Annals of Intensive Care最新文献

Background: The association between bedside ventilatory parameters-specifically arterial carbon dioxide pressure (PaCO₂) and ventilatory ratio (VR)-and mortality in patients with acute respiratory distress syndrome (ARDS) remains a topic of debate. Additionally, the persistence of this association over time is unclear. This study aims to investigate the relationship between 28-day mortality in ARDS patients and their longitudinal exposure to ventilatory inefficiency, as reflected by serial measurements of PaCO₂ and VR.

Methods: We conducted a secondary analysis of four randomized controlled trials (FACTT, ALTA, EDEN, and SAILS) from the ARDS Network. All included patients were intubated and received mechanical ventilation. Patients were excluded if they underwent extracorporeal life support or were on mechanical ventilation for less than one day. The primary outcome was 28-day mortality. Bayesian joint models were employed to estimate the strength of associations over time.

Results: A total of 2,851 patients were included in our analysis. The overall 28-day mortality rate was 21.3%, with a median duration of invasive mechanical ventilation of 9 days (IQR: 4-28 days). After adjustment, each daily increment in PaCO₂ (HR 1.008, 95% CI 0.997-1.018) was not associated with mortality, while a daily increment in VR (HR 1.548, 95% CI 1.309-1.835) was associated with increased mortality. This association persisted during the prolonged stages (Days 0-23) of mechanical ventilation. Furthermore, a significant increase in the risk of death was related to daily exposure to VR > 2 (HR 1.088 per day, 95% CI 1.034-1.147) and its cumulative effect (HR 1.085 per area, 95% CI 1.050-1.122), whereas PaCO₂ was found to be insignificant.

Conclusion: VR, which reflects ventilatory inefficiency, should be closely monitored during invasive mechanical ventilation. Cumulative exposure to high intensities of VR may be associated with increased mortality in patients with ARDS.

Background: Excessive tachycardia is associated with impaired hemodynamics and worse outcome in critically ill patients. Previous studies suggested beneficial effect of β-blockers administration in ICU patients, including those with septic shock. However, comparisons in ICU settings are lacking. Our study aims to compare Landiolol and Esmolol regarding heart rate control and hemodynamic variables in general ICU patients.

Methods: This retrospective, observational study was conducted in a 56-bed ICU at a university hospital. A propensity score matching (PSM) was employed to balance baseline differences. Generalized estimating equations (GEE) were used to compare heart rate between two drugs. The primary outcome was heart rate control, while secondary outcomes included hemodynamic response, hospital length of stay (HLOS) and ICU length of stay (ICULOS).

Results: From June 2016 to December 2022, 438 patients were included after PSM, (292 in the Esmolol group and 146 the in Landiolol group). Baseline heart rate was similar between groups (Landiolol:120.0 [110.2, 131.0] bpm vs. Esmolol:120.0 [111.0, 129.0] bpm, p = 0.925). During 72 h. of β-blocker infusion, Landiolol reduced heart rate by 4.7 (1.3, 8.1) bpm, more than Esmolol (p = 0.007), while preserving a comparable proportion of patients able to stabilize vasopressor doses within the first 24 h. (82.9 vs. 80.8%, respectively, p = 0.596). Norepinephrine doses and lactate levels were similar between groups over 72 h., while the Landiolol group exhibited notably higher minimal ScvO₂ levels (72% [63%, 78%] vs 68% [55%, 73%], respectively, p = 0.006) and a lower maximal PCO2 gap compared to the Esmolol group (7.0 [6.0, 9.0] vs. 8.0 [6.0, 10.0] mmHg, respectively, p = 0.040). Patients in the Landiolol group were observed to experience shorter HLOS than patients in the Esmolol group (26.5 [13.0, 42.0] vs 30.0 [17.0, 47.2] days, respectively, p = 0.044) and ICULOS (4.9 [2.8, 10.0] vs.6.7 [3.4, 13.1] days, respectively, p = 0.011).

Conclusion: Landiolol provides superior heart rate control in critically ill patients with tachycardia compared to Esmolol, without increasing vasopressor requirements during the first 24 h. Findings from ScvO₂ levels and PCO₂ gap suggest that Landiolol may exert less impact on cardiac output than Esmolol. Further studies, incorporating comprehensive hemodynamic monitoring, are warranted to clarify the clinical implications of heart rate control with β-blockers in ICU patients with tachycardia.

