Anaesthesia Critical Care & Pain Medicine最新文献

This review reconsiders the classification of corticosteroids as immunosuppressants in the management of acute inflammatory conditions in critical care. Despite their widespread use in ARDS and septic shock, the association between corticosteroid therapy and increased infection risk remains contentious. By exploring alternative mechanisms and presenting new hypotheses, this review suggests that the traditional view of corticosteroids as immunosuppressants may be overly simplistic and context dependent.

Backgrounds: Early mobilization (EM) is vital for critically ill patients, yet various barriers hinder its implementation in daily critical care practice. This study aimed to explore the impact of multidisciplinary rounds (MDR) on the initiation of EM.

Methods: We conducted a retrospective, process-focused observational study in the medical/surgical intensive care unit (ICU) of a tertiary university medical center in Tokyo, Japan, including 301 patients who received physical therapy (PT) during their ICU stay. MDR implementation commenced in October 2016, followed by a year-long initiative to enhance awareness about the importance of EM. Patients admitted between April 2015 and September 2016 were categorized into the pre-MDR group (Phase 1, n = 110), while those admitted from October 2017 to March 2019 formed the post-MDR group (Phase 2, n = 191).

Results: EM practice was significantly increased in Phase 2, compared to Phase 1 (39.8% vs. 20.9%; p =  0.001), particularly among mechanically ventilated patients (33.8% vs. 9.3%; p <  0.001). The median time from ICU admission to PT initiation was significantly reduced in Phase 2 (3.0 vs. 6.0 days, p <  0.001). Additionally, PT consultations significantly increased from 9.2% to 16.5% (X² = 27.75, p <  0.001). MDR was associated with an 84% higher likelihood of initiating EM (adjusted relative risk 1.84, 95% CI 1.30-2.61).

Conclusions: MDR played a pivotal role in enhancing the initiation of EM for ICU patients, highlighting its significance in overcoming barriers to EM.

Background: Pancreatic Stone Protein (PSP) seems to have higher accuracy for sepsis detection compared to other biomarkers. As PSP has never been studied in patients with liver failure (LF), our purpose was to assess its accuracy for diagnosis of infection and prognosis in this population.

Methods: We conducted a prospective pilot cohort study on patients with LF consecutively admitted to the Intensive Care Unit of a liver transplant center in 2021-2023. Ongoing overt infection was an exclusion criterion. Daily measurements of biomarkers were performed until discharge, death, or for 21 days. Analysis was performed by adjusting the baseline for the first infection episode (median on D3), which was the reference for those non-infected.

Results: Sixteen patients were included, 7 with acute and 9 with acute-on-chronic LF. Median age was 54 (interquartile range 42-64) years, half were female, with admission SOFA score of 10 (IQR 8-12). Hospital mortality was 43.8% (n = 7). An infection was observed in 8 patients, who presented non-significantly higher levels of PSP than non-infected ones during follow-up. Levels were higher in non-survivors than survivors (p < 0.05 from D4 on and since the day of infection considering only infected patients). Similarly, patients under renal replacement therapy had higher PSP levels than others (p < 0.05, D2 to D7 after admission).

Conclusion: This pilot study provides early insights into PSP kinetics, suggesting a potential role for prognosis in patients with LF. PSP rises in both ALF and ACLF to levels sustainably higher than those expected for healthy adults. Further research is needed to reassess its diagnostic accuracy for infection and redefine cut-offs in this population.

Background: Research links gut microbiota to postoperative delirium (POD) through the gut-brain axis. However, changes in gut microbiota and fecal short-chain fatty acids (SCFAs) in POD patients during the perioperative period and their association with POD are unclear.

Methods: We conducted a nested case-control study among patients undergoing off-pump coronary artery bypass grafting, focusing on POD as the main outcome. POD patients were matched 1:1 with non-POD patients based on sociodemographic characteristics, health, and diet. Fecal samples were collected pre- and post-surgery to assess gut microbiota and SCFA changes. Postoperative fecal samples were transplanted into antibiotic-treated mice to evaluate delirium-like behavior and neuroinflammation.

Results: Out of 120 patients, 60 were matched. Before surgery, gut microbiota in both groups was similar. After surgery, POD patients had lower alpha diversity and distinct microbiota compared to non-POD patients. LEfSe analysis showed POD was linked to increased opportunistic pathogens (Enterococcus) and decreased SCFA producers (Bacteroides, Ruminococcus, etc.). SCFAs were significantly reduced in POD patients and negatively correlated with delirium severity and plasma inflammation. Mice receiving fecal transplants from POD patients exhibited delirium-like behavior and neuroinflammation.

Conclusions: Postoperative delirium is associated with gut microbiota dysbiosis, marked by an increase in opportunistic pathogens and a decrease in SCFA-producing genera.

Registration: Chinese Clinical Trial Registry ChiCTR2300070477.