Critical care science最新文献

Objective: Traumatic brain injury leads to disruption of the hypothalamic-pituitary axis. The aim of this study was to evaluate anterior pituitary gland function in the acute phase following traumatic brain injury and its relationship with patient outcomes.

Methods: This was a prospective cohort of traumatic brain injury patients admitted to the intensive care unit. The levels of adrenocorticotropic hormone, growth hormone, and thyroid-stimulating hormone on Days 0, 3 and 7 after the injury were measured. The Glasgow Outcome Scale-Extended (GOSE) was used for 6-month outcomes.

Results: A total of 88 traumatic brain injury patients (79% male, 41 ± 19 years old) who were admitted to the intensive care unit were studied. The frequencies of hormone levels below the range were as follows: adrenocorticotropic hormone, 81% on Day 0, 75% on Day 3, and 68% on Day 7; growth hormone, 76% on Day 0, 65% on Day 3, and 61% on Day 7; and thyroid-stimulating hormone, 42% on Day 0, 41% on Day 3, and 14% on Day 7. Traumatic brain injury severity was associated with Day 0 adrenocorticotropic hormone (p = 0.03) and Day 7 growth hormone (p = 0.03) levels and inversely associated with Day 3 thyroid-stimulating hormone (p = 0.03) levels. Glial fibrillary astrocytic protein was directly associated with Day 3 adrenocorticotropic hormone (OR 1.02, 95%CI 1.01 - 1.03; p < 0.001) and inversely associated with Day 7 thyroid-stimulating hormone (OR 1.02, 95%CI: 1.02 - 1.03; p = 0.04) levels. There was no significant association between hormone levels and mortality or the 6-month Glasgow Outcome Scale-Extended score.

Conclusion: Anterior pituitary hormone disturbances are common following a traumatic brain injury, and the degree of dysfunction is related to the injury severity. No associations were found with mortality or disability. Further investigations are warranted to standardize the measurement of pituitary function after traumatic brain injury and clarify its prognostic/therapeutic role.

Background: Rapid Response Teams have been widely implemented in high-income countries and play a crucial role in the early identification and management of clinically deteriorating patients. However, their implementation in low and middle-income settings has not been adequately described. Our goal was to map the current evidence in this setting.

Methods: We conducted a scoping review to map the published literature about Rapid Response Teams in low- and middle-income countries, according to year of publication, study type, team composition, reported outcomes, and potential roles of the team.

Results: After screening 6,679 studies, 52 fulfilled eligibility criteria: 36 full-text studies and 16 conference abstracts. Most of the studies were from Brazil (51.2%), followed by India (19.2%) and Turkey (7.7%), with the two earliest reports being conference abstracts published in 2009. The predominant design was before-and-after studies (20; 38.4%), followed by cohort studies (16; 30.8%). An intensive care unit physician was always a member of the Rapid Response Teams in 55.9% of the studies and an intensive care unit nurse in 23.5%. The number of Rapid Response Teams calls in the before-and-after studies ranged from 2.39 to 124 per 1,000 admissions. Reported outcomes varied, with most studies focusing on mortality (26, 50%) and code blue incidence (21; 40.4%). Four (7.7%) studies reported an active role of Rapid Response Teams in goals of care discussions.

Conclusion: We found that evidence on Rapid Response Teams in low- and middle-income countries remains limited, with a time lag in publications compared to high-income countries. Our findings highlight the need for further studies and policy initiatives to evaluate the effectiveness of implementing Rapid Response Teams in resource-constrained settings.

Objective: To investigate the relationship between sonographic and radiological scores of lung edema with metrics of shunt, dead space, and respiratory mechanics in critically ill patients under invasive ventilation for greater than 24 hours.

Methods: This is a secondary analysis of a prospective observational study involving invasively ventilated critically ill patients. The radiographic assessment of lung edema score and the global lung ultrasound score were utilized to evaluate pulmonary edema. Measurements for assessing shunt and dead space included the ratio of partial pressure of oxygen to fraction of inspired oxygen ratio, ventilatory ratio, and corrected minute volume, respectively. Respiratory mechanics were assessed through dynamic respiratory system compliance, driving pressure, and mechanical power of ventilation.