Background: Continuous veno-venous hemodiafiltration (CVVHDF) is used in critically ill patients, but its impact on O₂ and CO₂ removal, as well as the accuracy of resting energy expenditure (REE) measurement using indirect calorimetry (IC) remains unclear. This study aims to evaluate the effects of CVVHDF on O₂ and CO₂ removal and the accuracy of REE measurement using IC in patients undergoing continuous renal replacement therapy.

Design: Prospective, observational, single-center study.

Methodology: Patients with sepsis undergoing CVVHDF had CO₂ flow (QCO₂) and O₂ flow (QO₂) measured at multiple sampling points before and after the filter. REE was calculated using the Weir equation based on V̇CO₂ and V̇O₂ measured by IC, using true V̇CO₂ accounting for the CRRT balance, and estimated using the Harris-Benedict equation. The respiratory quotient (RQ), the ratio of V̇CO₂ to V̇O₂, was evaluated by comparing measured and true values.

Results: The mean QCO₂ levels measured upstream of the filter were 76.26 ± 17.33 ml/min and significantly decreased to 62.12 ± 13.64 ml/min downstream of the filter (p < 0.0001). The mean QO₂ levels remained relatively unchanged. The mean true REE was 1774.28 ± 438.20 kcal/day, significantly different from both the measured REE of 1758.59 ± 434.06 kcal/day (p = 0.0029) and the estimated REE of 1619.36 ± 295.46 kcal/day (p = 0.0475). The mean measured RQ value was 0.693 ± 0.118, while the mean true RQ value was 0.731 ± 0.121, with a significant difference (p < 0.0001).

Conclusions: CVVHDF may significantly alter QCO₂ levels without affecting QO₂, influencing the REE and RQ results measured by IC. However, the impact on REE is not clinically significant, and the REE value obtained via IC is closer to the true REE than that estimated using the Harris-Benedict equation. Further studies are recommended to confirm these findings.

Objective: Evidence of the overall estimated prevalence of post-intensive care cognitive impairment among critically ill survivors discharged from intensive care units at short-term and long-term follow-ups is lacking. This study aimed to estimate the prevalence of the post-intensive care cognitive impairment at time to < 1 month, 1 to 3 month(s), 4 to 6 months, 7-12 months, and > 12 months discharged from intensive care units.

Methods: Electronic databases including PubMed, Cochrane Library, EMBASE, CINAHL Plus, Web of Science, and PsycINFO via ProQuest were searched from inception through July 2024. Studies that reported on cognitive impairment among patients discharged from intensive care units with valid measures were included. Data extraction and risk of bias assessment were performed independently for all included studies according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Newcastle-Ottawa Scale was used to measure risk of bias. Data on cognitive impairment prevalence were pooled using a random-effects model. The primary outcome was pooled estimated proportions of prevalence of the post-intensive care cognitive impairment.

Results: In total, 58 studies involving 347,940 patients were included. The pooled post-intensive care cognitive impairment prevalence rates at the follow-up timepoints < 1 month, 1-3 month(s), 4-6 months, 7-12 months, > 12 months were 49.8% [95% Prediction Interval (PI), 39.9%-59.7%, n = 19], 45.1% (95% PI, 34.8%-55.5%, n = 23), 47.9% (95% PI, 35.9%-60.0%, n = 16), 28.3% (95% PI, 19.9%-37.6%, n = 19), and 30.4% (95% PI, 18.4%-43.9%, n = 7), respectively. Subgroup analysis showed that significant differences of the prevalence rates between continents and study designs were observed.

Conclusions: The prevalence rates of post-intensive care cognitive impairment differed at different follow-up timepoints. The rates were highest within the first three months of follow-up, with a pooled prevalence of 49.8% at less than one month, 45.1% at one to three months, and 47.9% at three to six months. No significant differences in prevalence rates between studies that only included coronavirus disease 2019 survivors. These fundings highlight the need for further research to develop targeted interventions to prevent or manage cognitive impairment at short-term and long-term follow-ups.

Background: Extubation failure is associated with an increased morbidity, emphasizing the need to identify factors to further optimize extubation practices. The role of biomarkers in the prediction of extubation failure is currently limited. The aim of this study was to investigate the prognostic value of cardiac (N-terminal pro-B-type natriuretic peptide (NT-proBNP), High-sensitivity Troponin T (Hs-TnT)) and inflammatory biomarkers (Interleukin-6 (IL-6) and Procalcitonin (PCT)) for extubation failure in patients with COVID-19 Acute Respiratory Distress Syndrome (C-ARDS).

