世界危重病急救学杂志(英文版)最新文献

Intensivists are often plagued with the challenges of managing critically ill patients in the neurocritical intensive care unit (neuro ICU); one such challenge is the level of illness and the need for sedation, inhibiting the provider's ability to adequately assess the patient. Most sedatives alter neurological and physical exam findings, only compounding potential barriers to providing the best care for each patient. It is important to emphasize that even in the altered mentation of these patients, physical and neurological exams reign supreme as diagnostic tools and should be used in conjunction with multimodal neuromonitoring methods, rather than labs or imaging alone. Additionally, selecting the appropriate analgesic(s) and sedative(s) based on these findings are highly important when determining the best course of individualized management. Thus, providers in the neuro ICU should be highly familiar with the appropriate analgesic and sedative options available in order to determine not only which may be best for each patient, but to also better understand how each drug may impact assessment findings. This comprehensive review aims to provide a structured overview of the pertinent sedatives commonly used in neuro ICUs, their risks and benefits, and how providers can best utilize each in practice to further improve patient outcomes. The novel contribution of this work provides comparative drug tables, dosing guidance for pediatric and very elderly (> 85-years-old) populations, and an exploration into the future possibilities of utilizing artificial intelligence and the human gut microbiome to further enhance the prospects of precision medicine.

Background: Managing left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM) of the mitral valve can be challenging, especially in the context of circulatory shock and pulmonary edema post cardiac surgery.

Case summary: We describe a case of an 80-year-old female patient with a history of severe aortic stenosis and hypertrophic obstructive cardiomyopathy that underwent aortic valve replacement and myectomy. The patient presented with acute pulmonary edema and low blood pressure due to LVOTO and SAM post cardiac surgery in the intensive care unit. She was paced with an epicardial dual-chamber pacing system due to complete atrioventricular block and treated initially with norepinephrine, furosemide, and esmolol infusion and continuous positive pressure ventilation. The patient remained hypoxemic and kept deteriorating hemodynamically despite titrating up norepinephrine. The addition of vasopressin infusion and tapering of norepinephrine finally stabilized the patient with significant reduction of LVOTO, confirmed by transthoracic echocardiography assessment, improved oxygenation and increased urine output.

Conclusion: Vasopressin seems to be the preferred vasopressor for managing LVOTO and SAM post-cardiac surgery, because of its absence of inotropic effects. Echocardiography is crucial for early diagnosis and therapeutic management.

Background: Traumatic brain injury (TBI) is the second most common presentation of trauma victims. Among the various non-neurological complications after TBI, acute kidney injury (AKI) is not uncommon.

Aim: To establish the incidence, risk factors, and predictors of AKI in TBI victims. The secondary aim was to study the impact of AKI development on the outcomes of patients with TBI.

Methods: This was a single-center retrospective cohort study of TBI victims with a Glasgow coma scale (GCS) ≤ 11 in an apex trauma center in a metropolitan city.

Results: The incidence of AKI after TBI was 11%. The risk factors for AKI after TBI were old age (P < 0.001), comorbidities (P = 0.023), shock (P < 0.001), blood transfusion (P = 0.016), consecutive neurosurgical intervention (P = 0.029), high intracranial pressure (ICP) (P < 0.001), rhabdomyolysis (P < 0.001), and diabetes insipidus (P < 0.001). The predictors of AKI after TBI were, on point-biserial correlation: Lower GCS (r_pb = -0.27, n = 331, P < 0.001); and on multivariate logistic regression: (1) Shock (odds ratio [OR]: -11.94, P < 0.001); (2) Rhabdomyolysis (OR: -7.33, P = 0.001); (3) High ICP (OR: -4.39, P = 0.018); (4) High Carlson comorbidity index (OR: -1.97, P = 0.001); and (5) High acute physiology and chronic health evaluation-2 (APACHE-2) score (OR: -1.13, P < 0.001). The phenomenon of post-TBI AKI increased the extent of stay in intensive care unit (P = 0.008), demand for ventilators (P = 0.0170), ventilator days (P < 0.001), incidence of brain death (P < 0.001), and mortality (P < 0.001).

