世界危重病急救学杂志(英文版)最新文献

Background: Hematoma expansion (HE) typically portends a poor prognosis in spontaneous intracerebral hemorrhage (ICH). Several radiographic and laboratory values have been proposed as predictive markers of HE.

Aim: To perform a systematic review and meta-analysis on the association of neutrophil-to-lymphocyte ratio (NLR) and HE in ICH. A secondary outcome examined was the association of NLR and perihematomal (PHE) growth.

Methods: Three databases were searched (PubMed, EMBASE, and Cochrane) for studies evaluating the effect of NLR on HE and PHE growth. The inverse variance method was applied to estimate an overall effect for each specific outcome by combining weighted averages of the individual studies' estimates of the logarithm odds ratio (OR). Given heterogeneity of the studies, a random effect was applied. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The study was conducted following the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The protocol was registered in PROSPERO (No. CRD42024549924).

Results: Eleven retrospective cohort studies involving 2953 patients were included in the meta-analysis. Among those, HE was investigated in eight studies, whereas PHE growth was evaluated in three. Blood sample was obtained on admission in ten studies, and at 24 hours in one study. There was no consensus on cut-off value among the studies. NLR was found to be significantly associated with higher odds of HE (OR = 1.09, 95%CI: 1.04-1.15, I ² = 86%, P < 0.01), and PHE growth (OR = 1.28, 95%CI: 1.19-1.38, I ² = 0%, P < 0.01). Qualitative analysis of each outcome revealed overall moderate risk of bias mainly due to lack of control for systemic confounders.

Conclusion: The available literature suggests that a possible association may exist between NLR on admission and HE, and PHE growth. Future studies controlled for systemic confounders should be designed to consolidate this finding. If confirmed, NLR could be added as a readily available and inexpensive biomarker to identify a subgroup of patients at higher risk of developing HE.

The global incidence of critical illness has been steadily increasing, resulting in higher mortality rates thereby presenting substantial challenges for clinical management. Among these conditions, sepsis stands out as the leading cause of critical illness, underscoring the urgent need for continued research to enhance patient care and deepen our understanding of its complex pathophysiology. Lymphocytes play a pivotal role in both innate and adaptive immune responses, acting as key regulators of the balance between pro-inflammatory and anti-inflammatory processes to preserve immune homeostasis. In the context of sepsis, an impaired immunity has been associated with disrupted lymphocytic metabolic activity, persistent pro-inflammatory state, and subsequent immunosuppression. These disruptions not only impair pathogen clearance but also predispose patients to secondary infections and hinder recovery, highlighting the importance of targeting lymphocyte dysfunction in sepsis management. Moreover, studies have identified absolute lymphocyte counts and derived parameters as promising clinical biomarkers for prognostic assessment and therapeutic decision-making. In particular, neutrophil-to-lymphocyte ratio, and lymphopenia have gained recognition in the literature as a critical prognostic markers and therapeutic target in the management of sepsis. This review aims to elucidate the multifaceted role of lymphocytes in pathophysiology, with a focus on recent advancements in their use as biomarkers and key findings in this evolving field.

Advancements in healthcare technology have improved mortality rates and extended lifespans, resulting in a population with multiple comorbidities that complicate patient care. Traditional assessments often fall short, underscoring the need for integrated care strategies. Among these, fluid management is particularly challenging due to the difficulty in directly assessing volume status especially in critically ill patients who frequently have peripheral oedema. Effective fluid management is essential for optimal tissue oxygen delivery, which is crucial for cellular metabolism. Oxygen transport is dependent on arterial oxygen levels, haemoglobin concentration, and cardiac output, with the latter influenced by preload, afterload, and cardiac contractility. A delicate balance of these factors ensures that the cardiovascular system can respond adequately to varying physiological demands, thereby safeguarding tissue oxygenation and overall organ function during states of stress or illness. The Venous Excess Ultrasound (VExUS) Grading System is instrumental in evaluating fluid intolerance, providing detailed insights into venous congestion and fluid status. It was originally developed to assess the risk of acute kidney injury in postoperative cardiac patients, but its versatility has enabled broader applications in nephrology and critical care settings. This mini review explores VExUS's application and its impact on fluid management and patient outcomes in critically ill patients.

Background: The burden of cannabis use disorder (CUD) in the context of its prevalence and subsequent cardiopulmonary outcomes among cancer patients with severe sepsis is unclear.

Aim: To address this knowledge gap, especially due to rising patterns of cannabis use and its emerging pharmacological role in cancer.

Methods: By applying relevant International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes to the National Inpatient Sample database between 2016-2020, we identified CUD(+) and CUD(-) arms among adult cancer admissions with severe sepsis. Comparing the two cohorts, we examined baseline demographic characteristics, epidemiological trends, major adverse cardiac and cerebrovascular events, respiratory failure, hospital cost, and length of stay. We used the Pearson χ ² d test for categorical variables and the Mann-Whitney U test for continuous, non-normally distributed variables. Multivariable regression analysis was used to control for potential confounders. A P value ≤ 0.05 was considered for statistical significance.

