世界危重病急救学杂志(英文版)最新文献

The intra-arterial catheter is a fundamental tool in contemporary critical care medicine. Intra-arterial catheters are widely used for a range of diagnostic and therapeutic purposes, and catheter insertion is an important clinical skill for clinicians managing critically unwell patients. The concepts and practical implications of catheter design on procedural technique and outcomes are frequently overlooked. This narrative review describes the clinical application of arterial catheters, the evidence supporting their use, and the rationale for key device characteristics.

Background: Traumatic brain injury (TBI) is a significant public health issue, leading to long-term neurological impairments. Current treatments offer limited recovery, particularly in restoring lost functions. Mesenchymal stem cell-derived exosomes (MSCdE) have shown potential for promoting neuroprotection and regeneration. This study evaluates the safety and efficacy of MSCdE therapy in TBI patients.

Aim: To evaluate the safety and efficacy of MSCdE therapy in TBI patients.

Methods: Five patients (mean age 27.00 ± 4.06 years) with TBI from combat injuries were treated with six rounds of MSCdE therapy (3 mL intrathecally and 3 mL intramuscularly per round). The patients were followed for one year. Adverse events were assessed using the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0), and functional outcomes were evaluated with the functional independence measure (FIM), Modified Ashworth Scale (MAS), and Karnofsky Performance Scale (KPS).

Results: No serious adverse events occurred, and only mild side effects [subfebrile fever (37.5 °C-37.9 °C), pain] were reported (CTCAE Grade 1). FIM motor scores improved significantly (46.20 ± 16.39 to 64.20 ± 18.20, P < 0.01), and FIM cognitive scores also showed significant improvement (30.60 ± 4.56 to 34.00 ± 1.41, P < 0.001). While MAS scores improved (right/left: 4.60/3.60 to 2.20/1.60), these changes were not statistically significant (P > 0.05), possibly due to low baseline spasticity. KPS scores significantly improved (46.00 ± 11.40 to 72.00 ± 8.37, P < 0.001), indicating enhanced overall functional status and quality of life.

Conclusion: MSCdE therapy is safe and effective in improving motor function, cognition, and quality of life in TBI patients. Larger, controlled trials are needed to further validate these findings and optimize MSCdE therapy for TBI treatment.

Right ventricular (RV) failure accounts for significant morbidity and mortality in critically ill patients. The RV is particularly vulnerable in conditions characterized by elevated pulmonary vascular afterload, which are commonly encountered in the intensive care unit (ICU). Conditions such as acute respiratory distress syndrome, pulmonary embolism, and decompensated pulmonary arterial hypertension are associated with acute and acute-on-chronic RV failure. In the ICU, RV failure may develop or worsen in patients with parenchymal pulmonary disease who acutely experience fluctuations in preload, excessive afterload, and/or insufficient myocardial contractility, often in addition to mechanical ventilation and circulatory compromise. This dynamic clinical scenario demands early recognition and intervention tailored to an individual patient's physiology. Distinguishing between acute and chronic RV failure in critical illness informs diagnostic workup, hemodynamic monitoring, and resuscitative efforts. This narrative review will provide an overview of common conditions associated with RV failure in critical illness, highlighting a practical, physiology-oriented approach to diagnosis and optimization of ventilator support, fluid resuscitation, vasopressor and inotrope use, and mechanical circulatory support. RV failure due to RV infarction or severe LV failure and decompensated congenital heart disease are distinct pathophysiologic entities. These conditions require distinct treatment approaches and are beyond the scope of this review.

Background: Sepsis is a life-threatening condition caused by a dysregulated host response to infection. Peripheral blood mononuclear cells (PBMCs) are critical mediators of the immune response and may exhibit redox imbalance during sepsis. Reactive oxygen species (ROS) are known to influence immune cell signaling, and excessive ROS accumulation may contribute to sepsis-associated immune alterations.

Aim: To assess intracellular ROS levels in PBMC subsets from septic patients and determine whether norepinephrine (NE) or N-acetylcysteine (NAC) modulate ROS levels following inflammatory stimulation in vitro.

Methods: PBMCs were isolated from Department of Emergency patients meeting SEP-1/SEP-2 sepsis criteria and from healthy controls without signs of infection. Intracellular ROS levels were measured using a total ROS detection assay and analyzed by flow cytometry. PBMCs were also stimulated in vitro with lipopolysaccharide (LPS) or hydrogen peroxide (H₂O₂), with or without co-treatment with NE or NAC.

