Pub Date : 2024-12-01DOI: 10.1016/j.ccrj.2024.09.002
Kyle C. White MBBS MPH , Rahul Costa-Pinto FCICM , Anis Chaba MD , Philippa McIlroy MBBS FCICM , Siva Senthuran MBBS FCICM , Stephen Luke MBBS FCICM , Antony G. Attokaran MBBS FCICM , Peter Garrett MBBS FCICM , Mahesh Ramanan MBBS FCICM , Alexis Tabah MD FCICM , Kiran Shekar MBBS PhD , Kevin B. Laupland MS PhD , Hayden White FCICM PhD , James McCullough CFCICM MMed , Andrew Udy FCICM PhD , Glenn Eastwood MD PhD , Rinaldo Bellomo MD PhD
Objective
The optimal timing of vasopressin initiation as an adjunctive vasopressor remains unclear. We aimed to study the association between the timing of vasopressin commencement, pre-specified physiological parameters, and hospital mortality.
Design
We conducted a multicentre, retrospective, observational study.
Setting
Twelve ICUs in Queensland, Australia between January 2015 and December 2021.
Participants
Adult patients with septic shock who received vasopressin as an adjunctive vasopressor within 72 hours of ICU admission.
Main Outcome
Hospital mortality.
Results
Overall, 2747 patients fulfilled the inclusion criteria. Of these, 1850 (67%) started vasopressin within six hours of vasopressor therapy start, while 897 (33%) started vasopressin between six hours and 72 hours. APACHE III score, peak lactate, and creatinine were higher in the early start group. Early vasopressin start was independently associated with decreased hospital mortality (aOR = 0.69, 95% CI = 0.57-0.83). Vasopressin infusion start was also associated with an immediate decrease in the noradrenaline-equivalent dose regardless of timing. There was a statistically significant favourable breakpoint at vasopressin start for the course of arterial pH, lactate, heart rate and crystalloid infusion rate (p<0.001).
Conclusions
In patients with septic shock, early adjunctive vasopressin initiation was independently associated with lower hospital mortality. Vasopressin starting at any time was also associated with reduced tachycardia, acidosis, and hyperlactatemia.
目的：抗利尿激素作为辅助抗利尿激素的最佳起始时间尚不清楚。我们的目的是研究抗利尿激素开始使用的时间、预先规定的生理参数和住院死亡率之间的关系。设计：我们进行了一项多中心、回顾性、观察性研究。背景：2015年1月至2021年12月期间，澳大利亚昆士兰州的12个icu。参与者：感染性休克的成年患者，在ICU入院72小时内接受血管加压素作为辅助血管加压素。主要结局：医院死亡率。结果：2747例患者符合纳入标准。其中，1850例（67%）在抗利尿激素治疗开始的6小时内开始使用抗利尿激素，而897例（33%）在6小时至72小时内开始使用抗利尿激素。早开始组APACHE III评分、乳酸峰值和肌酐较高。抗利尿激素早期使用与住院死亡率降低独立相关（aOR = 0.69, 95% CI = 0.57-0.83）。抗利尿激素输注开始也与去甲肾上腺素当量剂量的立即减少有关，与时间无关。在动脉pH值、乳酸、心率和晶体输注速率的过程中，抗利尿激素开始时有一个具有统计学意义的有利断点(结论：在感染性休克患者中，早期辅助抗利尿激素开始与较低的住院死亡率独立相关。任何时间开始的抗利尿激素也与心动过速、酸中毒和高乳酸血症的减少有关。
{"title":"Timing of adjunctive vasopressin initiation for septic shock patients and hospital mortality: A multicentre observational study","authors":"Kyle C. White MBBS MPH , Rahul Costa-Pinto FCICM , Anis Chaba MD , Philippa McIlroy MBBS FCICM , Siva Senthuran MBBS FCICM , Stephen Luke MBBS FCICM , Antony G. Attokaran MBBS FCICM , Peter Garrett MBBS FCICM , Mahesh Ramanan MBBS FCICM , Alexis Tabah MD FCICM , Kiran Shekar MBBS PhD , Kevin B. Laupland MS PhD , Hayden White FCICM PhD , James McCullough CFCICM MMed , Andrew Udy FCICM PhD , Glenn Eastwood MD PhD , Rinaldo Bellomo MD PhD","doi":"10.1016/j.ccrj.2024.09.002","DOIUrl":"10.1016/j.ccrj.2024.09.002","url":null,"abstract":"<div><h3>Objective</h3><div>The optimal timing of vasopressin initiation as an adjunctive vasopressor remains unclear. We aimed to study the association between the timing of vasopressin commencement, pre-specified physiological parameters, and hospital mortality.</div></div><div><h3>Design</h3><div>We conducted a multicentre, retrospective, observational study.</div></div><div><h3>Setting</h3><div>Twelve ICUs in Queensland, Australia between January 2015 and December 2021.</div></div><div><h3>Participants</h3><div>Adult patients with septic shock who received vasopressin as an adjunctive vasopressor within 72 hours of ICU admission.</div></div><div><h3>Main Outcome</h3><div>Hospital mortality.</div></div><div><h3>Results</h3><div>Overall, 2747 patients fulfilled the inclusion criteria. Of these, 1850 (67%) started vasopressin within six hours of vasopressor therapy start, while 897 (33%) started vasopressin between six hours and 72 hours. APACHE III score, peak lactate, and creatinine were higher in the early start group. Early vasopressin start was independently associated with decreased hospital mortality (aOR = 0.69, 95% CI = 0.57-0.83). Vasopressin infusion start was also associated with an immediate decrease in the noradrenaline-equivalent dose regardless of timing. There was a statistically significant favourable breakpoint at vasopressin start for the course of arterial pH, lactate, heart rate and crystalloid infusion rate (p<0.001).</div></div><div><h3>Conclusions</h3><div>In patients with septic shock, early adjunctive vasopressin initiation was independently associated with lower hospital mortality. Vasopressin starting at any time was also associated with reduced tachycardia, acidosis, and hyperlactatemia.</div></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 4","pages":"Pages 295-302"},"PeriodicalIF":1.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704155/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142957562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01DOI: 10.1016/j.ccrj.2024.08.003
