世界危重病急救学杂志(英文版)最新文献

Background: Acute colonic pseudo-obstruction (ACPO) is defined as colonic obstruction without a mechanical or extrinsic inflammatory factor. Colonic decompression is advised for patients with ACPO after the failure of conservative and medical management.

Aim: To systematically review and analyze the efficacy and safety of colonoscopic decompression in ACPO.

Methods: A search was conducted in MEDLINE, EMBASE, and Scopus from inception to August 2024. Studies reporting the clinical success, perforation, recurrence, and need for surgery after colonoscopic decompression in ACPO were included. A random-effects inverse-variance model was used to calculate the pooled proportion.

Results: Sixteen studies were included in the final analysis. The pooled rates of success after the first session of colonoscopic decompression and overall success were 78.8% (95%CI: 72.0-85.6) and 91.5% (95%CI: 87.0-96.0), respectively. The first session of colonoscopic decompression had a significantly higher success than the first dose of neostigmine with OR 3.85 (95%CI: 2.00-7.42). The pooled incidence of perforation was 0.9% (95%CI: 0.0-2.0), while recurrence was observed in 17.1% (95%CI: 12.9-21.3) of the patients after clinical success. The pooled rates of surgery in all cases undergoing colonoscopic decompression and those who had a successful procedure were 10.5% (95%CI: 5.0-15.9) and 3.7% (95%CI: 0.3-7.1), respectively. Subgroup analysis, excluding the low-quality studies, did not significantly change the event rates.

Conclusion: Colonoscopic decompression for ACPO is associated with a clinical success rate of > 90% with a perforation rate of < 1%, demonstrating high efficacy and safety.

Background: Systemic immunoinflammatory diseases can affect multiple systems and organs. They have a severe course and severe complications, causing multiple organ failure and death. Quite often these patients are required to be hospitalized in the intensive care unit (ICU). Approximately 50% of patients with multisystem inflammatory syndrome associated with coronavirus disease 2019 in children and systemic lupus erythematosus need admission to the ICU.

Aim: To find early predictors of death in patients with immunoinflammatory diseases who are hospitalized in the ICU.

Methods: The retrospective continuous cohort study included 51 patients (23 males, 28 females) with immunoinflammatory diseases, including multisystem inflammatory syndrome associated with coronavirus disease 2019 (n = 18), systemic rheumatic diseases (n = 24), and generalized infections (n = 9). The patients ranged in age from 7 months to 17 years old and were admitted to the ICU of the clinic of Saint Petersburg State Pediatric Medical University from 2007 to 2023.

Results: Thirteen patients (25.5%) died within 39 (17; 62) days after ICU admission. Patients with an unfavorable outcome were significantly older and were admitted to the ICU later than patients who survived (30 days vs 7 days, P = 0.013) and had a longer stay in the ICU (30 days vs 6 days, P = 0.003). The main predictors of the fatal outcome were age > 162 months [odds ratio (OR) = 10.7; 95% confidence interval (CI): 2.4-47.2], P = 0.0006], time to ICU admission > 26 days from the disease onset (OR = 12.0; 95%CI: 2.6-55.3, P = 0.008), preceding immune suppression treatment (OR = 6.2; 95%CI: 1.6-24.0, P = 0.013), invasive mycosis during the ICU stay (OR = 18.8; 95%CI: 1.9-184.1, P = 0.0005), systemic rheumatic diseases (OR = 7.2; 95%CI: 1.7-31.1, P = 0.004), and ICU stay over 15 days (OR = 19.1; 95%CI: 4.0-91.8, P = 0.00003). Multiple regression analysis (r ² = 0.422, P < 0.000002) identified two predictors of the fatal outcomes: Systemic rheumatic diseases (P = 0.015) and ICU stay over 15 days (P = 0.00002).

Conclusion: Identifying patients at high risk of an unfavorable outcome is the subject of the most careful monitoring and appropriate treatment program. Avoiding ICU stays for patients with systemic rheumatic diseases, close monitoring, and preventing invasive mycosis might improve the outcome in children with systemic immune-mediated diseases.

