世界危重病急救学杂志(英文版)最新文献

Background: Sepsis is a critical medical condition, and poses a substantial global health burden, with significant morbidity, mortality, and economic costs, particularly pronounced in low- and middle-income countries. Effective management of sepsis relies on early recognition and appropriate intervention, underscoring the importance of accurate classification to guide treatment decisions. The correct diagnosis will lead to effective antimicrobial stewardship practices.

Aim: To assess the distribution of sepsis categories and the use of empirical antibiotics classified by the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) system in a tertiary care hospital in Northern India and to correlate antibiotic usage with sepsis classifications.

Methods: This longitudinal observational study in the Department of General Medicine, in a tertiary care hospital in Northern India, from 2023 to 2024, aimed to assess the use of empirical antibiotics classified by the WHO AWaRe system. The study also aimed to correlate antibiotic usage. Patients were categorized into sepsis classes (Asepsis, Possible Sepsis, Probable Sepsis, Confirmed Sepsis) and followed until discharge or Day-28. Descriptive and inferential statistical analyses were employed to assess sepsis categories and empirical antibiotic usage classified by the WHO AWaRe system.

Results: A total of 1867 patients admitted with suspected sepsis were screened, with 230 meeting the inclusion criteria. Among the study cohort (mean age 40.70 ± 14.49 years, 50.9% female), initial sepsis classification predominantly included probable sepsis (51.3%) and possible sepsis (35.7%), evolving to asepsis (57.8%) upon final classification, but all received antibiotics. Empirical antibiotic use showed a predominance of Watch group antibiotics (72.2%), with ceftriaxone and piperacillin-tazobactam being the most commonly prescribed; however, no statistical association could be established among the different classes of sepsis with the AWaRe groups.

Conclusion: Accurate sepsis classification is pivotal for clinical decision-making, optimizing antibiotic use, and combating antimicrobial resistance. The majority of the asepsis category was labelled as probable or possible sepsis and given antibiotics at initial hospitalization. The high reliance on Watch group antibiotics in empirical therapy signals a need for enhanced diagnostic strategies to refine treatment initiation, potentially reducing unnecessary antibiotic exposure. Future efforts should focus on establishing sepsis classification checklists as in this study and promoting adherence to antimicrobial stewardship principles to mitigate the global threat of antimicrobial resistance.

Background: Accurate measurement of energy expenditure (EE) is critical for optimizing nutritional support in critically ill patients. Indirect calorimetry (IC) is the reference method used, but its availability at the bedside is limited. As a result, numerous predictive equations have been devised to estimate EE in critically ill patients, along with other more novel methods recently proposed.

Aim: To evaluate current methods of measuring EE in critical care, focusing on practical challenges, accuracy, feasibility, and limitations. We will also discuss how these methods contribute to improving nutrition support strategies for intensive care unit patients for a more personalised and effective solution.

Methods: A comprehensive search was conducted in PubMed and EMBASE for studies published from December 2014 to December 2024. Eligible studies compared EE measurement methods in critically ill populations. Data extraction and quality assessment followed PRISMA guidelines. Adherence to reporting standards was assessed using the TRIPOD questionnaire and risk of bias was evaluated using the PROBAST tool.

Results: Twenty five original studies met the inclusion criteria and were analysed.

Conclusion: Each method has unique strengths and limitations. We found that while IC remains the reference standard, less accurate predictive equations have greater accessibility and ease of implementation. Emerging technologies show promise for bedside applicability. Future research should address practical barriers and validate newer approaches.

Unplanned intensive care unit (ICU) admissions (UP-ICU) following initial general ward placement are associated with poor patient outcomes and represent a key quality indicator for healthcare facilities. Healthcare facilities have employed numerous predictive models, such as physiological scores (e.g., Acute Physiology and Chronic Health Evaluation II, Revised Trauma Score, and Mortality Probability Model II at 24 hours) and anatomical scores (Injury Severity Score and New Injury Severity Score), to identify high-risk patients. Although physiological scores frequently surpass anatomical scores in predicting mortality, their specificity for trauma patients is limited, and their clinical applicability may be limited. Initially proposed for ICU readmission prediction, the stability and workload index for the transfer score has demonstrated inconsistent validity. Machine learning offers a promising alternative. Several studies have shown that machine learning models, including those that use electronic health records (EHR) data, can more accurately predict trauma patients' deaths and admissions to the ICU than traditional scoring systems. These models identify unique predictors that are not captured by existing methods. However, challenges remain, including integration with EHR systems and data entry complexities. Critical care outreach programs and telemedicine can help reduce UP-ICU admissions; however, their effectiveness remains unclear because of costs and implementation challenges, respectively. Strategies to reduce UP-ICU admissions include improving triage systems, implementing evidence-based protocols for ICU patient management, and prioritizing prehospital intervention and stabilization to optimize the "golden hour" of trauma care. To improve patient outcomes and reduce the burden of UP-ICU admissions, further studies are required to validate and implement these strategies and refine machine learning models.