Melissa J. Ankravs BPharm MClinPharm , Andrew Udy FCICM PhD , Rinaldo Bellomo MD PhD , Jeffrey J. Presneill MBBS PhD , Laura Adams RN , Yasmine Ali Abdelhamid MBBS PhD FRACP FCICM , Michael Bailey PhD , Jasmin Board RN PostGradDipNurs (ICU) MPH , Kathleen Byrne RN MNSc , Glenn Eastwood RN PhD , Maurice Le Guen MBBS MPH , Emma-Leah Martin BPharmSc MPH , Mark P. Plummer MBBS PhD , Megan Richardson BPharm GradDipClinPharm , Lucy Sharrock BPharm MHA , Meredith Young RN MPH , Adam M. Deane MBBS PhD
Background
Patients in the intensive care unit (ICU) frequently develop hyperactive delirium, which may be accompanied by behaviour that increases clinical risks to themselves as well as other patients and staff. There is a paucity of evidence to inform the urgent enteral administration of antipsychotic drugs to treat such hyperactive delirium and behavioural disturbances.
Objective
The aim of this study is to test the efficacy and safety of administering enteral olanzapine when compared to quetiapine in critically ill patients with hyperactive delirium.
Design, setting, participants, and interventions
This is a cluster-randomised, double-crossover, clinical trial. Critically ill adult patients admitted to three tertiary Australian intensive care units over a 12-month period will be eligible. Randomisation will occur at the site level, with allocation to open-label olanzapine or quetiapine use over four treatment periods of 3-month duration.
Main outcome measure
The primary outcome and days alive and delirium-/coma-free (censored at 14 days post enrolment) will be analysed using median quantile regression accounting for clustering at sites' level and time period and treatment order.
Results and conclusion
This trial will compare the effect of enteral olanzapine to quetiapine in critically ill adults with hyperactive delirium on an important indicator of patient outcome.
{"title":"Olanzapine versus quetiapine in critically ill patients with hyperactive delirium: Protocol for a multicentre, cluster-randomised, double-crossover, pragmatic clinical trial (CALM-ICU)","authors":"Melissa J. Ankravs BPharm MClinPharm , Andrew Udy FCICM PhD , Rinaldo Bellomo MD PhD , Jeffrey J. Presneill MBBS PhD , Laura Adams RN , Yasmine Ali Abdelhamid MBBS PhD FRACP FCICM , Michael Bailey PhD , Jasmin Board RN PostGradDipNurs (ICU) MPH , Kathleen Byrne RN MNSc , Glenn Eastwood RN PhD , Maurice Le Guen MBBS MPH , Emma-Leah Martin BPharmSc MPH , Mark P. Plummer MBBS PhD , Megan Richardson BPharm GradDipClinPharm , Lucy Sharrock BPharm MHA , Meredith Young RN MPH , Adam M. Deane MBBS PhD","doi":"10.1016/j.ccrj.2024.08.003","DOIUrl":"10.1016/j.ccrj.2024.08.003","url":null,"abstract":"<div><h3>Background</h3><div>Patients in the intensive care unit (ICU) frequently develop hyperactive delirium, which may be accompanied by behaviour that increases clinical risks to themselves as well as other patients and staff. There is a paucity of evidence to inform the urgent enteral administration of antipsychotic drugs to treat such hyperactive delirium and behavioural disturbances.</div></div><div><h3>Objective</h3><div>The aim of this study is to test the efficacy and safety of administering enteral olanzapine when compared to quetiapine in critically ill patients with hyperactive delirium.</div></div><div><h3>Design, setting, participants, and interventions</h3><div>This is a cluster-randomised, double-crossover, clinical trial. Critically ill adult patients admitted to three tertiary Australian intensive care units over a 12-month period will be eligible. Randomisation will occur at the site level, with allocation to open-label olanzapine or quetiapine use over four treatment periods of 3-month duration.</div></div><div><h3>Main outcome measure</h3><div>The primary outcome and days alive and delirium-/coma-free (censored at 14 days post enrolment) will be analysed using median quantile regression accounting for clustering at sites' level and time period and treatment order.</div></div><div><h3>Results and conclusion</h3><div>This trial will compare the effect of enteral olanzapine to quetiapine in critically ill adults with hyperactive delirium on an important indicator of patient outcome.</div></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 4","pages":"Pages 249-254"},"PeriodicalIF":1.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704082/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142957633","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
To describe the incidence of bleeding and thrombotic complications in VA-ECMO according to anticoagulation strategy.