Background: Nosocomial fever of unknown origin (nFUO) is a frequent and challenging diagnostic entity, encompassing diverse infectious and non-infectious etiologies. Timely identification is crucial, yet evidence on the diagnostic accuracy of commonly employed sepsis screening tools and biomarkers remains sparse. We hypothesized that these tools and biomarkers measured at fever onset could distinguish infectious from non-infectious causes of nFUO in critically ill adults.

Aim: To evaluate the diagnostic utility of sepsis tools and biomarkers in identifying infectious causes of nFUO.

Methods: This prospective observational study included patients admitted to the Acute Care Emergency Medicine Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India (July 2023 to December 2024). nFUO was defined by Durack and Street criteria. Diagnostic performance of sepsis screening tools (systemic inflammatory response syndrome, Sequential Organ Failure Assessment, quick Sequential Organ Failure Assessment, National Early Warning Score, and Modified Early Warning Score) and biomarkers [procalcitonin (PCT), C-reactive protein (CRP)] at fever onset was assessed using receiver operating characteristic curve analysis.

Results: Of 80 cases (mean age 42.9 ± 16.5 years; 80% male), 42.5% had infectious causes, 38.7% non-infectious, and 18.8% remained undiagnosed. Pneumonia (26.2%) and bloodstream infections (11.2%) were the most common infectious etiologies, while central fever and thrombophlebitis (each 7.5%) were predominant among non-infectious causes. Sepsis tools showed poor diagnostic accuracy, with area under the receiver operating characteristic curve (AUC) values close to 0.5. PCT demonstrated modest performance (AUC = 0.61; optimal cut-off: 0.85 μg/L), while CRP was paradoxically higher in non-infectious cases (AUC = 0.45). Overall mortality was 20% and was highest among undiagnosed patients (33.3%). Fever duration and hospitalization length were significantly greater in infectious cases.

Conclusion: Sepsis tools, PCT, and CRP have limited utility in identifying infectious causes of nFUO in critically ill adults and should not solely guide initial decision-making.

Integration of artificial intelligence increases in all aspects of human life, particularly in healthcare systems. Traumatic brain injury is a significant cause of mortality and long-term disability, with an important impact on the socio-economic system of healthcare. The role of artificial intelligence in imaging and outcome prediction for traumatic brain injury patients is reviewed with a particular emphasis to the characteristics of machine and deep learning methods. Evidence of potential improvement in the clinical practice in discussed.

Background: Sepsis and septic shock pose critical public health challenges with high mortality, particularly in critical care. While racial differences in sepsis incidence are documented, the impact of race on sepsis outcomes remains inconsistent.

Aim: To evaluate racial disparities in clinical outcomes among patients hospitalized with septic shock, focusing on in-hospital mortality, length of stay (LOS), and hospitalization costs.

Methods: We conducted a retrospective cohort study using the National Inpatient Sample database from 2016 to 2021. Patients diagnosed with septic shock were identified using ICD-10 code R65.21. The primary outcome was in-hospital mortality; secondary outcomes included trends in septic shock hospitalizations, mortality, length of stay, and cost of hospitalizations.

Results: Among 3581504 hospitalizations for septic shock, the racial distribution was 67% Non-Hispanic White (NHW), 15% Non-Hispanic Black (NHB), 11% Hispanic, and 7% other groups, with a mean age of 66.3 years. In-hospital mortality was 33.6%, highest among other racial groups (36.7%). Mortality was stable across racial groups from 2016-2019 but rose sharply in 2020-2021, especially among Hispanic patients. Adjusted in-hospital mortality were higher for NHB and Hispanic compared to NHW patients. NHB patients had the longest LOS, while other racial groups incurred the highest cost of hospitalizations.

Conclusion: We found higher mortality among NHB, Hispanic, and other racial groups in septic shock patients, likely driven by higher risk of in-hospital complications among these racial groups. This highlights the need for future research to identify the factors contributing to the adverse outcomes in these populations.