Conclusion: Every tenth TBI victim suffers from AKI. AKI after TBI can be predicted by the patient's underlying comorbidities, on arrival low GCS, high APACHE-2 score, shock, rhabdomyolysis, and high ICP. The occurrence of AKI in TBI victims adversely affects outcome variables; however, this may be a reflection of the severe nature of TBI in the AKI group. New research is needed to understand the effects of AKI on outcome variables.

A thyroid storm (TS) or thyrotoxic crisis is an infrequent, life-threatening endocrinological emergency due to the worsening of the hyperthyroid state. Thyroid hormones (THs) influence almost all the body cells and tissues' differentiation, growth, and energy metabolism. Consequently, excess THs are expected to lead to profound organ function, regulation, and hemodynamic changes. In addition to their roles in metabolism and thermoregulation, THs play critical role in maintaining cardiovascular homeostasis through both genomic and non-genomic mechanisms. Receptors for THs are expressed in myocardial and vascular endothelial tissues, allowing fluctuations in circulating hormone levels to directly influence cardiovascular function. Excess TS induces a hyper-dynamic cardiovascular state, characterized by increased ventricular contractility and improved systolic and diastolic performance. The chronotropic and inotropic properties of THs result in dysregulation of blood pressure, heart rate, contractility, cardiac output, and systemic vascular resistance. This could lead to serious consequences such as cardiomyopathy, heart failure, and life-threatening arrhythmia, ultimately contributing to cardiocirculatory collapse and cardiac death. The management of TS necessitates a systematic approach that emphasizes the significance of resuscitation and identification of the underlying causes. It is crucial to prioritize assessing cardiac function in patients with TS. This review explores the clinical impact of TS on the heart and its clinical repercussions, emphasizing the intricate molecular and pathophysiological mechanisms and the interplay between TS and key cardiovascular parameters. This review summarizes the current knowledge of pathophysiology, pharmacological and mechanical interventions, ranging from beta-blocker use to the surgical approach.

Ivabradine, a selective inhibitor of the funny current in the sinoatrial node, has emerged as a promising agent for heart rate modulation in acute and critical care settings. Unlike beta-blockers, ivabradine reduces heart rate without affecting myocardial contractility, making it a valuable option for patients contraindicated for traditional therapies. This review examines its mechanism of action, clinical applications, comparative efficacy, and safety profile. It incorporates recent literature to assess its expanding role in managing acute coronary syndrome, acute decompensated heart failure, and sepsis-induced tachycardia.

Background: Prolonged immobility during intensive care unit (ICU) admission has been a cause of muscle atrophy and worsening functional outcomes with longer recovery times. Prior research has demonstrated that mobilization within a week of ICU admission potentially benefits physical function in critically ill patients.

Aim: To evaluate the effects of initiating mobilization within 72 hours of ICU admission in critically ill patients through an updated systematic review and meta-analysis.

Methods: A systematic search was performed through MEDLINE, Scopus, and Cochrane Library from inception until September 2024 for randomized controlled trials (RCTs) comparing early mobilization (EM) with usual or conventional care in critically ill adult patients. Primary outcomes included length of ICU (days) and ventilation duration (days). Secondary outcomes included muscle strength, functional status, adverse events, all-cause mortality, and quality of life (QOL). A random effects meta-analysis was performed for pooled effect estimates and to derive risk ratios (RR) and corresponding 95% confidence intervals (CI).

