Critical care science最新文献

Objective: To assess the perceptions of intensive care unit health care professionals in Brazil regarding postintensive care syndrome and the importance attributed to it by individuals and institutions.

Methods: A web-based survey was conducted among intensive care unit professionals across all five Brazilian geopolitical regions. The questionnaire was used to collect demographic and professional data and to explore participants' perceptions of postintensive care syndrome, including a focus on patient/family-centered outcomes and long-term intensive care unit consequences.

Results: A total of 1,527 intensive care unit professionals responded, 61.3% of whom were women. The responses represented 12 professional categories, including physicians (51.1%), physiotherapists (16.9%), nurses (12.7%), and psychologists (5.8%). Among the participants, 50.4% had training or certification in critical care, and 59.9% had more than five years of experience. However, 24% had never heard of postintensive care syndrome. Awareness was significantly higher among those with specialized training (85.2% versus 66.6%; p < 0.001). Only 26.4% reported that their institutions had protocols for postintensive care syndrome assessment before hospital discharge. A significant difference emerged between individual and institutional priorities regarding patient/family-centered outcomes and postintensive care unit care (p < 0.001). In 60% of the cases, intensive care unit teams were not involved in patients' hospital discharge.

Conclusion: Despite moderate awareness of postintensive care syndrome among intensive care unit professionals, there is a considerable gap between staff and the institutional prioritization of postintensive care unit care in Brazil. This highlights the need to increase awareness and develop structured postintensive care unit care protocols, ensuring improved long-term outcomes for intensive care unit patients and their families.

Objective: To evaluate the impact of an ascending positive end-expiratory pressure titration strategy on respiratory mechanics and mechanical power in patients without lung injury.

Methods: An incremental positive end-expiratory pressure titration was performed in 4cmH2O steps, starting from zero end-expiratory pressure and progressing to 16cmH2O. Differences (Δ) in respiratory system static compliance, plateau pressure, driving pressure, and mechanical power were assessed during lung-protective ventilation. Mechanical power formulas proposed by Gattinoni et al. and Costa et al. were used. Analyses were also performed on the static elastic components, dynamic elastic components, total elastic power, and resistive components.

Results: Increasing positive end-expiratory pressure levels were associated with a progressive rise in mechanical power, plateau pressure, total and static elastic power, and a decline in compliance. Mechanical power showed strong positive correlations with: ΔPplat (p < 0.001); Δelastic dynamic power (p < 0.001); Δdriving pressure (p < 0.001); and Δtotal elastic power (p < 0.001). Δmechanical power correlated strongly with Δresistive power (p < 0.001), but not with other mechanical power components or mechanics.

Conclusion: Progressive positive end-expiratory pressure increase in patients without lung disease significantly raises total mechanical power and its elastic components, particularly static elastic power. These changes may occur silently and without significant alterations in driving pressure or compliance.

Background: The effect of different levels of positive end-expiratory pressure in invasively ventilated critically ill patients remains a matter of debate. The REstricted versus Liberal Positive End-Expiratory Pressure in Patients Without ARDS (RELAx) is a multicentric, randomized trial comparing a lower positive end-expiratory pressure strategy versus a higher positive end-expiratory pressure strategy in ventilated patients without acute respiratory distress syndrome, which demonstrated non-inferiority of lower positive end-expiratory pressure compared to higher positive end-expiratory pressure on ventilator-free days. The primary analysis was published in 2020, and a frequentist statistical approach was applied.

Aim: To present the protocol of the Bayesian analysis plan that will be used to re-analyse the RELAx trial to provide complementary and additional insight into this clinical trial.

Methods: This re-analysis will focus on the probability of superiority of the intervention. As an ordinal variable, the primary outcome will be ventilator-free days at day 28, and posterior estimates will be obtained by fitting a hierarchical cumulative logistic regression model. Secondary outcomes will be mortality at day 28, as a binary outcome, and ventilation duration, as a continuous outcome. We will adopt neutral, pessimistic, and optimistic priors informed by current literature, and a fourth prior derived from an expert's survey. Probability thresholds will be defined for superiority, severe harm, and a region of practical equivalence.

Discussion: The RELAx trial findings raise the hypothesis that a lower positive end-expiratory pressure strategy may be at least as effective, if not superior, in specific patient-centred outcomes. This analysis is designed to augment and contextualize the original frequentist analysis of the largest randomized trial comparing positive end-expiratory pressure strategies in non-acute respiratory distress syndrome patients. Results will be presented with a continuum of credible intervals and probabilities of effects to facilitate a nuanced interpretation. We offer clinically meaningful insights that complement and extend the trial's original analysis by reporting probabilities of benefit, harm, and equivalence.

Objective: To assess the impact of a multicomponent intervention on the health-related quality of life of patients with hypoxemic respiratory failure requiring invasive mechanical ventilation.

Methods: A cluster stepped-wedge randomized clinical trial will be conducted in intensive care units across Brazil. Intensive care units with ≥ 8 beds and the capacity to admit patients with acute hypoxemic respiratory failure will be included. Within each intensive care unit, adult patients with acute hypoxemic respiratory failure requiring invasive mechanical ventilation, in whom SARS-CoV-2 infection is part of the differential diagnosis, will be enrolled. The intervention consists of a telemedicine-based quality improvement program focused on disability prevention and rehabilitation strategies, implemented during the patient's intensive care unit stay, continued through ward admission, and extending up to 2 months post-hospital discharge. The primary outcome is health-related quality of life assessed using the EuroQol 5-Dimension 3-Level scale 90 days after discharge from the hospital. Secondary outcomes include rehospitalization within 30 days from hospital discharge, as well as all-cause mortality, anxiety, depression, cognitive impairment, new disabilities for instrumental activities of daily living, and return to work or studies 90 days after discharge from the hospital.