Design
This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies reporting bleeding and thrombotic complications in VA-ECMO. The incidence of primary outcomes according to anticoagulation drug and monitoring test was described.
Data sources
CENTRAL, MEDLINE, Embase and CINAHL (2010–January 2024).
Review methods
Data was extracted using Covidence. A meta-analysis of proportions was performed using STATA MP v18.1 metaprop.
Results
We included 159 studies with 21,942 patients. No studies were at low risk of bias. The incidence of major bleeding or thrombotic events was similar among heparin-, bivalirudin- and anticoagulation-free cohorts. The pooled incidence of major bleeding and thrombotic complications were 40% (95%CI 36–44, I2 = 97.12) and 17% (95%CI 14–19, I2 = 92.60%), respectively. The most common bleeding site was thoracic. The most common ischaemic complication was limb ischaemia. The incidences of major bleeding or thrombotic events, intracranial haemorrhage and ischaemic stroke were similar among all monitoring tests. Mechanical unloading was associated with a high incidence of major bleeding events (60%, 95%CI 43–77, I2 = 93.32), and ischaemic strokes (13%, 95%CI 7–19, I2 = 81.80).
Conclusions
Available literature assessing the association between anticoagulation strategies in VA-ECMO, and bleeding and thrombosis is of limited quality. We identified a substantially higher incidence of major bleeding events than a previous meta-analysis. Limited numbers of patients anticoagulated with alternatives to heparin were reported. Patients with additional mechanical LV unloading represent a cohort at particular risk of bleeding and thrombotic complications.
{"title":"Anticoagulation and associated complications in veno-arterial extracorporeal membrane oxygenation in adult patients: A systematic review and meta-analysis","authors":"Ruan Vlok MBBS , Hergen Buscher FCICM , Anthony Delaney FCICM, PhD , Tessa Garside FCICM, PhD , Gabrielle McDonald MD , Richard Chatoor MD , John Myburgh FCICM, PhD , Priya Nair FCICM, PhD","doi":"10.1016/j.ccrj.2024.10.003","DOIUrl":"10.1016/j.ccrj.2024.10.003","url":null,"abstract":"<div><h3>Objective</h3><div>To describe the incidence of bleeding and thrombotic complications in VA-ECMO according to anticoagulation strategy.</div></div><div><h3>Design</h3><div>This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies reporting bleeding and thrombotic complications in VA-ECMO. The incidence of primary outcomes according to anticoagulation drug and monitoring test was described.</div></div><div><h3>Data sources</h3><div>CENTRAL, MEDLINE, Embase and CINAHL (2010–January 2024).</div></div><div><h3>Review methods</h3><div>Data was extracted using Covidence. A meta-analysis of proportions was performed using STATA MP v18.1 metaprop.</div></div><div><h3>Results</h3><div>We included 159 studies with 21,942 patients. No studies were at low risk of bias. The incidence of major bleeding or thrombotic events was similar among heparin-, bivalirudin- and anticoagulation-free cohorts. The pooled incidence of major bleeding and thrombotic complications were 40% (95%CI 36–44, I<sup>2</sup> = 97.12) and 17% (95%CI 14–19, <em>I</em><sup><em>2</em></sup> = 92.60%), respectively. The most common bleeding site was thoracic. The most common ischaemic complication was limb ischaemia. The incidences of major bleeding or thrombotic events, intracranial haemorrhage and ischaemic stroke were similar among all monitoring tests. Mechanical unloading was associated with a high incidence of major bleeding events (60%, 95%CI 43–77, I<sup>2</sup> = 93.32), and ischaemic strokes (13%, 95%CI 7–19, I<sup>2</sup> = 81.80).</div></div><div><h3>Conclusions</h3><div>Available literature assessing the association between anticoagulation strategies in VA-ECMO, and bleeding and thrombosis is of limited quality. We identified a substantially higher incidence of major bleeding events than a previous meta-analysis. Limited numbers of patients anticoagulated with alternatives to heparin were reported. Patients with additional mechanical LV unloading represent a cohort at particular risk of bleeding and thrombotic complications.</div></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 4","pages":"Pages 332-363"},"PeriodicalIF":1.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704180/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142957520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
To assess current evidence regarding guanfacine use in hospitalized patients with delirium.
