Critical care science最新文献

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.