世界危重病急救学杂志(英文版)最新文献

Background: Previous studies have reported the high predictive accuracy of 4C Mortality Score derived at hospital admission in coronavirus disease 2019 (COVID-19) patients. Very few studies have assessed it at intensive care unit (ICU) admission and compared it with the Acute Physiology and Chronic Health Evaluation (APACHE) II score. There are no studies comparing its accuracy with APACHE III score.

Aim: To describe the characteristics and outcomes of patients admitted to ICU with COVID-19 infection and to compare the accuracy of 4C score and APACHE score in predicting mortality in these patients.

Methods: We conducted this retrospective cohort study using an electronic database in a tertiary ICU in Sydney. We included all adult patients (age > 16 years) admitted to ICU with COVID-19 infection over a 5-month period (July 1, 2021 to November 30, 2021). We collected the data on demographics, clinical characteristics, interventions and outcomes for all patients. We calculated the 4C Mortality Score for each patient using eight variables as described previously. We compared the predictive accuracy of 4C Mortality Score at hospital and ICU admission and APACHE II and III scores by area under the receiver operating characteristic curve (AUROC). We determined the optimal cut-off value for each of these scores using the 'nearest' method and its 95% confidence interval by bootstrapping.

Results: A total of 140 patients (62% males, mean age 56 ± 17 years, mean APACHE II score 13 ± 57) were included in the study. Nineteen (13.6%) of 140 patients died in the hospital. Compared to survivors, the non-survivors were older, males, had more comorbidities, higher rate of mechanical ventilation and vasopressor use. The AUROC for the 4C Mortality Score at hospital and ICU admission and APACHE II and II score was 0.75, 0.80. 0.75 and 0.79 respectively. The optimal cut-off value for these four scores was 9, 10, 14 and 56 respectively. The cut-point for all the scores had higher sensitivity than specificity.

Conclusion: The 4C score at ICU admission had a higher accuracy in predicting mortality than the 4C score at hospital admission. The predictive accuracy was similar to that for APACHE III score. The 4C score at ICU admission needs to be validated in future studies.

Background: We present the first known case of simultaneous myocardial infarction, stroke, and bowel infarction, likely triggered by a thrombotic crisis.

Case summary: A 72-year-old man was found unresponsive in his car and was diagnosed with acute inferoposterior ST-elevation myocardial infarction (STEMI) and slow atrial fibrillation (AF). A computed tomography (CT) brain scan initially ruled out stroke, and the preliminary diagnosis was cardiogenic shock, slow AF, and Killip 4 acute STEMI, complicated by lactic acidosis and delirium. The patient underwent catheterization, revealing a complete occlusion of the right coronary artery. Afterward, he suffered two episodes of pulseless electrical activity but regained spontaneous circulation. However, a repeat CT brain scan revealed an acute left insula and M2 ischemic stroke, with subtle findings already present on the initial scan. Blood tests showed increasing lactate levels, prompting a CT mesenteric angiogram that identified multiple infarcts in the spleen, kidney, and intestines, suggesting bowel infarction had already occurred. The patient passed away two days later.

Conclusion: This case underscores the diagnostic challenges and complexities of managing thrombotic storms, particularly when multiple ischemic events occur simultaneously. It highlights the importance of timely diagnosis and multidisciplinary coordination in such cases. We recommend a time-sensitive management approach and further research to establish evidence-based strategies for treating thrombotic storm.

Desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) is a synthetic analogue of arginine vasopressin, the body's natural antidiuretic hormone. It acts selectively on V2 receptors, promoting renal water reabsorption and stimulating the release of von Willebrand factor (vWF) and factor VIII, while exerting minimal vasoconstrictive effects through V1 receptors. Developed in the late 1960s and introduced clinically in the early 1970s for the management of central diabetes insipidus, desmopressin was engineered to provide a longer duration of action and reduced cardiovascular side effects compared to native vasopressin. Its haemostatic potential was later recognized when it was observed to enhance endogenous levels of vWF and factor VIII, leading to its incorporation into the treatment of mild haemophilia A and von Willebrand disease (vWD). This unique combination of antidiuretic and prohemostatic properties has broadened its therapeutic role across various clinical settings. In critical care, desmopressin has emerged as a potentially valuable agent in managing complex scenarios such as uremic platelet dysfunction, trauma-associated coagulopathy, intracranial hemorrhage, vWD, and central diabetes insipidus. However, despite its mechanistic appeal and broad pharmacologic utility, the full scope of desmopressin's applications in the intensive care unit (ICU) remains underrecognized. This review aims to provide a comprehensive examination of desmopressin's pharmacological characteristics, evidence-based indications in critically ill patients, therapeutic efficacy, safety profile, and practical considerations for dosing in the ICU setting.

