世界危重病急救学杂志(英文版)最新文献

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.

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.

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.