The Jahi McMath case represents a pivotal moment in the reevaluation of brain death or death by neurological criteria (BD/DNC) and disorders of consciousness. Declared brain dead on December 12, 2013, following surgical complications, Jahi's case became a landmark in challenging conventional BD/DNC definitions. As an independent consultant for the International Brain Research Foundation, I recommended advanced ancillary tests, including neuroimaging, electrophysiological, and heart rate variability assessments, conducted at Rutgers University Hospital and Jahi's apartment in New Jersey. My analyses revealed unprecedented findings: Significant preservation of intracranial structures, including the upper brainstem, despite extensive white matter damage and partial herniation. I identified residual cognitive processing and autonomic responses, which suggested a novel disorder of consciousness distinct from both BD/DNC, the unresponsive unawareness syndrome, the minimally conscious state, and the locked-in syndrome. These insights, reinforced by complementary evaluations by Dr. Alan Shewmon, who later documented Jahi's purposeful responses to commands by videos analysis, contributed to reshaping the discourse on consciousness disorders. Despite initial resistance from the scientific community, my findings during September 2014 were eventually published, presenting the first detailed anatomical and functional analysis of Jahi's condition. The Jahi McMath case underscores the need for advanced diagnostics, multidisciplinary collaboration, and a nuanced understanding of consciousness. This case has significant implications for the medical and legal communities, particularly in defining and diagnosing BD/DNC and studying disorders of consciousness. The novel disorder of consciousness might be integrated into existing diagnostic criteria and treatment protocols for BD/DNC and in classifying disorders of consciousness. It remains a cornerstone for future research and challenges in defining and diagnosing BD/DNC.

The Sengstaken-Blakemore tube (SB tube), introduced in the 1950s, was a pivotal device for managing acute gastrointestinal (GI) bleeding, particularly from esophageal varices. This multi-lumen tube, featuring esophageal and gastric balloons, applied mechanical pressure to control bleeding and provided a temporary solution until more definitive treatments could be employed. It was historically significant in resource-limited settings where advanced endoscopic options were unavailable, enabling patient stabilization and transfer to specialized centers. However, the advent of GI endoscopy and its increased availability has rendered the SB tube obsolete. SB tubes are associated with complications, including esophageal perforation, aspiration pneumonia, and gastric ulceration. Additionally, the tube can cause significant discomfort, and its migration may lead to inadequate. Techniques such as endoscopic variceal ligation and endoscopic sclerotherapy offer superior precision, efficacy, and safety for managing variceal bleeding. Improved hospital transfer protocols now facilitate prompt endoscopic or surgical interventions, reducing the need for temporary measures like the SB tube. Additionally, advancements in pharmacological treatments, including vasoactive drugs, reliance on mechanical compression devices. While the SB tube remains an important historical artifact, its role in current medical practice reflecting safer and more effective treatment options in emergency GI care. This review discusses the declining role of the Sengstaken -Blakemore tube and its replacement by current intervention methods.

Background: Return of spontaneous circulation (ROSC) following cardiopulmonary resuscitation (CPR) is a critical determinant of survival in patients experiencing cardiac arrest. This study aimed to investigate the relationship between the duration of CPR, the achievement of ROSC, and both short-term [intensive care unit (ICU) and in-hospital] and long-term survival outcomes in patients admitted to the medical intensive care unit (MICU) of Dr. Moopen's Medical College Hospital, Wayanad, Kerala, India.

Aim: To assess how cardiopulmonary resuscitation duration impacts short-term and long-term survival in cardiac arrest patients in intensive care.

Methods: A retrospective observational cohort study was conducted on adult patients who received CPR in the MICU between March 2023 and March 2024. Data were extracted from electronic medical records, including demographics, duration of CPR, ROSC achievement, and survival outcomes. Short-term survival was defined as survival to ICU discharge and in-hospital mortality, while long-term survival was assessed at six months post-arrest. Statistical analysis was performed using SPSS software, with Kaplan-Meier survival analysis and Cox regression used to identify predictors of mortality.