Background: Many causal factors influence acute liver failure (ALF), including the primary underlying cause, age, and socioeconomic conditions. ALF outcomes depend on etiology, coagulopathy, bilirubin, age, and understanding of hepatic encephalopathy (HE), and help us predict coma and death.

Aim: To evaluate the association between etiologies, clinical manifestations, and outcomes of adults admitted with ALF.

Methods: This institution-based, prospective cross-sectional study was conducted in the Department of Gastroenterology and Hepatology at Jinnah Postgraduate Medical Center, Karachi, from July 2019 to December 2022. A total of 102 patients diagnosed with ALF were included using consecutive sampling and data were collected from patients who visited Jinnah Postgraduate Medical Center, Karachi, the gastroenterology and hepatology department, entered into Microsoft Excel, and analyzed using Statistical Package for the Social Sciences version 26.0. Diagnosis was based on King's College criteria: Age, encephalopathy grade, bilirubin, prothrombin time, international normalized ratio, creatinine, and etiology. We assessed the association between socioeconomic status and various outcomes using chi-square tests with a level of significance was less than 0.05.

Results: Mean age of the ALF cohort was 27.37 ± 6.60 years. Of the 102 patients, 71 (69.6%) were female, including 55 (77.5%) pregnant women with a mean gestational age of 34.56 ± 3.80 weeks. Regarding HE severity, 45 (44.1%) had grade III, and 13 (12.7%) had grade II. Among the patients admitted to the intensive care unit, 51 (72.9%) did not survive, while 14 (43.8%) recovered.

Conclusion: This study observed a high mortality rate among ALF patients in a tertiary care hospital. Hepatitis E virus infection, HE severity, and sepsis were significantly associated with higher mortality.

Acute kidney injury (AKI) is common in patients with liver failure, and for a significant subset it is severe enough to require kidney replacement therapy (KRT). Patients with liver failure have distinct clinical characteristics (e.g., cardio-circulatory dysfunction and a tendency to bleed) that mandate customization of their overall care including KRT. Herein, we provide an overview of AKI in liver failure, discuss the basic pathophysiology of hepatorenal syndrome, including the often-underemphasized role of the heart in its clinical manifestations, and the current therapies afforded to these patients. We also discuss the general aspects of KRT and how they apply to patients with liver failure (e.g., preference for continuous renal replacement therapy and the need for regional, instead of systemic, anticoagulation). Moreover, we discuss hyperammonemia, an emerging non-renal indication of KRT in this patient population, and provide recommendations on how this therapy may be applied in this setting.

Sepsis is a life-threatening organ dysfunction associated with a robust systemic inflammatory and immune response to infection. Its pathological consequences lead to multiple organ deficits. Klotho was initially introduced as an antiaging molecule. Its deficiency significantly reduces lifespan, and its overexpression protects against organ injury. It reduces oxidative stress and apoptosis and has anti-inflammatory and antifibrotic properties. In this review, we discuss the underlying mechanisms of sepsis-related klotho down-regulation and the protective role of klotho in sepsis. In developing sepsis-induced multiple organ damage, klotho can modulate multiple downstream signals including nuclear factor-kappa β, mitogen activated protein kinase, and apoptosis. Multiple studies show klotho's protective effects in sepsis through activation of nuclear factor erythroid-related factor 2, Forkhead transcription factor O, and restoration of internal antioxidant activity. The proposed protective action of klotho is a promising therapeutic strategy for managing sepsis and ameliorating its related organ damage.

Background: Septic shock, the most severe form of sepsis, remains a major global health challenge with high mortality. The coronavirus disease 2019 (COVID-19) pandemic has exacerbated this burden, as severe acute respiratory syndrome coronavirus 2 infection often leads to sepsis and septic shock. Racial and ethnic differences in critical illness outcomes are well-documented, but their impact on COVID-19 associated septic shock remains unclear.

Aim: To examine epidemiologic data to explore racial and ethnic differences in outcomes in COVID-19 associated septic shock.

