Annals of Intensive Care最新文献

Background: Approximately half of the patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) remain ECMO-dependent beyond 14 days after ECMO initiation. The identification of factors associated with mortality during an ECMO run may update prognostic assessment and focus clinical interventions.

Methods: In this observational study, data from 1137 patients with COVID-19 ARDS receiving ECMO support in 29 German centers between January 1st 2020 and July 31st 2021 were analyzed. Multivariable stepwise logistic regression analyses were performed to build survival prediction models with day-by-day data during the first 14 days of an ECMO run. The primary endpoint was all-cause mortality in the intensive care unit.

Results: Mortality in this cohort was high (75%). Patients who remained ECMO-dependent on day 14 of their ECMO run showed comparable mortality to all patients receiving ECMO support on day 1. Yet, factors associated with mortality changed during the first 14 days of ECMO support. On day 1 of ECMO support, only patient age and lactate remained in the final mortality prediction model. On day 14 of an ECMO run, tidal volume was independently associated with mortality (adjusted Odds Ratio 0.693 (95%CI 0.564-0.851), p < 0.001 for 1 mL/kg increase in tidal volume per predicted body weight). The adjusted mortality for patients with a tidal volume below 2 mL/kg on day 14 of their ECMO run was above 80% (lower limit of the 95%CI interval). Higher tidal volume was mainly based on higher respiratory system compliance. Yet, the benefit of higher compliance was not observed in some patients who were still ventilated with very low driving pressures despite remaining ECMO-dependent on day 14 of ECMO support.

Conclusions: Mortality predictors change during the course of an ECMO run. In a cohort with high mortality, on day 14 of ECMO support for ARDS, tidal volume may be an independent predictor of mortality. Further analyses on ventilation strategies in patients who remain ECMO-dependent are needed.

Trial registration number: DRKS00022964, retrospectively registered.

Background: Vasoplegia is characterised by persistent hypotension and reduced systemic vascular resistance despite preserved cardiac output, commonly arising in sepsis, following major surgery, and within systemic inflammatory responses. Despite its clinical significance and association with poor outcomes, there is no universally accepted definition or standardised biomarker, impeding early diagnosis, stratification, and targeted therapy. While individual studies have examined biomarkers within specific clinical contexts such as septic shock or cardiac surgery, no comprehensive synthesis across all aetiologies of vasoplegia has previously been undertaken.

Objectives: To systematically evaluate and synthesise the current evidence regarding circulating biomarkers associated with the incidence, severity, prediction, and progression of vasoplegia across diverse critical care and perioperative populations. As well as review definitions used across literature.

Methods: This systematic review was conducted in accordance with PRISMA 2020 guidelines and registered on PROSPERO (CRD42024438786). Studies were included if they investigated adult patients in critical care or perioperative settings with vasoplegia defined by reduced vascular resistance and hypotension requiring vasopressors.

Results: A total of 43 studies met inclusion criteria. The included studies examined 39 unique biomarkers, with renin and adrenomedullin being the most frequently studied. Heterogeneity in definitions of vasoplegia, outcome measures, and comparator populations precluded meta-analysis. However, several biomarkers demonstrated potential clinical utility: elevated renin levels correlated with vasopressor requirements and haemodynamic instability, while adrenomedullin levels were predictive of vasoplegia development and duration.

Conclusions: The lack of standardisation in biomarker assay methods and vasoplegia definitions remains a significant barrier to comparative analysis. Whilst this review highlights renin and adrenomedullin as promising candidate biomarkers for vasoplegia, the heterogeneity in study design, biomarker measurement, and diagnostic criteria underscores the urgent need for a consensus definition of vasoplegia, standardised sampling protocols, and unified outcome measures. Future research should focus on biomarker-guided risk stratification and personalised therapies, with an emphasis on validating predictive and mechanistic roles across diverse vasoplegic phenotypes.