Introduction
Delirium is a common and important complication of critical illness. Central alpha-2 agonists are often used for symptomatic management. Guanfacine is an enteral central alpha-2 agonist approved for the treatment of attention deficit hyperactivity disorders. However, its use for delirium treatment has not been systematically assessed.
Inclusion criteria
All studies of guanfacine to treat patients with delirium during hospitalization. We excluded reviews, letters, commentaries, correspondence, conference abstracts, expert opinions or editorials.
Methods
We performed a systematic search of the literature using: MEDLINE (Ovid), Embase (Ovid), CENTRAL and SCOPUS (Elsevier) from inception until 29 February, 2024. Two independent reviewers assessed the identified citations and abstracts. Data on study and patient characteristics, as well as efficacy and safety outcomes, were extracted. Efficacy was defined by guanfacine's ability to relieve delirium and improve clinical outcomes, including intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Safety was assessed for hemodynamic stability or other reported side effects.
Results
We screened 908 articles and included two case reports, one case series, two retrospective descriptive cohorts, and one retrospective analytic cohort. Guanfacine therapy was associated with delirium attenuation and a reduction in the use of sedative agents. Median dosage was 1.5 mg daily, with a median time to delirium improvement of 3 days. However, guanfacine therapy was not associated with decreased ICU or hospital LOS. The most frequently reported adverse events were mild hypotension and bradycardia.
Conclusion
There is limited data on the efficacy of guanfacine for the treatment of delirium. However, given its pharmacologic properties and its available safety data, controlled investigations may be justified.
{"title":"Efficacy and safety of guanfacine in hospitalized patients with delirium: A scoping review","authors":"Nuttapol Pattamin MD , Atthaphong Phongphithakchai MD , Sofia Spano MD , Akinori Maeda MD , Anis Chaba MD , Yukiko Hikasa MD , Rinaldo Bellomo MD, PhD, FRACP, FCICM","doi":"10.1016/j.ccrj.2024.08.009","DOIUrl":"10.1016/j.ccrj.2024.08.009","url":null,"abstract":"<div><h3>Objective</h3><div>To assess current evidence regarding guanfacine use in hospitalized patients with delirium.</div></div><div><h3>Introduction</h3><div>Delirium is a common and important complication of critical illness. Central alpha-2 agonists are often used for symptomatic management. Guanfacine is an enteral central alpha-2 agonist approved for the treatment of attention deficit hyperactivity disorders. However, its use for delirium treatment has not been systematically assessed.</div></div><div><h3>Inclusion criteria</h3><div>All studies of guanfacine to treat patients with delirium during hospitalization. We excluded reviews, letters, commentaries, correspondence, conference abstracts, expert opinions or editorials.</div></div><div><h3>Methods</h3><div>We performed a systematic search of the literature using: MEDLINE (Ovid), Embase (Ovid), CENTRAL and SCOPUS (Elsevier) from inception until 29 February, 2024. Two independent reviewers assessed the identified citations and abstracts. Data on study and patient characteristics, as well as efficacy and safety outcomes, were extracted. Efficacy was defined by guanfacine's ability to relieve delirium and improve clinical outcomes, including intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Safety was assessed for hemodynamic stability or other reported side effects.</div></div><div><h3>Results</h3><div>We screened 908 articles and included two case reports, one case series, two retrospective descriptive cohorts, and one retrospective analytic cohort. Guanfacine therapy was associated with delirium attenuation and a reduction in the use of sedative agents. Median dosage was 1.5 mg daily, with a median time to delirium improvement of 3 days. However, guanfacine therapy was not associated with decreased ICU or hospital LOS. The most frequently reported adverse events were mild hypotension and bradycardia.</div></div><div><h3>Conclusion</h3><div>There is limited data on the efficacy of guanfacine for the treatment of delirium. However, given its pharmacologic properties and its available safety data, controlled investigations may be justified.</div></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 4","pages":"Pages 286-294"},"PeriodicalIF":1.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704153/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142957527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01DOI: 10.1016/j.ccrj.2024.09.004
Anis Chaba MD , Atthaphong Phongphithakchai MD , Oscar Pope MD , Sam Rajapaksha MD , Pratibha Ranjan MD , Akinori Maeda MD, PhD , Sofia Spano MD , Yukiko Hikasa MD , Glenn Eastwood RN, PhD , Nuttapol Pattamin MD , Nuanprae Kitisin MD , Ahmad Nasser MD , Kyle C. White MD, PhD , Rinaldo Bellomo MD, PhD , Severe Hypernatremia Assessment, Resolution, and Eradication (SHARE) Investigators
Background
Severe intensive care unit–acquired hypernatraemia (ICU-AH) is a serious complication of critical illness. However, there is no detailed information on how this condition develops.