Results: We identified a total of 743520 cancer patients admitted with severe sepsis, of which 4945 had CUD. Demographically, the CUD(+) cohort was more likely to be younger (median age = 58 vs 69, P < 0.001), male (67.9% vs 57.2%, P < 0.001), black (23.7% vs 14.4%, P < 0.001), Medicaid enrollees (35.2% vs 10.7%, P < 0.001), in whom higher rates of substance use and depression were observed. CUD(+) patients also exhibited a higher prevalence of chronic pulmonary disease but lower rates of cardiovascular comorbidities. There was no significant difference in major adverse cardiac and cerebrovascular events between CUD(+) and CUD(-) cohorts on multivariable regression analysis. However, the CUD(+) cohort had lower all-cause mortality (adjusted odds ratio = 0.83, 95% confidence interval: 0.7-0.97, P < 0.001) and respiratory failure (adjusted odds ratio = 0.8, 95% confidence interval: 0.69-0.92, P = 0.002). Both groups had similar median length of stay, though CUD(+) patients were more likely to have higher hospital cost compared to CUD(-) patients (median = 94574 dollars vs 86615 dollars, P < 0.001).

Conclusion: CUD(+) cancer patients with severe sepsis, who tended to be younger, black, males with higher rates of substance use and depression had paradoxically significantly lower odds of all-cause in-hospital mortality and respiratory failure. Future research should aim to better elucidate the underlying mechanisms for these observations.

Background: Acute respiratory distress syndrome (ARDS) is a critical condition characterized by acute hypoxemia, non-cardiogenic pulmonary edema, and decreased lung compliance. The Berlin definition, updated in 2012, classifies ARDS severity based on the partial pressure of arterial oxygen/fractional inspired oxygen fraction ratio. Despite various treatment strategies, ARDS remains a significant public health concern with high mortality rates.

Aim: To evaluate the implications of driving pressure (DP) in ARDS management and its potential as a protective lung strategy.

Methods: We conducted a systematic review using databases including EbscoHost, MEDLINE, CINAHL, PubMed, and Google Scholar. The search was limited to articles published between January 2015 and September 2024. Twenty-three peer-reviewed articles were selected based on inclusion criteria focusing on adult ARDS patients undergoing mechanical ventilation and DP strategies. The literature review was conducted and reported according to PRISMA 2020 guidelines.

Results: DP, the difference between plateau pressure and positive end-expiratory pressure, is crucial in ARDS management. Studies indicate that lower DP levels are significantly associated with improved survival rates in ARDS patients. DP is a better predictor of mortality than tidal volume or positive end-expiratory pressure alone. Adjusting DP by optimizing lung compliance and minimizing overdistension and collapse can reduce ventilator-induced lung injury.

Conclusion: DP is a valuable parameter in ARDS management, offering a more precise measure of lung stress and strain than traditional metrics. Implementing DP as a threshold for safety can enhance protective ventilation strategies, potentially reducing mortality in ARDS patients. Further research is needed to refine DP measurement techniques and validate its clinical application in diverse patient populations.

Background: Rhabdomyolysis (RML) as an etiological factor causing acute kidney injury (AKI) is sparsely reported in the literature.

Aim: To study the incidence of RML after surgical repair of an ascending aortic dissection (AAD) and to correlate with the outcome, especially regarding renal function. To pinpoint the perioperative risk factors associated with the development of RML and adverse renal outcomes after aortic dissection repair.

Methods: Retrospective single-center cohort study conducted in a tertiary cardiac center. We included all patients who underwent AAD repair from 2011-2017. Post-operative RML workup is part of the institutional protocol; studied patients were divided into two groups: Group 1 with RML (creatine kinase above cut-off levels 2500 U/L) and Group 2 without RML. The potential determinants of RML and impact on patient outcome, especially postoperative renal function, were studied. Other outcome parameters studied were markers of cardiac injury, length of ventilation, length of stay in the intensive care unit), and length of hospitalization.

Results: Out of 33 patients studied, 21 patients (64%) developed RML (Group RML), and 12 did not (Group non-RML). Demographic and intraoperative factors, notably body mass index, duration of surgery, and cardiopulmonary bypass, had no significant impact on the incidence of RML. Preoperative visceral/peripheral malperfusion, though not statistically significant, was higher in the RML group. A significantly higher incidence of renal complications, including de novo postoperative dialysis, was noticed in the RML group. Other morbidity parameters were also higher in the RML group. There was a significantly higher incidence of AKI in the RML group (90%) than in the non-RML group (25%). All four patients who required de novo dialysis belonged to the RML group. The peak troponin levels were significantly higher in the RML group.