Results: Out of 3487 results, 16 RCTs were included with a population of 2385 patients (1195 receiving EM and 1190 with usual care.) A significant reduction in the length of ICU stays [mean difference (MD) = -1.02, 95%CI: -1.96 to -0.09; P = 0.03; I ² = 60%] and ventilation duration (MD = -1.07, 95%CI: -1.91 to -0.23, P = 0.01; I ² = 57%) was observed in the EM group compared to usual care. EM significantly improved muscle strength [standard MD (SMD) = 0.47, 95%CI: 0.18-0.75, P = 0.001; I ² = 79%] and functional status (SMD = 0.70, 95%CI: 0.40-1.00, P < 0.00001; I ² = 81%) in ICU patients. No statistically significant difference was observed in adverse events (RR = 1.72, 95%CI: 1.01-2.94, P = 0.05; I ² = 31%), all-cause mortality (RR = 1.10, 95%CI: 0.79-1.53, P = 0.57; I ² = 30%), and QOL (SMD = 0.04, 95%CI: -0.07-0.15, P = 0.50; I ² = 9%) between the two groups.

Conclusion: Initiating mobilization within 72 hours of ICU admission is associated with improved functional outcomes and reduced ICU length of stay and ventilation duration. These findings indicate that EM may be a safe option for ICU patients, contributing to lower recovery times and healthcare costs. Further extensive research is required to validate the long-term effects on survival and QOL.

Sepsis remains a leading cause of morbidity and mortality worldwide, driven by a dysregulated host immune response to infection that culminates in multi-organ dysfunction. Recent advances highlight the gut microbiota's pivotal role in modulating immune responses and influencing the pathophysiology of sepsis through the organ-gastrointestinal tract axis. This review synthesizes current evidence on the bidirectional interplay between gut dysbiosis and the dysfunction of major organ systems-liver, lungs, kidneys, brain, and heart-during sepsis. We explore how gut-derived factors such as microbial translocation, endotoxins, and altered metabolite production exacerbate systemic inflammation and organ injury. In particular, we emphasize the roles of short-chain fatty acids, uremic toxins, bile acids, and trimethylamine-N-oxide in mediating immune dysfunction across the gut-organ axes. Therapeutic strategies targeting the gut microbiota- including prebiotics, probiotics, synbiotics, and fecal microbiota transplantation- show promise in preclinical and early clinical settings. However, challenges related to patient heterogeneity, safety, and the lack of precise biomarkers persist. This review consolidates disparate findings to underscore the gut as a central modulator in sepsis and advocates for microbiota-based interventions as adjunctive therapies in sepsis management.

Background: Systemic lupus erythematosus (SLE) patients are admitted to the intensive care unit (ICU) for disease flares and infections, both of which carry a high mortality risk. Studies characterizing the outcome predictors of SLE are few in the Asian continent. This study characterized the clinical profile, treatment, and outcome predictors of ICU admissions with SLE.

Aim: To ascertain the reasons for ICU admission among SLE patients and to explore outcome predictors in these patients. The primary outcome was ICU mortality. Secondary outcomes included need for ventilation, inotropes, renal replacement therapy, and length of ICU and hospital stay.

Methods: A retrospective study of 77 SLE patients was conducted in the medical ICU of a tertiary care teaching hospital in India. Clinical features, treatment, and outcomes of patients admitted between January 2018 and December 2022 were recorded. Factors associated with mortality were explored using bivariate and multivariate logistic regression analysis and reported as adjusted odds ratios with 95% confidence intervals.

