Critical Care Research and Practice最新文献

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.].

Purpose: Implicit bias in medicine is widespread, with minority populations historically underrepresented in research. Studies have shown racial and ethnic disparities in patient outcomes, including in acute respiratory distress syndrome (ARDS). This study examines the representation of minority patients in ARDS research in the USA. Methods: We examined the 1000 most cited ARDS studies from 2011 to 2021 in the top five critical care journals: AJRC, CHEST, Critical Care, CCM, and ICM. Results: 211 met the inclusion criteria, with 90 providing racial and ethnic demographic information for analysis. These included 17 in AJRC, 36 in CCM, 18 in CHEST, 11 in CC, and 8 in ICM. The average number of citations was 53 (±63). Publications peaked from 2015 to 2017 (15/year), while 2021 had the fewest. The mean patient count was 15,168, including 42 prospective, 29 randomized controlled, and 19 retrospective studies. Eighty-eight studies reported an average patient age of 53 years (±6), and 72% (±15%) of patients were White. Thirty-five studies reported only White patient demographics, while 53 included Black patients, 29 discussed Hispanic patients, 21 mentioned Asian patients. Most studies reported an average of 43% female participants, with no correlations found regarding White patient numbers, publication year, citations, or journals. Conclusion: A substantial number of highly cited studies about ARDS published in prominent critical care journals did not have detailed information regarding the racial composition of the patient population, and a large majority included overwhelmingly White patients and a preponderance of male gender patients.

Sepsis remains one of the leading causes of morbidity and mortality worldwide, particularly among critically ill patients in intensive care units (ICUs). Traditional diagnostic approaches, such as the Sequential Organ Failure Assessment (SOFA) and systemic inflammatory response syndrome (SIRS) criteria, often detect sepsis after significant organ dysfunction has occurred, limiting the potential for early intervention. In this study, we reviewed how artificial intelligence (AI)-driven methodologies, including machine learning (ML), deep learning (DL), and natural language processing (NLP), can aid physicians. AI, in this case, particularly ML, processes massive amounts of real-time clinical data, vital signs, lab results, and patient history and can detect subtle patterns and predict sepsis earlier than traditional methods like SOFA or SIRS, which often lag behind after the presentation of the sequela. Models like random forest, XGBoost, and neural networks achieve high accuracy and area under the receiver operating characteristic curve (AUROC) scores (0.8-0.99) in ICU and emergency settings, enabling timely intervention by distinguishing sepsis from similar conditions despite the lack of perfect biomarkers. In practice, however, there are several potential pitfalls. Algorithmic bias due to nonrepresentative data, data fragmentation, lack of validation, and explainability issues are current barriers in developed models. Future research should address these limitations and develop more sophisticated models.

Purpose: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving intervention for refractory cardiopulmonary failure. Identifying factors associated with survival is essential for optimizing patient selection and management. In this study, we aimed to identify VA-ECMO survival predictors and evaluate the associated complications, costs, and outcomes. Methods: A retrospective analysis was conducted on data from 123 adult patients who underwent VA-ECMO at the Songklanagarind Hospital between 2017 and 2023. Clinical characteristics, ECMO-related complications, hospital expenses, and survival outcomes were analyzed. Univariate and multivariate logistic regression analyses were used to determine independent predictors of survival. Results: Fifty (40.7%) patients survived until hospital discharge. Compared to central VA-ECMO, peripheral VA-ECMO was significantly associated with improved survival (adjusted OR: 26.44, 95% CI: 1.95-358.7, p = 0.014). Preexisting liver dysfunction (adjusted OR: 0.27, 95% CI: 0.09-0.79, p = 0.016) and renal dysfunction (adjusted OR: 0.29, 95% CI: 0.1-0.85, p = 0.023) were independent mortality predictors. Survival odds were significantly lower in patients with American Society of Anesthesiologists (ASA) Class 5 (adjusted OR: 0.07, 95% CI: 0.01-0.67, p = 0.022). Neurological complications were more common in nonsurvivors than in survivors (41.1% vs. 18%, p = 0.012). Survivors had significantly higher total hospital costs (997,563.5 vs. 696,191 THB, p = 0.004) and longer hospital stays (28.5 vs. 3 days, p < 0.001). The multivariate model demonstrated strong predictive performance, with an area under the curve of 0.85. Conclusions: ECMO cannulation strategy, preexisting liver and renal dysfunction, and ASA classification were key factors associated with survival. Peripheral VA-ECMO was associated with better outcomes, and organ dysfunction significantly increased the mortality risk.