American Journal of Critical Care最新文献

Background: Children undergoing extracorporeal membrane oxygenation (ECMO) are at risk of hematologic and coagulation complications, including intracranial hemorrhage. Thromboelastography is used to monitor anticoagulation in patients receiving ECMO, but no data for its use in children are available.

Objective: To evaluate the incidence of complications when managing anticoagulation with thromboelastography or with conventional coagulation tests (activated clotting time, plasma fibrinogen level, and platelet count) among children receiving venoarterial or venovenous ECMO.

Methods: This single-center, prospective, retrospective, observational study included patients less than 18 years old who required ECMO. Outcomes were compared between a conventional test group and a thromboelastography group. The primary outcome was critical hemorrhage or pump failure leading to treatment termination.

Results: Each group included 17 patients. Twenty-one patients (17 in the conventional test group, 4 in the thromboelastography group) were enrolled retrospectively. Thirteen patients (all in the thromboelastography group) were enrolled prospectively beginning December 26, 2022. Patient age did not differ between groups (median [IQR] age, 2 [0-6] months). Significantly fewer critical complications occurred in the thromboelastography group (11%) than in the conventional test group (59%) (odds ratio, 10.71; 95% CI, 1.84-62.5; P = .01). The 30-day survival rate after ECMO was higher in the thromboelastography group than in the conventional test group, but the difference was not significant (P = .08).

Conclusions: Managing anticoagulation with thromboelastography, as compared with conventional tests, decreased the frequency of critical complications among children undergoing ECMO.

Background: Mechanical circulatory support (MCS) devices are used to restore circulation in patients with end-stage heart failure. Serum anion gap is a marker of acid-base disorders.

Objective: To investigate whether serum anion gap is a predictor of hospital and intensive care unit mortality in patients receiving MCS and to compare its predictive utility with that of serum lactate level and Sequential Organ Failure Assessment (SOFA) score.

Methods: This retrospective analysis of data from Medical Information Mart for Intensive Care-IV database, 2008-2019, included adult patients receiving MCS. The Harrell C statistic was used to compare the predictive utility of serum anion gap with that of serum lactate level and SOFA score for hospital and intensive care unit mortality.

Results: Of 688 patients receiving MCS, 134 had an anion gap of less than 13 mEq/L; 139, of 13 to 14 mEq/L; 159, of 15 to 17 mEq/L; and 256, of greater than 17 mEq/L. The C statistic (95% CI) for hospital mortality was 0.632 (0.611-0.662) for serum anion gap, 0.684 (0.631-0.694) for lactate, and 0.689 (0.628-0.704) for SOFA score. The C statistic (95% CI) for intensive care unit mortality was 0.642 (0.623-0.662) for serum anion gap, 0.691 (0.646-0.702) for lactate, and 0.694 (0.668-0.711) for SOFA score.

Conclusions: Higher serum anion gaps were associated with greater levels of hospital and intensive care unit mortality among patients receiving MCS and had a low predictive utility for these outcomes.

Background: Due to their rapid onset and minimal accumulation, volatile agents are used for prolonged sedation in intensive care unit (ICU) patients. However, potential renal effects, particularly polyuria and nephrogenic diabetes insipidus, remain a concern during sevoflurane use.

Objective: To evaluate the prevalence of and the factors associated with polyuria during prolonged sevoflurane sedation in ICU patients.

Methods: This observational study included consecutive ICU patients (July 2019 to July 2023) receiving sevoflurane, excluding those with prior renal replacement therapy. Sevoflurane was administered via an anesthetic conserving device at physicians' discretion. Demographic data, clinical characteristics, and laboratory parameters were collected from ICU records. Multivariate analysis was used to identify factors associated with polyuria.

Results: Among 76 patients, 32 (42%) with a median (IQR) sevoflurane duration of 118 (76-165) hours developed polyuria (>3000 mL/d) during the first 7 days. Polyuria was associated with higher urine output, serum sodium level, and osmolarity. Multivariate analysis revealed that prolonged sevoflurane exposure (>1 day) increased the risk of polyuria (odds ratio [95% CI], 1.26 [1.08-1.53]; P = .009). Acute kidney injury was negatively associated with polyuria (odds ratio [95% CI], 0.25 [0.07-0.79]; P = .02). Baseline renal function, weight, and diuretic dose did not differ between patients with and patients without polyuria.