Results: The study protocol has been approved by the research ethics committees of all participant institutions. It was registered at ClinicalTrials.gov (NCT06343545) before the first participant was included. We aim to disseminate the findings through conferences and peer-reviewed journals.

Conclusion: The "Tele-Rehab MV trial" may provide further information on the role of early multicomponent interventions aimed at disability prevention and rehabilitation for critically ill patients with acute hypoxemic respiratory failure.

Objective: To investigate whether continuous positive airway pressure during spontaneous breathing trial is non-inferior to pressure support by comparing both techniques in mechanically ventilated children.

Methods: This is a multicenter, open-label, non-inferiority randomized controlled trial. The primary outcome is successful liberation from invasive mechanical ventilation for at least 48 hours post-extubation. Secondary outcomes include the need for post-extubation respiratory support and the length of stay in the pediatric intensive care unit. The sample size is estimated to be 170 participants. Non-inferiority will be assessed using the Farrington-Manning test. The trial registration number is NCT06593288 (clinicaltrials.gov). Infants older than 36 weeks corrected gestational age and < 18 years old admitted to the pediatric intensive care unit requiring invasive mechanical ventilation for at least 24 hours and ready to wean will be included. Patients with chronic pulmonary conditions, congenital heart disease, upper airway abnormalities, morbid obesity, and in palliative care will be excluded. Patients who have passed the extubation readiness test will be randomized to receive either continuous positive airway pressure or pressure support during a spontaneous breathing trial.

Results: the results of the study should be ready and published within a year.

Conclusion: The transition from mechanical ventilation to spontaneous breathing is a pivotal moment in the care of critically ill children. Yet, limited high-quality evidence informs the optimal approach to spontaneous breathing trials. Our protocol outlines a rigorously designed non-inferiority randomized controlled trial comparing spontaneous breathing trials conducted with and without pressure support.

Objective: To describe the epidemiology of patients requiring neurocritical care in intensive care units in Curitiba, Brazil, examine differences based on primary acute neurological diagnoses, and identify predictors of mortality and unfavorable intensive care unit outcomes.

Methods: This was a retrospective cohort study involving patients aged 18 years or older who were admitted to the intensive care units of seven hospitals from January 2017 to December 2022. Patients admitted for primary neurological diagnoses were compared with those admitted for other causes. Cox regression models were used to assess factors associated with mortality and unfavorable outcomes (modified Rankin Scale scores of 4-6) in neurocritical care.

Results: A total of 62,101 patients were included, with 10,884 admitted for neurological reasons. Compared with non-neurological patients, those with neurological diagnoses were significantly older and had lower levels of consciousness upon admission but lower APACHE II and SOFA scores, shorter intensive care unit stays, and lower mortality rates. Despite this, surviving patients admitted with neurological diagnoses experienced greater functional limitations. The leading causes of neurological admission included postoperative monitoring of intracranial surgery (32.6%), ischemic stroke (19%), traumatic brain injury (17%), seizure (7.1%), hemorrhagic stroke (6.5%), subarachnoid hemorrhage (4.5%), encephalopathy (4.2%), spinal cord conditions (3.8%), central nervous system infection (1.8%), neuromuscular diseases (0.8%), and other conditions (2.5%). Older age, use of vasoactive drugs upon admission, creatinine level ≥ 1.5mg/dL, lower level of consciousness within the first 24 hours, and primary neurological diagnoses of ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, encephalopathy, and other conditions emerged as independent predictors of an increased hazard ratio of death and an unfavorable intensive care unit outcome.

Conclusion: Patients admitted to intensive care units due to neurological disorders had lower mortality rates but developed higher degrees of functional dependence. Among neurocritically ill patients, those requiring vasoactive drugs upon admission, those with elevated creatinine levels (≥ 1.5mg/dL), and those admitted due to ischemic stroke, hemorrhagic stroke, or subarachnoid hemorrhage had a greater risk of death and unfavorable outcomes.

Objective: To perform a systematic literature review to summarise current evidence of the incidence and clinical impact of late-onset hyperlactatemia in intensive care patients about case-fatality and morbidity.

Methods: MEDLINE, EMBASE, and ClinicalTrials.gov were searched using medical subject headings from database inception to 27 November 2024. Before the search, the protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO). Two independent reviewers screened the search results, and studies were included if they were original research that assessed late-onset hyperlactatemia in critically ill patients. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the data were analysed using a descriptive approach without meta-analysis.

Results: Of the 10,388 screened studies, 6 were included in the final manuscript, 5 retrospective and 1 prospective. All were assessed as good quality studies. Five were cardiac surgical patients, and one was general intensive care patients. All six studies reported the incidence of late-onset hyperlactatemia, which ranged from 8.5 to 70.8%. Two studies reported increased intensive care unit and/or hospital case-fatality with late-onset hyperlactatemia; however, small absolute numbers limited the interpretability.

Conclusion: The limited data regarding late-onset hyperlactatemia make it difficult to draw significant conclusions regarding the relationship to clinical outcomes. However, the few available studies suggest that it is a common finding and highlight the need for further research to assess the underlying aetiologies and association with clinical outcomes.