Electrolyte disorders are pivotal determinants of morbidity and mortality in neurocritical care and exacerbated by acute brain injury, neuroendocrine dysfunction, and therapeutic interventions. This narrative review synthesized contemporary evidence on the pathophysiology, diagnosis, and management of hydroelectrolytic disturbances in neuroanesthesia and neurocritical populations. Dysnatremias (hyponatremia and hypernatremia) are prevalent with emerging data challenging historical correction paradigms: Rapid sodium normalization may reduce mortality without increasing complications. Distinct strategies are required for syndromes of inappropriate antidiuretic hormone secretion (fluid restriction, vaptans) vs cerebral salt wasting (volume resuscitation). Chloride dysregulation, driven by cation-chloride cotransporter imbalances, exacerbates cytotoxic edema and seizures, warranting trials of bumetanide and balanced crystalloids. Hypokalemia, prevalent in traumatic brain injury, demands proactive surveillance to prevent arrhythmias while hyperkalemia management prioritizes membrane stabilization and renal clearance. Hypocalcemia correlates with adverse outcomes in subarachnoid hemorrhage, necessitating timely replacement. Magnesium disorders lack consistent prognostic associations in neurocritical cohorts, contrasting with general critical care. Current evidence underscores the need for individualized, pathophysiology-driven correction, integrating endocrine and neurological principles. Innovations such as point-of-care testing and targeted therapies (e.g., acetate-buffered hypertonic saline) show promise, yet reliance on observational data and preclinical models highlights the urgency for randomized controlled trials. This review advocated for protocolized monitoring, dynamic assessments, and research to define optimal correction thresholds and validate emerging interventions in this high-risk population.

The intersection of cannabis use disorder (CUD) and critical illness outcomes in cancer patients represents a burgeoning area of research, particularly as cannabis legalization and therapeutic applications expand globally. Adjusted analyses of a retrospective cohort study by Sager et al revealed significantly lower odds of all-cause mortality (adjusted odds ratio (aOR) = 0.83) and respiratory failure (aOR = 0.8) in CUD-positive patients, alongside elevated hospitalization costs. These findings suggest the potential immunomodulatory and organ-protective effects of cannabinoids on sepsis. Future research must prioritize mechanistic studies, prospective clinical trials, and socioeconomic interventions to translate these findings into actionable clinical strategies, to align policy recommendations with guidelines, including those presented by the National Comprehensive Cancer Network.

Background: Administration of thrombolytics for acute ischemic stroke (AIS) via telemedicine has expanded in recent years at institutions without on-site neurology specialists. This helped to improve the care of stroke patients in rural areas. However, it is uncertain if telemedicine-administered thrombolytics is as safe and effective as in-person evaluation by neurology specialists.

Aim: The authors conducted a meta-analysis evaluating stroke metrics, safety and outcomes of telemedicine compared to in-person evaluation by neurologist specialist in AIS patients receiving intravenous thrombolytics.

Methods: PubMed, EMBASE, and Cochrane were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, were applied to calculate an overall effect estimate for each outcome by combining specific risk ratio (RR) or standardized mean difference (SMD). Risk of bias was analyzed using the Newcastle-Ottawa Scale. Primary outcome examined was door-to-needle time (DTN). Secondary outcomes were symptomatic intracranial hemorrhage (sICH), mortality, and mRS ≤ 2.

Results: Eleven retrospective cohort studies involving 2350 patients were included in the analysis. Of those, 34% (n = 794) received thrombolytics via telemedicine. Telemedicine was associated with a significantly longer mean DTN compared to in-person evaluation [SMD: 0.72 minutes; 95% confidence interval (CI) 0.22-1.22; P < 0.01], a similar rate of sICH [3.9% vs 4.2%; Odds ratio (OR): 0.75; 95%CI 0.42-1.37; P = 0.35], similar rate of mortality (13.2% vs 14.7%; OR: 0.87; 95%CI 0.47-1.63; P = 0.67), and comparable rate of favorable short-term functional outcome (46.8% vs 50.7%; OR: 0.79; 95%CI 0.41-1.53; P = 0.48). Risk of bias was low to moderate for each outcome.

Conclusion: The available literature suggests that telemedicine is associated with longer DTN compared to in-person evaluation. This difference in stroke metric does not affect safety or outcome. Further studies are needed to understand and address the underlying factors of the longer DTN time.