Results: ROS levels were significantly elevated in CD3+ and CD14+ cells from septic patients compared to controls. In vitro stimulation of control PBMCs with LPS or H₂O₂ increased ROS in CD3+ and CD14+ cells, which was attenuated by co-treatment with NE or NAC.

Conclusion: ROS levels are elevated in specific PBMC subsets in sepsis, particularly CD3+ T cells and CD14+ monocytes. NE and NAC reduced ROS accumulation in vitro, supporting their potential role as redox modulators. These findings warrant further mechanistic investigation into immune redox regulation in sepsis.

Background: Excessive noise in healthcare environments-commonly described as "unwanted sound"-has been linked to a range of negative impacts on both patients and staff. In clinical settings, elevated noise levels have been associated with sleep disruption, heightened cardiovascular stress, and an increased risk of delirium in patients. Among healthcare workers, noise can impair focus and cognitive performance, potentially compromising care quality.

Aim: To evaluate the effectiveness of educational and behavioural interventions in reducing noise levels within intensive care units (ICUs), recognizing their potential impact on patient outcomes and healthcare effectiveness.

Methods: A prospective interventional study in two Singaporean teaching hospitals compared peak and average sound levels between control and intervention groups. An educational and behavioural intervention comprising talks, posters, and self-audits by nurse champions was initiated in two ICUs in one hospital on November 18, 2023. Sound measurements were collected at 4 Locations within each ICU before and after intervention. Baseline measurements were taken from October 22, 2023 to October 29, 2023, and post-intervention measurements from December 21, 2023 to December 22, 2023. The hospitals served as the primary exposure variable, controlled for ICU type (medical vs surgical) and hour of the day.

Results: Our analysis generated 48 pairs of peak and average sound level readings for each unit (control n = 48 readings; intervention n = 48 readings). The effect of the intervention was associated with a significant 4.8 dB decrease in average sound level (P = 0.009) and a nonsignificant 4.3 dB decrease in peak sound level (P = 0.104), adjusted for hour of day and type of ICU.

Conclusion: Educational and behavioural interventions successfully reduced average sound levels, emphasizing their positive impact on noise control. These findings contribute valuable insights for optimizing noise reduction efforts in critical care settings. Future studies may explore additional systemic and environmental interventions to enhance noise management strategies.

Background: Cardiac arrest is a critical condition characterized by abrupt cessation of cardiac function, resulting in reduced oxygen delivery to vital organs and rapid progression to death if not timely treated. Despite advances in medical science and resuscitation techniques, cardiac arrest remains a significant burden globally, with survival rates remaining low. Comprehensive research on cardiac arrest, particularly comparisons between in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA), is limited.

Aim: To compare the survival rates, return of spontaneous circulation (ROSC), survival to discharge, and neurological outcomes after IHCA and OHCA in Arab Asian countries.

Methods: We systematically searched PubMed, Medline, EMBASE and Google Scholar (2000-2024) using keywords ("IHCA", "OHCA", "cardiac arrest", "Middle East", "Arab", "Asian") in titles/abstracts. The inclusion criterion was observational studies on adults (≥ 18 years) in Arab Asian countries reporting relevant outcomes. The exclusion criteria were narrative reviews, non-Arab Asian studies, non-English publications, inaccessible full texts, pediatric-only populations, and studies lacking outcome data.

Results: In total, 44 observational studies from nine Arab Asian countries comprising 32535 participants were included. This review highlights the substantial variability in cardiac arrest outcomes in Asian countries. OHCA mortality rates were alarmingly high in several nations, with Kuwait (99%), Bahrain (98.8%), and Qatar (97.6%) reporting the highest figures. In contrast, the Kingdom of Saudi Arabia (KSA) had a markedly lower OHCA mortality rate (8.2%). The rates of ROSC also varied, with Qatar achieving the highest (34.4%) and Kuwait the lowest (3.3%). Survival to hospital discharge ranged from 1.2% in Bahrain to 18.7% in Kuwait, with Qatar also reporting favorable rates (17.5%). For IHCA, mortality was 73.6% in the United Arab Emirates (UAE) and 72.8% in KSA, whereas Lebanon and Iraq reported higher rates of 94.6% and 88%, respectively. ROSC rates were the highest in Lebanon (55.9%) and the UAE (51.3%). Neurological outcome reporting has been inconsistent, although Qatar reported a high rate (68.6%) for OHCA survivors. Comparative data showed generally better survival and neurological outcomes with IHCA than with OHCA.

