Annals of Intensive Care最新文献

Background: Data on severe hemoptysis (SH) in the intensive care unit (ICU) remain scarce. We aimed to describe its clinical characteristics, etiologies, management strategies, and outcomes. This retrospective observational study analyzed patients admitted for SH to a referral center between 2009 and 2019. Data were compared to a historical cohort (1995-2009) using the Cochran-Armitage test.

Results: A total of 945 patients (75% males; median age 55 years [IQR 42-65]) were analyzed; 67% had respiratory comorbidities. Invasive mechanical ventilation was required in 13% within 24 h of ICU admission. Lung cancer was the leading cause of SH, followed by bronchiectasis, tuberculosis, pneumonia, and aspergillosis. Compared with the historical cohort, pneumonia-related hemoptysis increased (11% vs. 5%; P < 0·001), as did pulmonary arterial involvement (12% vs. 5%; P < 0·001), mainly associated with pneumonia (23%), cancer, or aspergillosis (each 20%). Vascular interventional radiology (VIR) was first attempted in 81% of cases, achieving bleeding control in more than 90% of cases. Major adverse events occurred in 4.4% of cases. Emergent surgical lung resection (within 72 h) was performed in 2% of cases, all after VIR. In-hospital mortality rate increased slightly (8.7% vs. 6.5%; P = 0.08).

Conclusions: Over the past decade, lung cancer became the leading cause of SH, with pneumonia increasingly contributing to pulmonary arterial involvement, reinforcing the need for multi-detector computed tomography angiography (MDCTA) screening. The high success rate of VIR confirms its key role, while surgery remains limited to rare cases. In-hospital mortality slightly increased, driven by a higher proportion of lung cancer.

The emergence and validation of capillary refill time (CRT) as a resuscitation target together with its rapid kinetics of response to increases in systemic blood flow makes it the ideal variable to assess clinical reperfusion and the status of macro-to-microcirculatory coupling in septic shock. Moreover, previous studies have shown that resuscitation can be safely stopped after CRT normalization, thus decreasing the risk of over-resuscitation. From a physiological point of view, CRT is a complex variable integrating microvascular flow and reactivity. Additionally, it may be understood as a dynamic test that evaluates the preservation or disruption of normal responses of the microcirculation to maintain blood flow after transient ischemic challenges. The relationship between systemic hemodynamics and CRT is complex. Indeed, single time-point asssessments of CRT are not able to predict absolute cardiac output values and this is logical since they belong to different phsyiological categories. An abnormal CRT may be explained by insufficient macrohemodynamic resuscitation but also by several derangements at the microvascular level that may preclude CRT normalization, thus signaling a state of macro-to-microcirculatory uncoupling. CRT response to an acute fluid or mean arterial pressure challenge, may not only reveal the adequacy of systemic blood flow but also contribute to tailor interventions to personalize septic shock resuscitation. The lack of CRT response to these challenges discloses a more complex pathophysiological condition that is associated with higher mortality. Further research efforts should be focused on better understanding the factors associated with CRT non-response as a first step to develop a more phsyiologically-based resuscitation, that could eventually improve outcomes.

Background: Intensive Care Unit (ICU) patients often experience significant discomfort and distress due to both the medical environment and the nature of their stay. While long-term sequelae such as depression, anxiety, and post-traumatic stress are well-documented, few studies have examined psychological disorders present at the time of ICU discharge. Based on the model of Post-Intensive Care Syndrome, specifically the mental component (PICS-M), we defined DICS-M (Discharge Intensive Care Syndrome - Mental component). This study aimed to estimate the prevalence of psychological disorders at ICU discharge and to identify potential mediators and risk factors.

Methods: We conducted a prospective observational study involving 243 patients admitted between January 2023 and April 2024.

Results: The prevalence of DICS-M was 53% [95% CI: 46-59], with acute stress, anxiety, and depression observed in 37%, 36%, and 23% of patients, respectively. The analyses revealed an overlap among these psychological components. Peritraumatic distress acted as the main mediator of DICS-M. Univariate and multivariable analyses identified female gender and a history of psychiatric and cardiac conditions as risk factors of DICS-M.

Conclusion: Psychological disorders are common at ICU discharge, mediated by peritraumatic distress, and associated with identifiable risk factors. These findings may help guide interventions to prevent long-term sequelae of ICU stays.

