世界危重病急救学杂志(英文版)最新文献

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.

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.