Acute liver failure (ALF) is a rare but life-threatening condition marked by rapid hepatic dysfunction, coagulopathy and encephalopathy in patients without prior liver disease. Common causes include drug-induced liver injury, viral hepatitis, and metabolic or autoimmune disorders. This review provides an updated overview of ALF's etiology, diagnosis, and management. Timely diagnosis and risk stratification using tools like the King's College Criteria and Model for End-Stage Liver Disease score are critical for guiding care. Early identification of etiology allows targeted treatments, such as N-acetylcysteine for acetaminophen toxicity or antivirals for hepatitis. Supportive care in specialized intensive care units, focused on hemodynamics, cerebral edema prevention, and metabolic stabilization, remains the cornerstone of management. Advances in extracorporeal liver support systems, such as molecular adsorbent recirculating systems and plasma exchange, offer promising bridges to recovery or liver transplantation - the definitive treatment for irreversible liver injury. Expanded donor criteria and improved allocation policies have enhanced transplantation access. Despite progress, ALF carries significant morbidity and mortality. Emerging therapies, including stem cell treatments and immunomodulatory agents, show potential to revolutionize care. This review emphasizes the need for a multidisciplinary approach and continued research to improve outcomes and refine therapeutic strategies.

Background: Cytokines and inflammatory mediators are the key factors that are involved in the pathology of sepsis. Extracorporeal cytokine hemoadsorption devices offer an innovative clinical support system to alleviate the effects of the cytokine storm associated with sepsis.

Aim: To retrospectively evaluate the efficacy of CytoSorb^® therapy as an adjunct to standard care in intensive care unit (ICU) patients with septic shock.

Methods: A retrospective study was designed. Data were obtained for the patients who were treated with the CytoSorb^® adsorber for the past 5 years. The effects of therapy were assessed by changes in vasopressor requirements, specifically, norepinephrine and epinephrine. In addition, cytokine levels, such as interleukin (IL)-6 and inflammatory biomarkers including C-reactive protein (CRP), procalcitonin, as well as substances such as serum lactate and lactate dehydrogenase were also evaluated. In addition, mean arterial pressure (MAP) and ventilator requirements were also recorded. The survival outcomes were analyzed based on the length of patients' stay in the ICU, and the severity of illness was assessed using Acute Physiology and Chronic Health Evaluation (APACHE II) and Sepsis-associated Organ Failure Assessment (SOFA) scores recorded at baseline and post-therapy.

Results: Following CytoSorb^® therapy, the requirement for vasopressor drugs, particularly norepinephrine, was reduced by 40% and a statistically significant improvement in MAP by 7.8%. Additionally, significant reductions were observed in IL-6 and serum lactate levels by 83% and 52% respectively. Around 56% had a delta lactate score of > 1.5, while 23% patients had a score ranging from 1 to < 1.5, and 16% patients had a score between 0.5 and < 1 and merely 5% patients had a score of ≤ 0.5. Besides, serum levels of creatinine, procalcitonin and CRP were significantly reduced by 17.2%, 41.5% and 53.8% respectively. There was a significant reduction in scores, including APACHE II [to 23 (18-29) from 27 (23-33)], and SOFA [to 12 (10-14) from 13 (11-15)]. Mechanical ventilation was required by 96% patients, with a median duration of 12 days, and the median length of hospital stay in overall patients was 26 days, while the median ICU stay was 18 days.

Conclusion: CytoSorb^® therapy seems to be a promising adjunctive approach in the management of septic shock.

Background: In critical care practice, difficult airway management poses a substantial challenge, necessitating urgent intervention to ensure patient safety and optimize outcomes. Extracorporeal membrane oxygenation (ECMO) is a potential rescue tool in patients with severe airway compromise, although evidence of its efficacy and safety remains limited.

Aim: To review the local experience of using ECMO support in patients with difficult airway management.

Methods: This retrospective case series study includes patients with difficult airway management who required ECMO support at a tertiary hospital in a Middle Eastern country.

Results: Between 2016 and 2023, a total of 13 patients required ECMO support due to challenging airway patency in the operating room. Indications for ECMO encompassed various diagnoses, including tracheal stenosis, external tracheal compression, and subglottic stenosis. Surgical interventions such as tracheal resection and anastomosis often necessitated ECMO support to maintain adequate oxygenation and hemodynamic stability. The duration of ECMO support ranged from standby mode (ECMO implantation is readily available) to several days, with relatively infrequent complications observed. Despite the challenges encountered, most patients survived hospital discharge, highlighting the effectiveness of ECMO in managing difficult airways.

Conclusion: This study underscores the crucial role of ECMO as a life-saving intervention in selected cases of difficult airway management. Further research is warranted to refine the understanding of optimal management strategies and improve outcomes in this challenging patient population.