世界危重病急救学杂志(英文版)最新文献

Background: Refractory septic shock is a critical and multifaceted condition that continues to pose significant challenges in critical care.

Aim: To systematically review randomized trials on emerging interventions for refractory septic shock, assessing mortality, vasopressor use, intensive care unit (ICU) length of stay, and organ dysfunction.

Methods: A systematic search was conducted in PubMed, EMBASE, Cochrane CENTRAL Library, and Web of Science for studies published between 2000 and 2024. Inclusion criteria encompassed randomized controlled trials (RCT) evaluating innovative therapies for refractory septic shock. Variables of interest: The primary outcome was all-cause mortality among patients treated with novel interventions. Secondary outcomes included length of stay in the ICU, total hospital length of stay, and use of vasoactive drugs. Methodological rigor was assessed using the Cochrane Risk of Bias tool.

Results: From 850 records, 24 RCTs met the inclusion criteria, evaluating therapies such as methylene blue, vasopressin, terlipressin, and combinations of hydrocortisone, vitamin C, and thiamine. Mortality rates ranged from 28.6% to 56.8%. Methylene blue reduced vasopressor dependency in patients requiring high norepinephrine doses by 1.0 vasopressor-free day, and terlipressin improved renal perfusion by 13.1%. Combination therapies enhanced secondary outcomes, including reductions in Sequential Organ Failure Assessment score. However, no single intervention consistently demonstrated significant survival benefits.

Conclusion: Adjunctive therapies for refractory septic shock may improve hemodynamics and organ function, however, they have not been shown to consistently reduce mortality. Larger trials are needed to confirm these findings. Multimodal approaches targeting inflammation are critical.

Background: The optic nerve sheath diameter (ONSD) measured by ultrasound has emerged as a significant noninvasive method for detecting elevated intracranial pressure (ICP), guiding timely interventions, and monitoring treatment response. Previous studies have shown that the baseline ONSD at admission is a prognostic indicator of mortality in adult patients with cerebrovascular events, traumatic brain injury, hepatic encephalopathy, and acute stroke. However, pediatric data on the dynamic changes in ONSD remain limited.

Aim: To study the association between within-48 hours admission dynamic ONSD changes and mortality in children with clinically relevant elevated ICP.

Methods: This single-institution prospective study was performed at a tertiary Children's Hospital in Vietnam, between November 2023 and August 2024. The primary outcome was in-hospital mortality rate. ONSD data were measured at admission, 24 hours, and 48 hours post-admission to pediatric intensive care unit (PICU). Linear mixed-effects models accounting for repeated measures within individuals were used to analyze the association between ONSD changes and in-hospital mortality.

Results: A total of 69 PICU-admitted children with clinically relevant raised ICP were enrolled and included in the analysis. The median patient age was 6 years (interquartile range: 1-12), and males accounted for 54% of all patients. The in-hospital mortality rate in children with clinically relevant raised ICP was 23.2%. Traumatic brain injury, sepsis-associated encephalopathy, and septic shock were the main causes of death in this cohort. Linear mixed-effects analysis showed that dynamic variability in ONSD values upon PICU admission and during the first 48 hours later correlated significantly with increased mortality. Nonsurvivors had a 5.3% increase in the mean ONSD at 48 hours compared to baseline levels, while the survivors showed a 5.6% reduction in ONSD.

Conclusion: Serial ultrasound-based ONSD measurements within 48 hours of admission better predicted mortality than baseline data in critically ill children, offering a practical, noninvasive tool for early prognosis in elevated ICP.

Nonthyroidal illness syndrome (NTIS) is a common finding in critically ill patients, characterized by disruptions in the hypothalamus-pituitary-thyroid axis, resulting in altered levels of thyroxine (T4), triiodothyronine (T3), and reverse T3. This condition, often considered to be an adaptive response aimed at conserving energy, can become maladaptive in prolonged critical illness, contributing to poor outcomes in intensive care unit patients. The pathophysiology of NTIS involves cytokine-driven alterations in thyroid hormone (TH) metabolism, impaired hormone transport, and reduced receptor sensitivity, which-collectively-suppress thyroid function. Despite these insights, the therapeutic role of TH replacement in patients with NTIS remains uncertain. Low doses of levothyroxine and T3 have been trialed, particularly in patients with cardiovascular comorbidities, but clinical studies report conflicting results regarding their impact on mortality and overall patient outcomes. While some evidence suggests potential benefits of T3 administration in specific subgroups, such as patients with septic shock or severe coronavirus disease 2019, robust clinical trials have yet to conclusively demonstrate improved survival or recovery. The heterogeneity in NTIS presentation and treatment protocols, as well as the complex nature of TH regulation in critically ill patients, complicates efforts to establish clear guidelines for hormone therapy. Future research should prioritize individualized approaches, optimizing hormone dosing and timing, while aiming to elucidate the long-term effects of such interventions on critically ill patients to improve morbidity and mortality outcomes.