Objectives
The objective of this study was to study the prevalence, risk factors, trajectory, management, and outcome of severe ICU-AH (≥155 mmol·L−1).
Methods
A retrospective study was conducted in a 40-bed ICU in a university-affiliated hospital. Assessment of sodium levels, factors associated with severe ICU-AH, urinary electrolyte measurements, water therapy, fluid balance, correction rate, and delirium was made.
Results
We screened 11,642 ICU admissions and identified 109 patients with severe ICU-AH. The median age was 57 years, 63% were male, and the median Acute Physiology and Chronic Health Evaluation III score was 64 (52; 80). On the day of ICU admission, 64% of patients were ventilated; 71% received vasopressors, and 22% had acute kidney injury. The median peak sodium level was 158 (156; 161) mmolL−1 at a median of 4 (1; 11) days after ICU admission. Only eight patients (7%) had urine sodium measurement (median concentration: 17 mmol·L−1). On the day of peak hypernatraemia, 80% of patients were unable to drink due to invasive ventilation; 34% were on diuretics; 25% had fever, and 50% did not receive hypotonic fluids. When available, the median electrolyte-free water clearance was −1.1 L (−1.7; −0.5), representing half of the urine output. After peak hypernatraemia, the correction rate was −2.8 mmol·L−1 per day (95% confidence interval: [-2.9 to −2.6]) during the first 3 d.
Conclusions
Severe hypernatraemia occurred in the setting of inability to drink, near-absent measurement of urinary free water losses, diuretic therapy, fever, renal impairment, and near-absent or limited or delayed water administration. Correction was slow.
{"title":"Severe intensive care unit–acquired hypernatraemia: Prevalence, risk factors, trajectory, management, and outcome","authors":"Anis Chaba MD , Atthaphong Phongphithakchai MD , Oscar Pope MD , Sam Rajapaksha MD , Pratibha Ranjan MD , Akinori Maeda MD, PhD , Sofia Spano MD , Yukiko Hikasa MD , Glenn Eastwood RN, PhD , Nuttapol Pattamin MD , Nuanprae Kitisin MD , Ahmad Nasser MD , Kyle C. White MD, PhD , Rinaldo Bellomo MD, PhD , Severe Hypernatremia Assessment, Resolution, and Eradication (SHARE) Investigators","doi":"10.1016/j.ccrj.2024.09.004","DOIUrl":"10.1016/j.ccrj.2024.09.004","url":null,"abstract":"<div><h3>Background</h3><div>Severe intensive care unit–acquired hypernatraemia (ICU-AH) is a serious complication of critical illness. However, there is no detailed information on how this condition develops.</div></div><div><h3>Objectives</h3><div>The objective of this study was to study the prevalence, risk factors, trajectory, management, and outcome of severe ICU-AH (≥155 mmol·L<sup>−1</sup>).</div></div><div><h3>Methods</h3><div>A retrospective study was conducted in a 40-bed ICU in a university-affiliated hospital. Assessment of sodium levels, factors associated with severe ICU-AH, urinary electrolyte measurements, water therapy, fluid balance, correction rate, and delirium was made.</div></div><div><h3>Results</h3><div>We screened 11,642 ICU admissions and identified 109 patients with severe ICU-AH. The median age was 57 years, 63% were male, and the median Acute Physiology and Chronic Health Evaluation III score was 64 (52; 80). On the day of ICU admission, 64% of patients were ventilated; 71% received vasopressors, and 22% had acute kidney injury. The median peak sodium level was 158 (156; 161) mmolL<sup>−1</sup> at a median of 4 (1; 11) days after ICU admission. Only eight patients (7%) had urine sodium measurement (median concentration: 17 mmol·L<sup>−1</sup>). On the day of peak hypernatraemia, 80% of patients were unable to drink due to invasive ventilation; 34% were on diuretics; 25% had fever, and 50% did not receive hypotonic fluids. When available, the median electrolyte-free water clearance was −1.1 L (−1.7; −0.5), representing half of the urine output. After peak hypernatraemia, the correction rate was −2.8 mmol·L<sup>−1</sup> per day (95% confidence interval: [-2.9 to −2.6]) during the first 3 d.</div></div><div><h3>Conclusions</h3><div>Severe hypernatraemia occurred in the setting of inability to drink, near-absent measurement of urinary free water losses, diuretic therapy, fever, renal impairment, and near-absent or limited or delayed water administration. Correction was slow.</div></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 4","pages":"Pages 311-318"},"PeriodicalIF":1.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704420/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142957646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.ccrj.2024.06.008
Julia K. Pilowsky RN, PhD , Jae-Won Choi MBiomedE, BE (Comp), BE-Health (HI) (ProfHons) , Aldo Saavedra PhD , Maysaa Daher BPsych, MAppStats , Nhi Nguyen MBBS, FCICM , Linda Williams RN, MHealthManagement , Sarah L. Jones RN, Grad Dip Ed (Nursing), Grad Cert (ICU)
Objectives
Natural language processing (NLP) is a branch of artificial intelligence focused on enabling computers to interpret and analyse text-based data. The intensive care specialty is known to generate large volumes of data, including free-text, however, NLP applications are not commonly used either in critical care clinical research or quality improvement projects. This review aims to provide an overview of how NLP has been used in the intensive care specialty and promote an understanding of NLP's potential future clinical applications.