Results: A total of 364 invasively ventilated patients were included; one-third of them were classified as having acute respiratory distress syndrome. Median radiographic assessment of lung edema and global lung ultrasound scores were 15 [8 to 20] and 7 [3 to 13], respectively. Both scores explained little of the variance in partial pressure of oxygen to fraction of inspired oxygen ratio, ventilatory ratio, corrected minute volume, respiratory system compliance, driving pressure, and mechanical power (R2 = 0.05-0.12). Patients without acute respiratory distress syndrome exhibited a stronger association between the radiographic assessment of lung edema score and partial pressure of oxygen to fraction of inspired oxygen ratio, as well as between the global lung ultrasound score and respiratory system compliance. In contrast, patients with acute respiratory distress syndrome demonstrated stronger associations between the radiographic assessment of lung edema score and mechanical power and between the global lung ultrasound score and dead space metrics. A positive interaction of positive end-expiratory pressure was found only for the association between partial pressure of oxygen to fraction of inspired oxygen ratio and the radiographic assessment of lung edema and global lung ultrasound scores.

Conclusion: The radiographic assessment of lung edema score and the global lung ultrasound score poorly correlate with shunt, dead space, and respiratory mechanics metrics in invasively ventilated patients. A counterintuitive moderation effect of acute respiratory distress syndrome status is observed in some of these associations.

Objective: To identify modifiable intensive care unit factors associated with outcomes among patients receiving invasive mechanical ventilation in a low-income setting.

Methods: This prospective, multicenter, registry-embedded observational study has two components: a prospective registry-based cohort assessing patient- and care-process-related factors and a cross-sectional intensive care unit survey evaluating organizational structure. Functional intensive care units in Uganda will be included. Patients aged ≥ 15 years old requiring invasive mechanical ventilation will be enrolled. Patients extubated within 48 hours, transferred after > 24 hours, and imminent early death will be excluded. Primary outcomes will include 28-day intensive care unit mortality, intensive care unit length of stay, and mechanical ventilation duration. Tracheostomy-related outcomes will be explored in a pre-planned sub-study. Factors potentially associated with outcomes will be categorized into non-modifiable and potentially modifiable factors. Non-modifiable factors will include patient-related factors like age, comorbidities, and illness severity; potentially modifiable factors include processes of care (e.g., sedation levels) and intensive care unit organizational structure (e.g., staffing patterns). Multilevel multivariable logistic regression models will assess association outcomes. Survival analysis (Kaplan-Meier curves) will explore mortality trends. Confounders will be identified using directed acyclic graphs.

Results (anticipated findings): This study will generate high-quality data on modifiable intensive care unit factors associated with ventilated patient outcomes in low-resource settings.

Conclusion: This is Uganda's first registry-embedded, multicenter intensive care unit study to systematically potentially modifiable factors associated with ventilated patient outcomes. This study will provide evidence-based insights to optimize critical care management in low- and middle-income countries by leveraging real-time intensive care unit registry data.

The cardiovascular system primarily delivers oxygen and nutrients to tissues. Oxygen delivery depends on cardiac output and arterial oxygen content. While left ventricular function is often emphasized, broader cardiovascular changes, including peripheral vascular function and right ventricular performance, are crucial, especially during shock or cardiopulmonary interactions with mechanical ventilation or fluid challenges. Indeed, the primary role of the left ventricle is to maintain a high central arterial pressure with a minimal filling pressure and to do so efficiently with every beat. Cardiac output is driven by tissue metabolic demand, as feeding arterioles adjust their vasomotor tone to autoregulate blood flow. These adjustments are reflected in proportional changes in venous return to the right ventricle. Right ventricular dysfunction reduces cardiac output primarily by causing systemic venous hypertension, a condition the cardiovascular system is poorly adapted to. Understanding these principles is vital for managing the optimization phase of shock resuscitation. In this narrative review, we aim to provide a comprehensive discussion of the physiological determinants of hemodynamics of circulatory function in shock. This structured yet flexible approach offers an integrative perspective on right ventricular and venous function, highlighting their complexity in hemodynamic regulation.

[This corrects the article doi: 10.62675/2965-2774.20250270].