Conclusions: Polyuria is a complication of prolonged sevoflurane sedation; prevalence increases with exposure duration. These findings highlight the need to monitor urine output and serum sodium level during sedation.

Background: Being deprived of the ability to speak is a dehumanizing experience for critically ill patients receiving prolonged mechanical ventilation support in the intensive care unit (ICU). A speaking valve is often used only once a patient with a tracheostomy can be disconnected from the ventilator.

Objective: To study the toleration of a one-way speaking valve connected in-line with the ventilator circuit in ICU patients with chronic critical illness and a tracheostomy.

Methods: A retrospective cohort study was conducted in a 15-bed ICU and a 5-bed post-ICU weaning center from October 2021 through February 2024. All patients had undergone tracheostomy placement in the ICU because of difficulty with weaning from mechanical ventilation.

Results: Of the 47 included patients, the in-line speaking valve trial was unsuccessful in only 4 (9%). Three of the patients in whom the trial was unsuccessful had severe obesity (no patients with successful trials had severe obesity, P < .001) and the fourth patient had severe laryngeal dysfunction. Patients in whom the in-line speaking valve trial was successful could be maintained under this mechanical ventilation modality until they were fully disconnected from the ventilator.

Conclusions: An in-line speaking valve trial was successfully performed in most of the patients with a tracheostomy. An in-line speaking valve can safely restore the natural way of communication for ventilator-dependent critically ill patients with tracheostomies. Larger studies are needed of patients with severe obesity or severe laryngeal dysfunction.

Background: Critical care nurses are regularly exposed to situations that may create moral distress. Moral distress has been correlated with higher rates of nursing burnout, emotional withdrawal, and traumatic stress syndrome.

Objectives: This descriptive correlational study aimed to describe the relationships between moral distress, coping resilience, and self-care practices.

Methods: An electronic survey was sent to nurses in 5 intensive care units within 1 hospital system from February 2023 through April 2023. Nurses were asked to answer questions about their demographic characteristics, moral distress, coping resiliency, and self-care practices.

Results: Seventy-four staff nurses participated in the survey. Overall, nurses reported the highest levels of moral distress from the following: a family's insistence on aggressive treatment, continuing to provide aggressive treatment despite unlikely effectiveness, and excessive documentation requirements. Results showed a statistically significant (but weak) positive correlation between mindful self-care and resilient coping (r65 = 0.27, P = .03).

Conclusions: A positive correlation between mindful self-care and coping resilience was identified, which suggests that self-care may influence resiliency. Participants indicated frequent use of outside support systems such as supportive structures and supportive persons. These systems may be ideal mechanisms through which to support nurses in the future.

Background: The impact of trained intensivist staffing on critically ill pediatric patients requiring intensive care unit (ICU) admission is not clear.

Objective: To examine whether trained intensivist coverage is associated with improved survival outcomes in critically ill pediatric patients.

Methods: The analysis included all pediatric patients hospitalized in ICUs in South Korea from 2017 through 2021. The intensivist and nonintensivist groups included pediatric ICU patients in hospitals with and without trained intensivists, respectively.

Results: This study included 28 047 critically ill pediatric patients. Among them, 9909 (35.3%) were admitted to ICUs of hospitals where trained intensivists were dedicated to patient management, and these patients were subsequently assigned to the intensivist group. After propensity score matching, 16 992 critically ill pediatric patients (8496 in each group) were included in the final analysis. The all-cause mortality rates for 90 days and 1 year were 6.7% (566/8496) and 8.3% (709/8496) in the intensivist group, and 8.6% (732/8496) and 9.8% (835/8496) in the nonintensivist group, respectively. In the Cox regression analysis, the intensivist group showed 24% (hazard ratio [HR], 0.76; 95% CI, 0.68-0.85; P < .001) and 17% (HR, 0.83; 95% CI, 0.75-0.92; P < .001) lower 90-day and 1-year all-cause mortality rates, respectively, than the nonintensivist group.

Conclusions: The presence of pediatric intensivists in the ICU substantially reduced the mortality of critically ill pediatric patients. The findings highlight the significant role of pediatric intensivists in reducing long-term mortality among critically ill pediatric patients.