Background: The optimal mechanical ventilation strategy to minimise ventilator-induced lung injury (VILI) remains uncertain. Mechanical power (MP) is a key VILI determinant, but whether and how MP should be normalised to individual patient characteristics is unclear. In this study, we aimed to evaluate whether the discriminatory accuracy of MP for ICU mortality in mechanically ventilated patients improves when normalised to physiologically relevant variables that reflect individual susceptibility to VILI. We also explored whether the relationship between MP, MP_ratio, and mortality is linear or exhibits a threshold effect.

Methods: In this retrospective observational study, we extracted granular electronic healthcare record data for mechanically ventilated adults in a single centre over a seven-year period. Primary exposures were MP with five normalisations: for dead space (expressed as corrected minute ventilation, ventilatory ratio, or end-tidal to arterial CO₂ ratio); aerated lung size (compliance), and normal idealised MP (MP_ratio). We used logistic regression to assess associations with ICU mortality. We calculated the Area Under the Receiver Operating Characteristic Curve (AUROC) to compare discriminative accuracy of individual models. Additionally, we evaluated the linearity or presence of a threshold for the relationships between MP, MP_ratio and ICU mortality.

Result: We included 3,578 patients in our analyses. We found MP normalised to compliance (AUROC 0.71, 95% confidence interval (CI) 0.69-0.73, p = 0.007 (DeLong's test)) and MP_ratio (AUROC 0.71, 95% CI 0.68-0.73, p = 0.0014) performed better than MP alone (AUROC 0.69, 95% CI 0.66-0.71) for predicting ICU mortality. Other methods of MP normalisation were no more discriminative than MP without normalisation. The relationship between MP and MP_ratio with ICU mortality showed a statistically significant but small departure from linearity.

Conclusions: Mechanical power normalised to compliance and MP_ratio had better discrimination for ICU mortality than MP, although the difference was modest and absolute predictive power remained limited.

Background: Sepsis-induced myocardial dysfunction (SIMD) remains poorly defined due to scarce longitudinal studies with advanced echocardiography. We characterized SIMD progression using speckle tracking echocardiography (STE).

Methods: Prospective single-center study in septic shock patients admitted to intensive care. SIMD was defined as any left ventricular (LV, systolic and/or diastolic) and/or right ventricular (RV) systolic dysfunction, using STE or non-STE criteria, on days 1, 7 and 30. We studied prevalence, evolution and prognosis of SIMD classified with either criteria using Cox regression.

Results: Ninety-eight consecutive patients were included. On day 1, SIMD was identified in n = 57/98 (58.2%) and n = 70/98 (71.4%;p = 0.072) by non-STE and STE parameters, respectively. No significant difference in diagnosis was seen for LV diastolic dysfunction: n = 50/98 (51.0%, non-STE) vs. n = 51/98 (52.0%, STE; p = 1.00). Prevalences of LV and RV systolic dysfunction were not significantly higher with STE criteria: n = 59/98 (60.2%, STE) vs. n = 47/98 (48.0%, non-STE; p = 0.115) for LV; n = 39/98 (39.8%, STE) vs. n = 27/98 (27.6%, non-STE; p = 0.096) for RV. More patients recovered from SIMD when evaluated with non-STE criteria at day 7 (35.3% vs. 17.5% STE; p = 0.033), but not at day 30 (24.5% vs. 18.8% STE; p = 0.501). The 30-day mortality (n = 33/98, 33.7%) was associated with SIMD diagnosed using non-STE (p = 0.010), but not with STE (p = 0.057). In Cox regression, only LVDD by non-STE criteria predicted 30-day mortality (p = 0.005).

Conclusions: The incidence of SIMD in septic shock is higher when using STE criteria, with lower reversibility in the first week. A broad definition of SIMD utilizing STE criteria does not seem to provide additional prognostic value.

Trial registration: ClinicalTrials.gov: NCT05552521 registered on the 20th of September 2022.