Conclusion: This systematic review underscores the clear disparity in survival outcomes between IHCA and OHCA in Arab Asian countries, with IHCA demonstrating superior outcomes. Despite progress in some countries, outcomes remain suboptimal compared with international standards. Future multicenter studies with standardized methodologies are required to generate high-quality evidence and provide region-specific interventions for cardiac arrest management.

Background: There has been a growing interest in noninvasive ventilation (NIV) in comparison to invasive mechanical ventilation (IMV) as a standard of care for acute respiratory failure (ARF), especially in the post-covid era, but direct head-to-head cost comparisons between the two modalities are not available in literature.

Aim: To compare the cost along with the clinical effectiveness of NIV in comparison to IMV in ARF.

Methods: A prospective observational single-center case control study including adult patients with ARF (PaO₂/FiO₂ ratio < 300) admitted from January 1, 2024 to December 31, 2024 in medical intensive care unit (ICU) of a tertiary care hospital requiring either NIV or invasive ventilation. NIV and IMV groups were compared based on average length of ICU and hospital stay, mortality, net cost of ICU treatment, need for intubation and tracheostomy.

Results: A total of 319 patients were included in the study (197 in NIV, 122 in IMV group). Statistically significant difference in length of ICU stay (NIV group: 5 ± 3.25 days, IMV group: 9 ± 2.6 days; P < 0.05) and mortality rate was seen (11% NIV vs 34% IMV; P < 0.01). On multivariate analyses, mortality showed a stronger association with IMV [odds ratio (OR) = 7.73; 95%CI: 3.12-19.18] as compared to ICU stay (OR = 2.73; 95%CI: 2.15-3.48). A total of 33 patients (17%) in NIV group required intubation of which 3 were tracheostomized, while 14 patients (11%) in IMV group needed tracheostomy. The net average cost of ICU stay was INR 83902 in NIV group while in IMV group, the net ICU cost was INR 476216. The average cost of ICU stay was five times higher with IMV.

Conclusion: NIV has potential economic and clinical benefits as compared to invasive ventilation in ARF.

Most studies assessing urine biochemistry for acute kidney injury (AKI) monitoring rely on paradigms from the 1970s. It was proposed that a single measurement of urinary parameters in the presence of increased serum creatinine (sCr) could help understand AKI pathophysiology and predict its duration. However, those studies produced variable and controversial results. Recently, an alternative "urine biochemical approach" has been proposed. In contrast with the traditional approach, it includes sequential urine electrolyte assessment, evaluation before AKI diagnosis, and interpretation of avid sodium retention as a marker of renal microcirculatory stress instead of low renal perfusion. This review highlights the rationale of this alternative approach, which is focused on early urinary biochemical changes that precede increases in sCr as well as signs of renal recovery before decreases in sCr. The relevance of urine composition in conjunction with urine volume for a proper evaluation of renal function is emphasized. This new approach aims to enhance the utility of urinary biochemical parameters in AKI monitoring, particularly in patients who are critically ill.

Background: Analgesia and sedation are commonly prescribed therapies within the intensive care unit (ICU) for patients receiving mechanical ventilation. Current guidelines recommend utilizing an analgesia-first approach to initially reach appropriate pain control, while potentially achieving sedation goals concurrently. Our system employs a guideline-based ICU sedation order-set that features an electronic medical record (EMR) integrated ICU checklist that combines analgesia and sedation.

Aim: To identify systems-based factors that are associated with the use of continuous midazolam infusion administration in mechanically ventilated patients.

Methods: We extracted EMR data from patients who received mechanical ventilation between January 1, 2021, and December 31, 2023. Subjects included were 18 years or older who received mechanical ventilation. "R" version 4.3.2 was used for data processing and statistical analysis. We performed a multivariable regression analysis to predict the administration of a continuous midazolam infusion with modified Sequential Organ Failure Assessment score, Charlson comorbidity index, and critical care medicine (CCM) primary service.

Results: Of 3805 patients that underwent mechanical ventilation, 62% were male, with a mean age of 66.9 years. 3429 patients were treated by a provider team with a CCM attending, and 376 patients were managed by a non-CCM primary team with CCM consultative services. A midazolam infusion was used in 187 of 3429 (5%) patients with CCM as primary and in 166 of 376 (56%) patients with non-CCM primary (χ ² 598.23, P < 0.001). Of the patients who received continuous midazolam, 117 (21%) died vs 236 (7%) survived hospitalization. Continuous midazolam was associated with more days with coma and more days with delirium (P < 0.0001).

Conclusion: Continuous midazolam infusion was more likely in patients admitted to the ICU under an open unit with a non-CCM physician with an intensivist consult available, despite guided order-sets and checklists integrated into the EMR.