Design
Scoping review.
Data sources
A systematic search was developed with an information specialist and deployed on the PubMed electronic journal database. Results were restricted to the last 10 years to ensure currency.
Review methods
Screening and data extraction were undertaken by two independent reviewers, with any disagreements resolved by a third. Given the heterogeneity of the eligible articles, a narrative synthesis was conducted.
Results
Eighty-seven eligible articles were included in the review. The most common type (n = 24) were studies that used NLP-derived features to predict clinical outcomes, most commonly mortality (n = 16). Next were articles that used NLP to identify a specific concept (n = 23), including sepsis, family visitation and mental health disorders. Most studies only described the development and internal validation of their algorithm (n = 79), and only one reported the implementation of an algorithm in a clinical setting.
Conclusions
Natural language processing has been used for a variety of purposes in the ICU context. Increasing awareness of these techniques amongst clinicians may lead to more clinically relevant algorithms being developed and implemented.
{"title":"Natural language processing in the intensive care unit: A scoping review","authors":"Julia K. Pilowsky RN, PhD , Jae-Won Choi MBiomedE, BE (Comp), BE-Health (HI) (ProfHons) , Aldo Saavedra PhD , Maysaa Daher BPsych, MAppStats , Nhi Nguyen MBBS, FCICM , Linda Williams RN, MHealthManagement , Sarah L. Jones RN, Grad Dip Ed (Nursing), Grad Cert (ICU)","doi":"10.1016/j.ccrj.2024.06.008","DOIUrl":"10.1016/j.ccrj.2024.06.008","url":null,"abstract":"<div><h3>Objectives</h3><p>Natural language processing (NLP) is a branch of artificial intelligence focused on enabling computers to interpret and analyse text-based data. The intensive care specialty is known to generate large volumes of data, including free-text, however, NLP applications are not commonly used either in critical care clinical research or quality improvement projects. This review aims to provide an overview of how NLP has been used in the intensive care specialty and promote an understanding of NLP's potential future clinical applications.</p></div><div><h3>Design</h3><p>Scoping review.</p></div><div><h3>Data sources</h3><p>A systematic search was developed with an information specialist and deployed on the PubMed electronic journal database. Results were restricted to the last 10 years to ensure currency.</p></div><div><h3>Review methods</h3><p>Screening and data extraction were undertaken by two independent reviewers, with any disagreements resolved by a third. Given the heterogeneity of the eligible articles, a narrative synthesis was conducted.</p></div><div><h3>Results</h3><p>Eighty-seven eligible articles were included in the review. The most common type (n = 24) were studies that used NLP-derived features to predict clinical outcomes, most commonly mortality (n = 16). Next were articles that used NLP to identify a specific concept (n = 23), including sepsis, family visitation and mental health disorders. Most studies only described the development and internal validation of their algorithm (n = 79), and only one reported the implementation of an algorithm in a clinical setting.</p></div><div><h3>Conclusions</h3><p>Natural language processing has been used for a variety of purposes in the ICU context. Increasing awareness of these techniques amongst clinicians may lead to more clinically relevant algorithms being developed and implemented.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 3","pages":"Pages 210-216"},"PeriodicalIF":1.4,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277224000243/pdfft?md5=baca71f4ef8b264efa157f45c9f3f932&pid=1-s2.0-S1441277224000243-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142230444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.ccrj.2024.07.001
Stuart C. Duffin BMedSci, MBBS, FCICM, DESA, EDIC, Judith H. Askew BAppSci, MBBS, FCICM, Timothy J. Southwood MBBS, MSc, FCICM, Paul Forrest MBCHB, FANZCA, Brian Plunkett MBChB, FRACS, Richard J. Totaro MBBS, FRACP, FCICM
{"title":"Response to: “More than one pathway: ECMO training and credentialing”","authors":"Stuart C. Duffin BMedSci, MBBS, FCICM, DESA, EDIC, Judith H. Askew BAppSci, MBBS, FCICM, Timothy J. Southwood MBBS, MSc, FCICM, Paul Forrest MBCHB, FANZCA, Brian Plunkett MBChB, FRACS, Richard J. Totaro MBBS, FRACP, FCICM","doi":"10.1016/j.ccrj.2024.07.001","DOIUrl":"10.1016/j.ccrj.2024.07.001","url":null,"abstract":"","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 3","pages":"Page 219"},"PeriodicalIF":1.4,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277224000267/pdfft?md5=b7e7d7886f372d75e1216e260de71fe2&pid=1-s2.0-S1441277224000267-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142230447","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.ccrj.2024.05.001
