American Journal of Critical Care最新文献

Background: Evidence for the effectiveness of the Sonoclot analyzer in improving clinical outcomes in disseminated intravascular coagulation (DIC) is lacking.

Objective: To evaluate the effectiveness of an algorithm based on the Sonoclot analyzer in improving the short-term prognosis of patients with DIC.

Methods: A total of 279 patients with overt DIC who were admitted to the hospital within 18 months before and after implementation of the new Sonoclot-based algorithm were enrolled in the study. They were assigned to either a conventional coagulation assay (CCA) group (n = 148) or a Sonoclot group (n = 131). Data associated with anti-coagulation and transfusion were collected and analyzed. The 30-day survival rate after hospital admission was compared between groups.

Results: The Sonoclot group had a higher 30-day survival rate than the CCA group (78.45% vs 63.64%; P = .02). The heparin dose, anticoagulation course, and major bleeding rate were significantly reduced in the Sonoclot group compared with the CCA group for all patients and for patients undergoing continuous renal replacement therapy (all P < .001). Fresh frozen plasma, platelet, and cryoprecipitate requirements were substantially lower in the Sonoclot group than in the CCA group (P = .007, .03, and .02, respectively). In a stratified analysis, improved survival rate was seen mainly in patients with moderately severe sepsis and heatstroke, with an Acute Physiology and Chronic Health Evaluation II score of 20 to 29.

Conclusion: The Sonoclot analyzer may be useful to guide coagulation management in patients with DIC. Use of the Sonoclot-based algorithm may improve outcomes for DIC patients with moderately severe sepsis or heatstroke.

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) contribute to morbidity and mortality. Noninvasive ventilation (NIV), a resource-intensive intervention, decreases mortality and the need for invasive mechanical ventilation.

Objective: To study NIV and mechanical ventilation use, NIV failure, and hospital NIV case volumes for inpatients with AECOPD from 2010 to 2019.

Methods: This retrospective cohort study used the Nationwide Readmissions Database (2010-2019) for adults (≥40 years old) hospitalized for AECOPD. Rates of NIV and mechanical ventilation use and NIV failure were compared per year. Multivariable hierarchical regression models were used. Hospital case volumes of NIV use (overall and for patients with AECOPD) were compared across years.

Results: Patients with AECOPD accounted for 3.35% of admissions in 2010 and 3.20% in 2019. Risk-adjusted rate (95% CI) of mechanical ventilation use decreased from 6.0% (5.6%-6.4%) to 4.5% (4.2%-4.8%); NIV use increased from 6.2% (5.6%-6.9%) to 10.9% (9.9%-12.0%). Noninvasive ventilation failure rate (95% CI) decreased from 7.8% (6.9%-8.7%) to 5.6% (5.0%-6.2%). Mean (SD) hospital case volume for NIV increased overall from 207.3 (237.0) in 2010 to 360.4 (447.4) in 2019 (P < .001); for patients with AECOPD, from 39.5 (37.8) to 79.0 (78.7) (P < .001).

Conclusions: From 2010 to 2019, mechanical ventilation use and NIV failure decreased; NIV use and hospital NIV case volumes increased. These results indicate greater need for monitored beds, equipment, and trained staff.

Background: Young adults in intensive care units (ICUs) are a subgroup of patients who have not been adequately studied. Their health and developmental issues differ from those of children and older adults, but little is known about their specific critical care needs.

Objectives: To describe the characteristics of a cohort of young adults (18 to 39 years of age) receiving care in specialty ICUs, examine differences in this population before and during the COVID-19 pandemic, and explore associations among clinical and demographic variables and advance directives.

Methods: Analysis of a deidentified data set of 3401 young adults who were admitted to ICUs at one academic health system from 2018 through 2021.

Results: The mean age of the young adult group was 29.7 years (SD, 6.0 years). A disproportionately higher number were male and Black compared with the catchment area and older adult groups. Most of the young adults were single with commercial or government health insurance. One-third had diagnoses of injury, poisonings, and trauma; other common diagnoses were infections and endocrine, circulatory, and digestive disorders. The patients' mortality rate was 6.6%, and more than 70% were eventually discharged to home. One-third had an advance directive. Over the COVID-19 pandemic years, there was a trend toward more Black young adults in the ICU and increased severity of illness and mortality rate.

Conclusions: Most young adults survived their ICU admission and were eventually discharged to home, highlighting needs for research into posthospitalization support.

Background: COVID-19 can cause severe acute respiratory distress syndrome or myocardial dysfunction requiring extracorporeal membrane oxygenation (ECMO). Whether comorbidities or sociodemographic factors influence outcomes in these patients is unclear.

Methods: Adult patients from the National Inpatient Sample dataset with COVID-19 pneumonia or non-COVID-19 pneumonia who underwent ECMO between 2016 and 2021 were included. Cohorts were matched in a 1:5 ratio using propensity scores. The primary outcome of interest was inpatient mortality; secondary outcomes included length of stay, total hospitalization costs, need for dialysis, rate of vascular complications, and discharge disposition.

Results: Weighted patient groups (COVID-19 pneumonia, 5680 patients; non-COVID-19 pneumonia, 430 patients) were identified. Mean (SD) age was 46.0 (11.2) years in the COVID-19 group, 45.1 (12.5) years in the non-COVID-19 group. After matching, unweighted groups (COVID-19 pneumonia, 1136 patients; non-COVID-19 pneumonia, 86 patients) were compared. Patients with COVID-19 pneumonia had higher mortality risk (odds ratio [OR], 1.98; 95% CI, 1.11-3.53; P = .02), longer stays (38.0 vs 28.5 days, P < .001), higher costs ($1 278 270 vs $967 866, P = .002), and less likelihood of discharge home (OR, 0.42; 95% CI, 0.21-0.85; P = .02) than patients with non-COVID-19 pneumonia. Vascular complication rate (OR, 0.77; 95% CI, 0.27-2.26; P = .64) and need for dialysis (OR, 1.01; 95% CI, 0.49-2.08; P = .97) did not differ between groups.

Conclusions: Among patients undergoing ECMO, those with COVID-19 pneumonia had worse outcomes than those with non-COVID-19 pneumonia after adjustment for sociodemographic factors and comorbidities.

Background: Patients undergoing medical procedures benefit from preprocedural education.

Objective: To evaluate a multisensory virtual reality preoperative educational program for patients undergoing elective cardiovascular surgical procedures with postoperative recovery in the intensive care unit (ICU) and assess its impact on patients' outcomes and experience.

Methods: Patients scheduled for elective cardiovascular surgical procedures with expected recovery in the ICU were enrolled. A multidisciplinary team designed the virtual reality simulation. Educational objectives focused on patient safety, family presence, ICU machinery and activities, reorientation, and communication with the care team. Historical control patients (n = 94) underwent medical record review and were contacted to complete surveys. Virtual reality simulation patients (n = 44) underwent medical record review, viewed the simulation at a preoperative appointment, and completed surveys. The study included patients admitted from June 4, 2019, to May 12, 2022.

Results: Durations of postoperative sedation and mechanical ventilation were lower in patients receiving virtual reality simulation. Most patients in the virtual reality simulation group (92%) said the simulation alleviated their anxiety and helped them understand what to expect in the ICU. The simulation improved their feeling of safety and decreased their fear of the unknown. Delirium incidence was not different in the 2 groups.

Conclusions: Preprocedural education via virtual reality simulation can improve the experience and outcomes of patients undergoing elective cardiothoracic surgery with recovery in the ICU.