Materials and methods: In this single-center retrospective cohort study, patient characteristics and laboratory measurements were extracted from electronic medical records. Patients were eligible for inclusion if they were extubated after mechanical ventilation. The primary endpoint was extubation failure, defined as the need for reintubation or death within the next seven days after extubation, regardless of whether post-extubation respiratory support was used. Uni- and multivariable logistic regression was performed to investigate the association between biomarkers and extubation failure. Biomarkers were log₂ transformed.

Results: Of the 297 patients included, 21.5% experienced extubation failure. In univariable analysis, NT-proBNP (OR 1.24, 95% CI 1.06-1.47), Hs-TnT (OR 1.72, 95% CI 1.37-2.19) and PCT (OR 1.38, 95% CI 1.16-1.65) measured on the day of extubation were significantly associated with extubation failure. After multivariable adjustment for clinical variables (age, duration of mechanical ventilation, SOFA score), Hs-TnT was the only biomarker that was independently associated with extubation failure (adjusted OR 1.38, 95% CI 1.02-1.90). Patients with both elevated Hs-TnT (≥ 14 ng/mL) and elevated PCT (≥ 0.25 ng/mL) carried the highest risk of extubation failure (46%), while in patients with normal Hs-TnT and PCT values, only 13% experienced extubation failure.

Conclusions: Hs-TnT, NT-proBNP and PCT measured on the day of extubation are associated with extubation failure in mechanically ventilated patients with C-ARDS. Since Hs-TnT is the only biomarker that is independently associated with extubation failure, Hs-TnT could offer additional objective measures for assessing readiness for extubation. Future studies should focus on an integrative approach of biomarkers combined with relevant clinical factors to predict extubation failure.

Sheldon Magder's article on applying Arthur Guyton's principles to clinical fluid management provides valuable insights into optimizing hemodynamics in critically ill patients. While emphasizing the role of right atrial pressure (RAP) in assessing cardiac output, challenges arise due to RAP's variable accuracy and the oversimplification of cardiovascular dynamics. Integrating RAP with dynamic assessments and bedside ultrasound can enhance fluid management strategies. Future research should aim to improve RAP's predictive accuracy and validate its clinical utility for individualized patient care.

Background: We aimed to investigate the association of intracranial complications diagnosed on neuroimaging with neurological outcomes of adults with severe pneumococcal meningitis.

Methods: We performed a retrospective multicenter study on consecutive adults diagnosed with pneumococcal meningitis requiring at least 48 h of stay in the intensive care unit (ICU) and undergoing neuroimaging, between 2005 and 2021. All neuroimaging were reanalyzed to look for intracranial complications which were categorized as (1) ischemic lesion, (2) intracranial hemorrhage (3) abscess/empyema, (4) ventriculitis, (5) cerebral venous thrombosis, (6) hydrocephalus, (7) diffuse cerebral oedema. The primary outcome was unfavorable outcome at 90 days after ICU admission, defined by a modified Rankin Scale (mRS) score > 2.

Results: Among the 237 patients included, intracranial complications were diagnosed in 68/220 patients (31%, 95%CI 0.25-0.37) who underwent neuroimaging at ICU admission and in 75/110 patients (68%, 95%CI 0.59-0.77) who underwent neuroimaging during ICU stay. At 90 days, 103 patients (44%, 95%CI 37-50) had unfavorable outcome, including 71 (30%) deaths. The most frequent intracranial complications were ischemic lesion (69/237 patients, 29%), diffuse cerebral oedema (43/237, 18%) and ventriculitis (36/237, 15%). Through multivariable analysis, we found that intracranial complications (adjusted odds ratio (aOR) 2.88, 95%CI 1.37-6.21) were associated with unfavorable outcome, along with chronic alcohol consumption (aOR 3.10, 95%CI 1.27-7.90), chronic vascular disease (aOR 4.41, 95%CI 1.58-13.63), focal neurological sign(s) (aOR 2.38, 95%CI 1.11-5.23), and cerebrospinal fluid leukocyte count < 1000 cell/microL (aOR 4.24, 95%CI 2.11-8.83). Competing risk analysis, with persistent disability (mRS score 3-5) as the primary risk and ICU-death as the competing risk, revealed that chronic alcohol consumption was the sole significant variable associated with persistent disability at 90 days (cause-specific hazard ratio 4.26, 95%CI 1.83-9.91), whereas the remaining variables were associated with mortality.

Conclusions: In adults with severe pneumococcal meninigitis, intracranial complications were independently associated with a higher risk of poor functional outcome, in the form of persistent disability or death. This study highlights the value of neuroimaging studies in this population, and provides relevant information for prognostication.