Rachael L. Parke RN, PhD , Shay P. McGuinness MBChB , Alana Cavadino PhD , Keri-Anne Cowdrey RN, MN , Samantha Bates RN, MN , Shailesh Bihari MBBS, PhD , Amanda Corley RN, PhD , Eileen Gilder RN, PhD , Carol Hodgson PhD , Edward Litton MBChB, PhD , Colin McArthur MBChB , Alistair Nichol MBBCh, PhD , Jane Parker RN, MPH , Anne Turner RN, MPH , Steve Webb MBBS, PhD , Frank MP. Van Haren MD, PhD , SAGE-ANZ Study Investigators and the Australia and New Zealand Intensive Care Society Clinical Trials Group
Objective
Acute respiratory distress syndrome (ARDS) is associated with significant mortality, morbidity, and cost. We aimed to describe characteristics and management of adult patients admitted to intensive care units (ICUs) in Australia and New Zealand with moderate-severe ARDS, to better understand contemporary practice.
Mechanically ventilated patients with moderate-severe ARDS.
Main outcome measures
Baseline demographic characteristics, ventilation characteristics, use of adjunctive support therapy and all-cause mortality to day 28. Data were summarised using descriptive statistics.
Results
200 participants were enrolled, mean (±SD) age 55.5 (±15.9) years, 40% (n = 80) female. Around half (51.5%) had no baseline comorbidities and 45 (31%) tested positive for COVID-19. On day 1, mean SOFA score was 9 ± 3; median (IQR) PaO2/FiO2 ratio 119 (89, 142), median (IQR) FiO2 70% (50%, 99%) and mean (±SD) positive end expiratory pressure (PEEP) 11 (±3) cmH2O. On day one, 10.5% (n = 21) received lung protective ventilation (LPV) (tidal volume ≤6.5 mL/kg predicted body weight and plateau pressure or peak pressure ≤30 cm H2O). Adjunctive therapies were received by 86% (n = 172) of patients at some stage from enrolment to day 28. Systemic steroids were most used (n = 127) followed by neuromuscular blockers (n = 122) and prone positioning (n = 27). Median ventilator-free days (IQR) to day 28 was 5 (0, 20). In-hospital mortality, censored at day 28, was 30.5% (n = 61).
Conclusions
In Australia and New Zealand, compliance with evidence-based practices including LPV and prone positioning was low in this cohort. Therapies with proven benefit in the treatment of patients with moderate-severe ARDS, such as lung protective ventilation and prone positioning, were not routinely employed.
{"title":"Management of severe acute respiratory distress syndrome in Australia and New Zealand (SAGE-ANZ): An observational study","authors":"Rachael L. Parke RN, PhD , Shay P. McGuinness MBChB , Alana Cavadino PhD , Keri-Anne Cowdrey RN, MN , Samantha Bates RN, MN , Shailesh Bihari MBBS, PhD , Amanda Corley RN, PhD , Eileen Gilder RN, PhD , Carol Hodgson PhD , Edward Litton MBChB, PhD , Colin McArthur MBChB , Alistair Nichol MBBCh, PhD , Jane Parker RN, MPH , Anne Turner RN, MPH , Steve Webb MBBS, PhD , Frank MP. Van Haren MD, PhD , SAGE-ANZ Study Investigators and the Australia and New Zealand Intensive Care Society Clinical Trials Group","doi":"10.1016/j.ccrj.2024.05.001","DOIUrl":"10.1016/j.ccrj.2024.05.001","url":null,"abstract":"<div><h3>Objective</h3><p>Acute respiratory distress syndrome (ARDS) is associated with significant mortality, morbidity, and cost. We aimed to describe characteristics and management of adult patients admitted to intensive care units (ICUs) in Australia and New Zealand with moderate-severe ARDS, to better understand contemporary practice.</p></div><div><h3>Design</h3><p>Bi-national, prospective, observational, multi-centre study.</p></div><div><h3>Setting</h3><p>19 ICUs in Australia and New Zealand.</p></div><div><h3>Participants</h3><p>Mechanically ventilated patients with moderate-severe ARDS.</p></div><div><h3>Main outcome measures</h3><p>Baseline demographic characteristics, ventilation characteristics, use of adjunctive support therapy and all-cause mortality to day 28. Data were summarised using descriptive statistics.