Conclusion: In this study, we noticed a high incidence of RML after aortic dissection surgery, coupled with an adverse renal outcome and the need for post-operative dialysis. Prompt recognition and management of RML might improve the renal outcome. Further large-scale prospective trials are warranted to investigate the predisposing factors and influence of RML on major morbidity and mortality outcomes.

Management of patients with acute hemorrhage requires addressing the source of bleeding, replenishing blood volume, and addressing any coagulopathy that may be present. Assessing coagulopathy and predicting blood requirements in real-time in patients experiencing ongoing bleeding can pose substantial challenges. In these patients, transfusion concepts based on ratios do not effectively address coagulopathy or reduce mortality. Moreover, ratio-based concepts do not stop bleeding; instead, they just give physicians more time to identify the bleeding source and plan management strategies. In clinical practice, standard laboratory coagulation tests (SLCT) are frequently used to assess various aspects of blood clotting. However, these tests may not always offer a comprehensive understanding of clinically significant coagulopathy and the severity of blood loss. Furthermore, the SLCT have a considerable turnaround time, which may not be ideal for making prompt clinical decisions. In recent years, there has been a growing interest in point-of-care viscoelastic assays like rotational thromboelastometry, which provide real-time, dynamic information about clot formation and dissolution.

Acute liver failure (ALF) and acute-on-chronic LF (ACLF) are prevalent hepatic emergencies characterized by an increased susceptibility to bacterial infections (BI), despite significant systemic inflammation. Literature indicates that 30%-80% of ALF patients and 55%-81% of ACLF patients develop BI, attributed to immunological dysregulation. Bacterial sepsis in these patients is associated with adverse clinical outcomes, including prolonged hospitalization and increased mortality. Early detection of bacterial sepsis is critical; however, distinguishing between sterile systemic inflammation and sepsis poses a significant challenge due to the overlapping clinical presentations of LF and sepsis. Conventional sepsis biomarkers, such as procalcitonin and C-reactive protein, have shown limited utility in LF patients due to inconsistent results. In contrast, novel biomarkers like presepsin and sTREM-1 have demonstrated promising discriminatory performance in this population, pending further validation. Moreover, emerging research highlights the potential of machine learning-based approaches to enhance sepsis detection and characterization. Although preliminary findings are encouraging, further studies are necessary to validate these results across diverse patient cohorts, including those with LF. This article provides a comprehensive review of the magnitude, impact, and diagnostic challenges associated with BI in LF patients, focusing on novel advancements in early sepsis detection and characterization.

Interventional pulmonology (IP) represents a rapidly growing and developing subspecialty within pulmonary medicine. To the intensivist, given the elaborate undertakings with respect to airway, lung and pleural disease management-IP has shown an increasing presence and remain a major ally in the care of these patients. Thus, an understanding of the different roles that IP could offer to the intensivist is of prime importance in the multi-disciplinary care of the complex patients within the intensive care units, particularly in relation to lung, airway and pleural diseases. This review article will explore the different intersections of IP in critical care and discuss the applications of this discipline within the highly complex critical care environment.

Background: Managing critical care emergencies in children with autism spectrum disorder (ASD) presents unique challenges due to their distinct sensory sensitivities, communication difficulties, and behavioral issues. Effective strategies and protocols are essential for optimal care in these high-stress situations.

Aim: To systematically evaluate and synthesize current evidence on best practices for managing critical care emergencies in children with ASD. The review focuses on key areas, including sensory-friendly environments, communication strategies, behavioral management, and the role of multidisciplinary approaches.

Methods: A comprehensive search was conducted across major medical databases, including PubMed, Embase, and Cochrane Library, for studies published between 2000 and 2023. Studies were selected based on their relevance to critical care management in children with ASD, encompassing randomized controlled trials, observational studies, qualitative research, and case studies. Data were extracted and analyzed to identify common themes, successful strategies, and areas for improvement.

Results: The review identified 50 studies that met the inclusion criteria. Findings highlighted the importance of creating sensory-friendly environments, utilizing effective communication strategies, and implementing individualized behavioral management plans. These findings, derived from a comprehensive review of current evidence, provide valuable insights into the best practices for managing critical care emergencies in children with ASD. Sensory modifications, such as reduced lighting and noise, visual aids, and augmentative and alternative communication tools, enhanced patient comfort and cooperation. The involvement of multidisciplinary teams was crucial in delivering holistic care. Case studies provided practical insights and underscored the need for continuous refinement of protocols.

Conclusion: The review emphasizes the need for a tailored approach to managing critical care emergencies for children with ASD. Sensory-friendly adjustments, effective communication, and behavioral strategies supported by a multidisciplinary team are integral to improving outcomes. Despite progress, ongoing refinement of care practices and protocols is necessary. This ongoing process addresses remaining challenges and engages healthcare professionals in continuous improvement of care for children with ASD in critical settings.