Results: A total of 142 patients were included in the study. The median duration of CPR was 15 minutes. ROSC was achieved in 68 patients (47.9%). A significant association was observed between the duration of CPR and ROSC achievement (P < 0.001). Patients who achieved ROSC early had significantly higher rates of short-term and long-term survival compared to those who did not (P < 0.001). Each additional minute of CPR was associated with a 7% decrease in the odds of achieving ROSC. Longer CPR duration (HR: 1.05, 95%CI: 1.02-1.08), absence of ROSC (HR: 4.87, 95%CI: 2.31-10.28), older age (HR: 1.03, 95%CI: 1.01-1.06) and unwitnessed arrest (HR: 1.89, 95%CI: 1.05-3.41) were independent predictors of mortality.

Conclusion: Timely, effective cardiopulmonary resuscitation improves survival in intensive care. Duration significantly predicts return of circulation and outcomes. Further research should explore factors affecting resuscitation length and optimize treatment strategies.

Cardio-cerebral coupling (CCC) refers to the dynamic interplay between cardiac function and cerebral blood flow, essential for maintaining hemodynamic stability. Disruptions in CCC are particularly relevant in critical care, where they can exacerbate primary and secondary brain injuries. Ultrasound-based techniques, including transcranial Doppler, transcranial color-coded Doppler, and echocardiography, provide non-invasive methods to assess this relationship at the bedside. This scoping review explores the pathophysiology of CCC, ultrasound methodologies for its evaluation, and its clinical relevance. Key mechanisms such as cerebral autoregulation and neurovascular coupling are discussed, along with ultrasound-derived parameters like pulsatility index, resistance index, and cerebral perfusion pressure. While ultrasound is a valuable tool, its limitations include operator dependency and equipment variability. Emerging evidence suggests that ultrasound-guided protocols, including ultrasound-guided cardio-cerebral resuscitation protocol and ultrasound-guided brain injury treatment protocol, may improve resuscitation strategies and neurocritical care monitoring. Despite its potential, further research is necessary to standardize assessment methods and integrate ultrasound-based CCC evaluation into routine clinical practice. Ongoing multicenter studies are expected to provide robust evidence supporting its clinical utility in managing brain-injured patients.

Background: Early hemodynamic assessment remains crucial for proper management in trauma settings. Hypotension is a vital indication in trauma patients to be considered upon initial triaging to assess the risk of bleeding and hypovolemic shock which entails significant clinical attention during initial resuscitation.

Aim: To assess whether an initial episode of prehospital or emergency department hypotension is associated with an increased risk of morbidity and mortality in trauma patients.

Methods: A retrospective analysis was performed to include all trauma patients hospitalized between 2011 and 2021. Hypotension was defined as a systolic blood pressure ≤ 90 mmHg in the prehospital setting or upon arrival to the hospital. Patients were classified into normotensive vs hypotensive and survivors vs non-survivors. Data was analyzed and compared, and multivariable logistic regression analysis was performed to identify the predictors of mortality.

Results: Over the ten years, 17341 trauma admissions were analyzed, of which 1188 (6.9%) patients had hypotension episodes either at the scene or upon hospital arrival. Patients with hypotension were two years younger (P = 0.001) in age and were more likely to have higher pulse rate (P = 0.001), elevated shock index (P = 0.001), sustained more severe injuries, frequently required blood transfusion and laparotomy, and had higher complications and mortality rates. Multivariable regression analysis identified hypotension [adjusted odds ratio (aOR) = 2.505; 95% confidence interval (95%CI) = 1.798-3.489; P = 0.001] and acute respiratory distress syndrome (ARDS; aOR = 5.482; 95%CI = 3.297-9.116; P = 0.001) as independent predictors of mortality. Among hypotensive trauma patients, only ARDS (aOR = 3.518; 95%CI = 1.385-7.204; P = 0.006) was significantly associated with mortality.

Conclusion: Hypotensive episodes following trauma are associated with higher severity and mortality. The development of ARDS is an independent predictor of mortality in hypotensive trauma patients. A hypotensive episode is a warning sign and calls for aggressive, timely management following trauma.