Prediction of weaning success from invasive mechanical ventilation remains a challenge in everyday clinical practice. Several prediction scores have been developed to guide success during spontaneous breathing trials to help with weaning decisions. These scores aim to provide a structured framework to support clinical judgment. However, their effectiveness varies across patient populations, and their predictive accuracy remains inconsistent. In this review, we aim to identify the strengths and limitations of commonly used clinical prediction tools in assessing readiness for ventilator liberation. While scores such as the Rapid Shallow Breathing Index and the Integrative Weaning Index are widely adopted, their sensitivity and specificity often fall short in complex clinical settings. Factors such as underlying disease pathophysiology, patient characteristics, and clinician subjectivity impact score performance and reliability. Moreover, disparities in validation across diverse populations limit generalizability. With growing interest in artificial intelligence (AI) and machine learning, there is potential for enhanced prediction models that integrate multidimensional data and adapt to individual patient profiles. However, current AI approaches face challenges related to interpretability, bias, and ethical implementation. This paper underscores the need for more robust, individualized, and transparent prediction systems and advocates for careful integration of emerging technologies into clinical workflows to optimize weaning success and patient outcomes.

Background: Lung ultrasonography is being increasingly used in mechanically ventilated patients to evaluate the lung aeration during incremental positive end expiratory pressure (PEEP) adjustments and to evaluate the weaning process from mechanical ventilation. The effects of PEEP may vary across different lung pathologies and may not consistently correlate with changes in lung aeration as assessed by lung ultrasound scores (LUSs).

Aim: To assess the role of lung ultrasonography in evaluating lung aeration during the application of PEEP in mechanically ventilated patients with various lung pathologies.

Methods: An observational study was conducted over 18 months in a tertiary care hospital. Patients of both genders, aged between 18-75 years, who had been admitted to the intensive care unit, and required mechanical ventilation, were studied. A standard ventilatory strategy was used and incremental levels of PEEP [5, 10, and 15 cm water (H₂O)] were applied. Baseline characteristics, including oxygen saturation (SpO₂), LUS, mean arterial pressure (MAP), heart rate (HR), and their changes with incremental PEEP levels, were recorded and analyzed.

Results: In this study, 45.9% of patients required a PEEP of 5 cm H₂O to achieve the endpoint of lung aeration (LUS of 0). In addition, 86.5% and 13.5% of patients reached the endpoint of lung aeration at PEEP levels of 10 and 15 cm H₂O, respectively. The proportion of patients with higher lung scores decreased significantly with increasing PEEP levels (P < 0.001 for 5 and 10 cm H₂O and P = 0.032 for 15 cm H₂O). SpO₂ increased significantly with higher PEEP levels (P < 0.001), confirming the effectiveness of PEEP in improving oxygenation. The results also revealed a significant increase in HR and a decrease in MAP following the application of higher PEEP levels.

Conclusion: Increasing PEEP levels in mechanically ventilated patients improves lung aeration, which can be effectively assessed using bedside lung ultrasonography.

This opinion review paper explores the application of artificial intelligence (AI) as a decisive tool in managing complex coronavirus disease 2019 (COVID-19) cases within critical care medicine. Available data have shown that very severe cases required intensive care, most of which required endotracheal intubation and mechanical ventilation to avoid a lethal outcome if possible. The unprecedented challenges posed by the COVID-19 pandemic necessitate innovative approaches to patient care. AI offers significant potential in enhancing diagnostic accuracy, predicting patient outcomes, and optimizing treatment strategies. By analyzing vast amounts of clinical data, AI can support healthcare professionals in making informed decisions, thus improving patient outcomes. We also focus on current technologies, their implementation in critical care settings, and their impact on patient management during the COVID-19 crisis. Future directions for AI integration in critical care are also discussed.

Background: In recent years, the utilization of telemedicine in emergency situations, particularly in the context of cardiac arrest, has garnered increasing attention. This study addresses the comparative effectiveness of video-instructed dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) vs audio-instructed DA-CPR, offering valuable insights into the evolving landscape of emergency medical guidance through telecommunication methods.

Aim: To compare the effectiveness of video-instructed DA-CPR and audio-instructed DA-CPR in terms of survival rates to hospital discharge.