Results: The mean (SD) age was 31.1 (10.3) years; 83.1% were female. The median (interquartile) duration of SLE before admission was 12 (1-60) months; SLE was newly diagnosed in the current admission in 23.4%. The median Acute Physiology and Chronic Health Evaluation II score was 16.3 (14.5-18.2) and similar among survivors and non-survivors; 32 had evidence of disease flare, 44 had an infection, and one patient had an intracranial bleed. ICU admission was for respiratory failure (46.7%), hemodynamic instability (32.5%), and status epilepticus (14.3%). Twenty-nine patients (37.7%) had autoimmune hemolytic anemia, and 11 (14.3%) had diffuse alveolar hemorrhage. Immunomodulation included corticosteroids (96.1%), cyclophosphamide (33.8%), mycophenolate (23.4%), plasma exchange (13%), and immunoglobulins (11.7%). All patients received broad-spectrum antibiotics. Respiratory support, inotropes, and renal replacement therapy were required in 93.5%, 51.7%, and 32.5%, respectively. ICU mortality was 50.7% (95% confidence interval: 39%-62%). The mean ± SD hospital length of stay was 18.9 ± 14.3 days. On multivariate analysis, only shock (P = 0.004) was independently associated with mortality.

Conclusion: Intercurrent infection and disease flare are common reasons for ICU admission in SLE patients. Despite multimodal therapy, mortality is high. Shock was independently associated with mortality.

Background: Intensive care units (ICUs) are stressful milieus for patients, particularly when under mechanical ventilation. Music is a non-pharmacological intervention that has shown a positive impact on physiological and psychological parameters in patients on mechanical ventilation.

Aim: To evaluate outcome of music therapy on patients who are critically ill to note the effect on ICU stays.

Methods: One-hundred-and-thirty-six adult patients with acute respiratory failure requiring mechanical ventilation for 48 hours or more were randomized into the music therapy or routine care (control) groups. Patients were assessed for weaning criteria before music therapy was given. If eligible, a 30-minute music therapy was given prior to the extubation. Vital parameters were recorded at 5-minute intervals of therapy. Visual Analog Scale (VAS)-Dyspnea and VAS-Anxiety (VAS-A) were assessed before and after therapy. Richmond Agitation-Sedation Scale and Numerical Rating Scale scoring were conducted.

Results: The difference in times of ventilator support in the music therapy intervention group (58.22 ± 14.90 hours) and the control group (56.88 ± 13.10 hours) was not statistically significant. ICU length of stay was significantly lower in the music therapy group (4.97 ± 1.70 days vs control group: 5.70 ± 1.74 days). ICU mortality was significantly lower in the music therapy group as compared with the control group (7.4% vs 19.1%; P = 0.043). At 0 minute the VAS-A scores of the music therapy (6.82 ± 1.36) and control group (7.07 ± 1.07) were comparable. During the remainder of the observation period, the VAS score of the music therapy group was significantly lower than that of the control group.

Conclusion: Music therapy is an inexpensive non-pharmacological intervention for patients in the ICU. However, future multicenter studies are warranted before routinely using music therapy in patients in the ICU.

Background: Pulmonary arterial hypertension (PAH) is a debilitating and progressive pulmonary pathology that often leads to death. Guidelines recommend the use of palliative care (PC) early in the treatment course to ease the burden of symptoms; however, uptake remains low.

Aim: To evaluate barriers to PC uptake and determine its association with mortality in patients with PAH.

Methods: All studies discussing PC in PAH were selected in our review and analysis. Clinical and cross-sectional studies were included. Barriers were described in a qualitative fashion. A random-effects meta-analysis was also conducted, in which the odds ratio for mortality was pooled and reported, along with 95% confidence intervals.

Results: A total of 19 studies were included in the review. The most common barriers identified included feeling like the patients were "not sick enough", belief that PC is only appropriate for end-of-life care, belief that it would burden family members, and general feelings of hopelessness. Physicians identified structural causes, such as a lack of funding and low levels of PC-related knowledge, as barriers to recommending PC. The meta-analysis showed no statistically significant difference in mortality across four included studies (Log odds ratio = 0.89, 95% confidence intervals: -3.06-1.28). Heterogeneity was high (I ² = 80.32%).

Conclusion: Uptake of PC in PAH is low due to patient and physician-level barriers, which can be overcome with systematic PC integration. Long-term studies are also needed to investigate the impact of PC on outcomes in PAH, as the current limited data show no significant difference.