Methods: Using the National Inpatient Sample (2020-2021), we conducted a retrospective cohort study to assess racial and ethnic disparities in septic shock outcomes among adults (≥ 18 years) with concurrent COVID-19. Primary and secondary outcomes included in-hospital mortality, acute kidney injury (AKI), AKI requiring dialysis, and mechanical ventilation. Adjusted multivariable logistic regression accounted for demographics, comorbidities, hospital characteristics, and in-hospital events.

Results: Among 396795 weighted hospitalizations, Non-Hispanic Black (NHB) (25.3%) and Hispanic (30.4%) populations were younger and had greater comorbidity burdens than Non-Hispanic White (NHW) patients. Compared to NHW, adjusted analyses showed higher in-hospital mortality [adjusted odds ratio (aOR) = 1.21, 95%CI: 1.15-1.27], mechanical ventilation use (aOR = 1.19, 95%CI: 1.12-1.27) and AKI requiring dialysis (aOR = 1.16, 95%CI: 1.07-1.25, P < 0.001) among Hispanic patients. NHB patients had similar mortality to NHWs but had higher risk of mechanical ventilation (aOR = 1.15, 95%CI: 1.09-1.22) and AKI requiring dialysis (aOR = 1.65, 95%CI: 1.54-1.76). Mean length of stay and cost were longest and highest for Hispanic patients.

Conclusion: Our study showed that there was higher mortality in Hispanic patients, and higher renal and respiratory complication in both NHB and Hispanic groups compared to NHW group. Future research identifying the causes of the observed differences in complications are required to inform targeted strategies that may mitigate modifiable risk factors and optimize early detection of organ failure to optimize outcomes in this population.

Methylene blue (MB) is a versatile medicine with a long history of use in various medical applications, including dye, antiseptic, and treatment for methemoglobinemia. It has a role in vasoconstriction, methemoglobin reduction, inhibition of guanylate cyclase, and anti-inflammatory effects. We reviewed PubMed and Google Scholar literature for relevant studies on MB in intensive care unit (ICU). We created search criteria using a combination of free text words, including MB, critical care, intensive care, sepsis, surgery, pharmacokinetics, and pharmacodynamics. Relevant articles published in the English language were analyzed and incorporated. MB has been used in managing patients with refractory shock, including septic shock, vasoplegic shock, surgical patients, and some instances of drug-induced hypotension. In conclusion, MB in the ICU is a promising medication for sepsis and vasoplegic shock. Further research with randomized trials on its long-term safety in the ICU, time of initiation, dose, and duration is necessary.

Critically ill patients have a variety of complex pathologies and are in a multifarious state of catabolism supplanted by external and internal factors. Early enteral nutrition (EEN) is defined as the initiation of enteral feeding within 24-48 hours of hospitalization. Previous studies show the benefits of EEN include supporting the healing process through preservation of the gut mucosa, modulation of the immune response, and suppression of inflammation. However, recent studies suggest the advantages of EEN may not be as robust as previously believed. This review aims to discuss the outcomes of EEN when used in different critical care settings while managing complex disease states such as burns, sepsis, pancreatitis, and upper gastrointestinal bleeding. Evidence indicates that EEN has a positive impact on patient outcomes, hospital costs, length of intensive care unit stay, and preventing complications.

Management of intracranial hypertension (IH) has improved in the last decades driven by advancements in monitoring technologies and a deeper understanding of its pathophysiology. Although intracranial pressure (ICP) catheters are still recommended by current guidelines for monitoring patients at risk of IH, these methods are not without limitations. Challenges include procedural complications, availability of these devices in many healthcare settings and technical issues. In this context, management in the absence of ICP monitoring is common and now it can be augmented by intensivist-led point-of-care ultrasound, which includes tools such as transcranial doppler, optic nerve sheath measurement and brain ultrasound. These methods offer anatomic information that can sometimes withhold repeated head computed tomography (CT) scans, but they are also a window into ICP dynamics without the associated risks of invasive monitoring and are reasonable alternatives for guiding treatment, provided an integration between neurological examination, head CT anatomical findings and noninvasive monitors is considered. This manuscript synthesizes the evidence for using invasive ICP monitoring and methods for non-invasive monitoring, more focused on the role of ultrasound, given its wider availability. We also propose a practical approach of how to integrate this information at bedside to avoid both under and overtreatment, by embracing a clinical epidemiology paradigm to guide management decisions.