Methods: We conducted a comprehensive search of electronic databases, including PubMed, from inception to October 2023, using keywords such as cardiopulmonary resuscitation (CPR), cardiac arrest, and telemedicine combined with Boolean operators. Language was restricted to English, with no date of publication restrictions. We included studies assessing the impact of DA-CPR guidance through video or audio instruction on the quality of CPR performed by bystanders in real-life and simulated environments.

Results: Our research strategy yielded 537 references. After the final analysis, we selected 27 articles from the PubMed database that met our inclusion criteria. The mean age of the included participants was 37.1 years. The study presents compelling evidence in favor of video-instructed DA-CPR, showing a significant improvement in survival rates to discharge compared to audio-instructed DA-CPR.

Conclusion: DA-CPR plays a crucial role in the chain of survival for out-of-hospital cardiac arrest patients. Extensive research has consistently demonstrated its effectiveness in increasing bystander-initiated CPR and improving patient outcomes. Ongoing technological advancements, such as video calls and automated external defibrillator integration, continue to refine and enhance the delivery of DA-CPR. However, continuous efforts are required to standardize dispatcher training and further optimize communication strategies to ensure the highest quality of care for cardiac arrest victims.

Transgender individuals often undergo gender-affirming hormonal therapy (GAHT) to align their physical characteristics with their gender identity, which introduces unique challenges in the management of critically ill patients. In the setting of critical illness, the interactions between GAHT and the body's endocrine response are complex. GAHT can influence the hypothalamic-pituitary-adrenal axis, sex hormone levels, and metabolic parameters, potentially complicating the clinical picture. For example, estrogen therapy in transgender women increases the risk of venous thromboembolism, which is further exacerbated by the immobility and hypercoagulable state often present in critically ill patients. Testosterone therapy in transgender men can lead to erythrocytosis, increasing the risk of thromboembolic events during critical illness. The potential for drug interactions, particularly with medications used in the intensive care unit, also requires careful consideration. Monitoring hormone levels and adjusting GAHT in the acute setting are crucial, although evidence-based guidelines are lacking. The need for individualized care and vigilant monitoring of endocrine and metabolic parameters is paramount to improve outcomes in this vulnerable population.

Background: Atrial fibrillation (AF) represents a common arrhythmia with significant implications and may occur pre-, intra-, or postoperatively (POAF). After cardiac surgery POAF occurs in approximately 30% of patients, while non-cardiac/non-thoracic surgery has a reported incidence between 0.4% to 15%, with new onset POAF occurring at a rate of 0.4% to 3%. While AF has been extensively studied, it has not been well described in emergent non-cardiac surgery associated with increased surgical stress in an intensive care unit setting (ICU).

Aim: To investigate the incidence/predictors of POAF in emergent non-cardiac surgery and its associations with postoperative outcomes in the ICU.

Methods: This retrospective study included patients ≥ 18 years who underwent exploratory laparotomy or lower extremity amputation between October 2012 and September 2023 and were admitted in the ICU. Data of interest included occurrence of POAF, demographic characteristics, comorbidities, laboratory values, administered fluids, medications, and postoperative outcomes. Statistical analyses consisted of identifying predictors of POAF and associations of POAF with outcomes of interest.

Results: A total of 347 ICU patients were included, 16.4% had a history of AF, 13.0% developed POAF, and 7.9% developed new-onset POAF. Patients with new-onset POAF were older (79.6 ± 9.1 vs 68.1 ± 14.8 years, < 0.001), of white race (47.8% vs 28.8, P < 0.001), hypertensive (87.0% vs 71.2%, P = 0.011), had longer ICU length of stay (ICU-LOS) (13.4 vs 6.7 days, P = 0.042), higher mortality (43.5% vs 17.6%, P = 0.016) and higher rate of cardiac arrest (34.8% vs 14.6%, P = 0.005) compared to patients without new-onset POAF. Multivariable analysis revealed increased POAF risk with advanced age (OR = 1.06; 95%CI: 1.02-1.10, P = 0.005), white race (OR = 2.85; 95%CI: 1.26-6.76, P = 0.014), high intraoperative fluid (OR > 1; 95%CI: 1.00-1.00, P = 0.018), and longer ICU-LOS (OR = 1.04; 95%CI: 1.00-1.08, P = 0.023). After adjusting for demographics, new onset POAF significantly predicted mortality (OR = 3.07; 95%CI: 1.14-8.01, P = 0.022).

Conclusion: POAF was associated with prolonged ICU-LOS, white race, and high intraoperative fluid. New-onset POAF was associated with increased risk of cardiac arrest and death in critically ill patients.