dosing, patient selection, and outcome reporting limit generalizability. Evidence is drawn primarily from small, retrospective studies, some available only as abstracts.

Conclusion: Available evidence on droxidopa for vasopressor weaning in ICU patients remains limited and heterogeneous, with very low certainty. Further research is warranted. No funding was received for this review, and the review was not prospectively registered.

Objective: Clinical decision-making is one of the most difficult responsibilities of healthcare personnel in the neonatal intensive care unit (NICU). Meanwhile, nurses in NICU are facing countless challenges to take care of these neonates due to complex clinical conditions, prematurity, low birth weight, and physiological instability of the neonates, making clinical decision-making difficult. Thus, it is essential to identify and investigate the challenges in clinical decision-making for nurses in NICU. The aim of the present study was to explore the challenges that nurses face in clinical decision-making in NICU in southern Iran.

Methods: The present study is a qualitative study with the content analysis in Iran from February 2023 to January 2024. Twenty-one NICU nurses participated in this study. Data were collected from individual, in-depth, and semistructured interviews. The interview questions, according to the opinion of the research team, were designed around the research question: "What are the challenges in clinical decision-making for nurses in NICU?" In order to analyze the data, the researchers used the conventional content analysis method.

Results: The means of the participants' ages and work experience were 36.52 ± 5.71 and 12.45 ± 5.83 years, respectively. Three main themes with nine subthemes were obtained in this study. The main themes were "inadequate clinical competence" (lack of knowledge about caring for neonates, lack of clinical skill and experience, and shortage of nurse practitioners in NICUs); "poor self-efficacy" (poor self-confidence, inefficient stress management, and lack of motivation); and "resistance to change" (physician-centeredness, lack of organizational support, and ambiguities about legal rights).

Conclusion: The findings of the study revealed that lack of knowledge, poor clinical skills, and not having a master's degree in neonatal intensive care adversely affect nurses' self-confidence in providing care and making clinical decisions. Also, the common belief that physicians are superior to nurses in the organizational culture and lack of support for nurses undermines nurses' motivation for enhancing their competence and participating in clinical decision-making. Based on the findings, managers and policy makers, by providing a supportive environment, as well as improving the knowledge and clinical skills of nurses, can encourage them to participate in clinical decision-making.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving mechanical support in patients with cardiogenic shock. There are great variations in the reported rates of neurological complications and associated mortality. Our aim was to analyze our cohort of adult patients supported with VA-ECMO to identify the incidence, outcomes, and predictors of acute ischemic and hemorrhagic strokes.

Methods: A total of 195 patients between January 2016 and January 2023 were reviewed, 22 (11.3%) ECPR patients were excluded, and 173 (88.7%) patients were analyzed. We divided the patients into stroke and nonstroke groups according to the presence of radiologically confirmed acute ischemic and hemorrhagic strokes.

Results: Thirty-five (20.2%) patients had acute cerebrovascular strokes. 13 (7.5%) patients had intracranial hemorrhage (ICH) while 22 (12.7%) patients had ischemic stroke. The median age was 48 years (IQR: 31, 56), 98 (56.6%) patients were males, and 152 (87.9%) patients had cardiac surgeries. The patients who developed cerebrovascular stroke had higher blood lactate at ECMO initiation (8.9 [5.5, 11.2] versus 5.7 [4.6, 11.9] mmol/L, p = 0.02) and 12 h later (8.7 [4.7, 14.5] versus 5.8 [4.6, 15] mmol/L, p = 0.024) with lesser lactate clearance (LC) at 12 h (6.35 [-51.5, 40.6] versus 14.65% [-43.55, 38.3], p < 001) compared to the patients in the nonstroke group. The stroke group had longer ICU stay (21 vs. 15.5 days, p = 0.03), higher frequency of new hemodialysis (62.9% vs. 46.4%, p = 0.026), and on-ECMO mortality (54.3% vs. 44.9%, p = 0.041) compared with the nonstroke group. The ICH was associated with higher hospital mortality (p = 0.021) compared to the ischemic stroke. Logistic multivariate regression revealed that the initial lactate level (OR: 1.6, 95% CI: 1.2-8.92, p = 0.031), cardiopulmonary bypass time (OR:1.8, 95% CI: 1.32-6.42, p = 0.02), and LC at 12 h (OR: 2.4, 95% CI: 1.91-17.4, p = 0.042) were associated with ischemic stroke. Thrombocytopenia (OR: 3.22, 95% CI: 1.82-7.83, p = 0.001) and low body mass index (OR: 2.1, 95% CI: 1.31-4.6, p = 0.02) were associated with ICH.

Conclusions: Ischemic and hemorrhagic strokes are frequent with VA-ECMO support and associated with worse outcomes, especially the hemorrhagic type. Awareness of the incidence and the factors associated with strokes is crucial in early identification and management.

[This corrects the article DOI: 10.1155/ccrp/4660819.].