</p></div><div><h3>Results</h3><p>200 participants were enrolled, mean (±SD) age 55.5 (±15.9) years, 40% (n = 80) female. Around half (51.5%) had no baseline comorbidities and 45 (31%) tested positive for COVID-19. On day 1, mean SOFA score was 9 ± 3; median (IQR) PaO<sub>2</sub>/FiO<sub>2</sub> ratio 119 (89, 142), median (IQR) FiO<sub>2</sub> 70% (50%, 99%) and mean (±SD) positive end expiratory pressure (PEEP) 11 (±3) cmH<sub>2</sub>O. On day one, 10.5% (n = 21) received lung protective ventilation (LPV) (tidal volume ≤6.5 mL/kg predicted body weight and plateau pressure or peak pressure ≤30 cm H<sub>2</sub>O). Adjunctive therapies were received by 86% (n = 172) of patients at some stage from enrolment to day 28. Systemic steroids were most used (n = 127) followed by neuromuscular blockers (n = 122) and prone positioning (n = 27). Median ventilator-free days (IQR) to day 28 was 5 (0, 20). In-hospital mortality, censored at day 28, was 30.5% (n = 61).</p></div><div><h3>Conclusions</h3><p>In Australia and New Zealand, compliance with evidence-based practices including LPV and prone positioning was low in this cohort. Therapies with proven benefit in the treatment of patients with moderate-severe ARDS, such as lung protective ventilation and prone positioning, were not routinely employed.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 3","pages":"Pages 161-168"},"PeriodicalIF":1.4,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277224000139/pdfft?md5=d534b9440be94c4ac8edd575b084a64d&pid=1-s2.0-S1441277224000139-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142230330","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.ccrj.2024.05.003
Toby Jeffcote FCICM, PhD , Kuan-Ying Lu MBiomedEng , Philip Lewis PhD , Dashiell Gantner FCICM, PhD , Camila R. Battistuzzo PhD , Andrew A. Udy FCICM, PhD
Modern intensive care for moderate-to-severe traumatic brain injury (msTBI) focuses on managing intracranial pressure (ICP) and cerebral perfusion pressure (CPP). This approach lacks robust clinical evidence and often overlooks the impact of hypoxic injuries. Emerging monitoring modalities, particularly those capable of measuring brain tissue oxygen, represent a promising avenue for advanced neuromonitoring. Among these, brain tissue oxygen tension (PbtO2) shows the most promising results. However, there is still a lack of consensus regarding the interpretation of PbtO2 in clinical practice. This review aims to provide an overview of the pathophysiological rationales, monitoring technology, physiological determinants, and recent clinical trial evidence for PbtO2 monitoring in the management of msTBI.
{"title":"Brain tissue oxygen monitoring in moderate-to-severe traumatic brain injury: Physiological determinants, clinical interventions and current randomised controlled trial evidence","authors":"Toby Jeffcote FCICM, PhD , Kuan-Ying Lu MBiomedEng , Philip Lewis PhD , Dashiell Gantner FCICM, PhD , Camila R. Battistuzzo PhD , Andrew A. Udy FCICM, PhD","doi":"10.1016/j.ccrj.2024.05.003","DOIUrl":"10.1016/j.ccrj.2024.05.003","url":null,"abstract":"<div><p>Modern intensive care for moderate-to-severe traumatic brain injury (msTBI) focuses on managing intracranial pressure (ICP) and cerebral perfusion pressure (CPP). This approach lacks robust clinical evidence and often overlooks the impact of hypoxic injuries. Emerging monitoring modalities, particularly those capable of measuring brain tissue oxygen, represent a promising avenue for advanced neuromonitoring. Among these, brain tissue oxygen tension (PbtO<sub>2</sub>) shows the most promising results. However, there is still a lack of consensus regarding the interpretation of PbtO<sub>2</sub> in clinical practice. This review aims to provide an overview of the pathophysiological rationales, monitoring technology, physiological determinants, and recent clinical trial evidence for PbtO<sub>2</sub> monitoring in the management of msTBI.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 3","pages":"Pages 204-209"},"PeriodicalIF":1.4,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277224000152/pdfft?md5=e58a24cff9d40d7de6e006570777fc6b&pid=1-s2.0-S1441277224000152-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142230443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.ccrj.2024.08.005
Ary Serpa Neto MD, MSc, PhD
{"title":"ARDS, guidelines and ANZ practice: The persistent disconnect","authors":"Ary Serpa Neto MD, MSc, PhD","doi":"10.1016/j.ccrj.2024.08.005","DOIUrl":"10.1016/j.ccrj.2024.08.005","url":null,"abstract":"","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 3","pages":"Pages 159-160"},"PeriodicalIF":1.4,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277224000322/pdfft?md5=4c206667cb8d6cc357879153406c2ecc&pid=1-s2.0-S1441277224000322-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142230329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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