Background: Families confronting the death of a loved one in the intensive care unit (ICU) are at greater risk of experiencing complicated grief than families bereaved in other circumstances. The primary objective of this scoping review was to identify interventions that have been explored in the literature for supporting ICU bereaved families. Secondary objectives were to map the findings to a core outcome set (COS) developed to measure bereavement interventions for adults, and to identify existing knowledge gaps, with particular attention to considerations of equity, diversity, and inclusion (EDI).

Methods: We searched five electronic databases: Web of Science, CINAHL, EMBASE, APA PsycInfo, and MEDLINE. Primary research articles that described bereavement program(s) and/or support(s) for bereaved loved ones in the setting of an adult ICU were included. We extracted data on study aims, methods, setting, patient and bereaved loved one demographics, design, analysis, and results. Four reviewers independently screened references and performed data extraction.

Findings: We identified 11 bereavement interventions, including memorial services, condolence letters/sympathy cards, mementos, ICU diaries completed by staff or family, storytelling interventions, personalized/individual final wishes, information booklets/referrals to resources, meetings with ICU professionals, follow up telephone calls, training for staff, and other specific interventions. Most studies (35 out of 39) reported outcomes that aligned with a previously developed COS. Only three studies addressed cultural diversity in the development or implementation of bereavement interventions.

Conclusions: This scoping review summarizes the range of bereavement interventions described in the literature and highlights key areas for future development, including cultural inclusivity in the development and implementation of interventions, and the use of standardized outcomes for evaluation.

Registration: The protocol is registered on the Open Science Framework ( https://osf.io/ue7t9 ).

A fundamental objective of hemodynamic resuscitation is to reverse tissue hypoperfusion and prevent progression to multiorgan failure and death. Conventional tools such as clinical examination, lactate levels, and central or mixed venous oxygen saturation (ScvO₂ and SvO₂, respectively) have intrinsic limitations. These drawbacks can be mitigated by incorporating additional markers of tissue hypoperfusion and altered tissue metabolism, such as carbon dioxide (CO₂)-derived variables, into other multimodal macro and micro hemodynamic monitoring. Specifically, the mixed or central venous-to-arterial difference in partial pressure of CO₂ (Pv-aCO₂ or Pcv-aCO₂) reflects the adequacy of blood flow to transport CO₂ from peripheral tissues to the lungs for its elimination. Consequently, Pv-aCO₂ serves as a reliable marker for assessing the adequacy of blood flow relative to CO₂ production. Importantly, unlike SvO₂ and ScvO₂, Pv-aCO₂ remains informative even when oxygen extraction is impaired, as commonly occurs in septic conditions. However, Pv-aCO₂ and Pcv-aCO₂ in isolation are not direct markers of anaerobic metabolism, as these can also be influenced by oxygen consumption rates. Conversely, the ratio between Pv-aCO₂ (or Pcv-aCO₂) and the arteriovenous oxygen content difference may provide a more reliable indication of ongoing anaerobic metabolism. This review discusses the physiological foundations, prognostic significance, clinical implications, and potential applications of CO₂-derived parameters in patient management.

Background: Neurological complications significantly contributed to mortality in patients with acute respiratory distress syndrome (ARDS) supported by venovenous extracorporeal membrane oxygenation (VV ECMO). Early fluctuations in arterial partial pressure of carbon dioxide (PaCO₂) during ECMO initiation may have affected cerebral perfusion and increased the risk of brain injury. This study investigated the association between early changes in PaCO₂ and pH levels and subsequent neurological outcomes in patients with ARDS receiving VV ECMO.

Methods: We conducted a retrospective cohort study using data from adult ARDS patients who underwent VV ECMO between January 2018 and December 2022, sourced from the Chinese Society of Extracorporeal Life Support (CSECLS) Registry. Patients were stratified into clusters based on absolute changes in PaCO₂ and pH using K-means clustering. Logistic regression models and restricted cubic splines were used to evaluate the associations between these clusters and the occurrence of neurological complications, adjusting for potential confounders.

Results: Among 983 patients included, the incidence of neurological complications was 2.95%. Cluster 1, characterized by significant reductions in PaCO₂ (median: -50 mmHg, relative reduction: -58%), exhibited the highest rate of neurological complications (11.94%). Cluster 3, with substantial increases in pH and minimal reductions in PaCO₂, showed a relatively lower rate of neurological complications (3.96%), suggesting that PaCO₂ fluctuations, rather than pH changes, were primarily associated with neurological complications.

Conclusions: Excessive reductions in PaCO₂ during the early initiation of VV ECMO, rather than pH elevation, were associated with an increased risk of neurological complications in ARDS patients. Close monitoring and management of PaCO₂ during ECMO initiation may mitigate this risk.