Annals of Intensive Care最新文献

Background: Sepsis is characterized by a dysregulated immune response to infection, with a balance between hyperinflammation and immunosuppression, which determines the patient's immune status. Real-time monitoring of the immune status in sepsis is crucial for guiding immunotherapy. However, reliable biomarkers are lacking. This study aims to identify a panel of biomarkers for rapid bedside assessment of immune status in sepsis to guide immunotherapy decisions.

Results: TBX21, GNLY, PRF1, and IL2RB represent the immune status in sepsis. These genes demonstrated discriminatory power in the external validation, with area under the curve values ranging from 0.891 to 0.909 across several machine learning models. 99 double-blind randomized patients with sepsis were clustered into two endotypes on the basis of the expression of the four-gene panel. Higher 90-day mortality was observed in patients with sepsis treated with hydrocortisone (Odds ratio 12.46, 95% confidence intervals 3.11 to 65.72) or thymosin (Odds ratio 4.17, 95% confidence intervals 1.13 to 16.51) within the high-expression 4-gene panel endotype, but not in another endotype.

Conclusions: The results support the potential utility of a four-gene panel to assess immune status and guide immunotherapy; further prospective validation and translational studies are warranted. Trial registration National Medical Research Registration and Filing Information of China, 2022ZDSYLL196-P01. Registered 26 May 2023, https://www.medicalresearch.org.cn/login.

Background: Patients with septic shock who survive the early resuscitation phase are prone to ICU-acquired infections. Although hyperglycemia harbors potent immunomodulatory properties, the impact of preexisting diabetes and the control of acute stress-induced hyperglycemia on the risk of further infections remains unclear.

Materials and methods: We conducted a retrospective (2008-2023) single-center study in patients with septic shock who remained alive in the ICU after 72 h. Glycemic control was assessed during the first 72 h. Mild and severe hyperglycemia were defined by blood glucose levels > 8 mmol/L and > 10 mmol/L, respectively. Poor glycemic control was defined when blood glucose levels were above 8 mmol/L for more than 20% of time. The primary outcome was ICU-acquired infections.

Results: The study involved 901 patients, with preexisting diabetes present in 22% of them. Most patients (71%) experienced hyperglycemic episodes > 8 mmol/L, prompting fast-acting insulin treatment. ICU-acquired infections developed in 243 patients (26.9%), with median time from ICU admission to diagnosis of 9 days, interquartile range [6-13]. There was no association between preexisting diabetes and ICU-acquired infections. Patients with further ICU-acquired infections displayed poorer control of stress-induced hyperglycemia, with longer exposure to hyperglycemia (78% with mild or severe hyperglycemia for more than 20% of time compared to 68% of patients without subsequent infections (p = 0.005)). Poor glycemic control was independently associated with the development of ICU-acquired infections.

Conclusion: 72-hour poor glycemic control, but not preexisting diabetes, was independently associated with an increased risk of ICU-acquired infections in septic shock patients and may therefore contribute to the post-aggressive immunosuppressive response. This argues for effective glycemic management to improve outcomes in this setting.

Objective: To understand the impact of obesity on outcomes of weaning from invasive mechanical ventilation (MV).

Methods: The study population consisted of patients enrolled in the WEAN SAFE study. We defined 4 groups based on body mass index (BMI), namely: Normal weight (BMI 18.5-24.9 kg/m²), Overweight (BMI 25-29.9 kg/m²), Obesity Class I (BMI 30-34.9 kg/m²), and obesity classes II and III (BMI ≥ 35 kg/m²). The primary outcome was the rate of successful extubation in patients in each BMI group. Secondary outcomes included the ICU and hospital survival, and PEEP levels at time of weaning eligibility in patients in each BMI group.

Results: In the study population, 1728 (38.2%) were of normal weight, 1395 (30.8%) were overweight, 590 (13.1%) were class I Obesity, and 431 (9.5%) were obesity classes II and III. Patients with obesity were more likely to be female, to be a medical admission, and to have comorbidities. Patients with grade II-III obesity had lower levels of sedation, later timing of the first separation attempt, longer time to weaning success, they received more noninvasive ventilation post extubation, and they had a longer ICU stay. In contrast, weaning success, and ICU and hospital mortality rates were not different in obese patients. There was no independent relationship between obesity and weaning delay, weaning success, or with overall survival outcomes. Higher PEEP at weaning eligibility was associated with weaning failure in normal and overweight patients but not in patients with obesity.

Conclusions: Patients with obesity had a more complex and longer weaning process, but obesity per se was not independently associated with adverse weaning outcomes.

Severe polytrauma and hemorrhage is a common and life-threatening condition often leading to intensive care unit admission for those who survive their initial injury. The injury itself, hypoperfusion from hemorrhagic shock, and resuscitative efforts introduce a complex set of hemostatic derangements collectively referred to as trauma-induced coagulopathy (TIC). Although the trauma population is notoriously heterogenous, TIC can generally be divided into an "early" hypocoagulable phase and then a "late" hypercoagulable, prothrombotic phase. Existing literature on TIC focuses heavily on reversing and preventing hypocoagulation in the early, acute phase. However, intensivists commonly manage patients throughout the later post-acute resuscitation phase of TIC, during which thrombotic complications are common and may lead to major morbidity and mortality. Derangements in platelet activation, endothelial dysfunction, suppression of fibrinolysis, and crosstalk between the innate immune and coagulation systems all contribute to the prothrombotic late TIC phenotype. Deep venous thrombosis and other macrovascular thrombotic complications also commonly occur after trauma. Thrombosis prophylaxis and treatment present a challenge for patients still at high risk for bleeding. An in-depth understanding of risk factors specific to trauma patients, including iatrogenic contributions from resuscitation and hemostatic efforts in the pre-intensive care phase, can help stratify thromboembolic risk and optimize prophylaxis and surveillance efforts. We stress the importance of an individualized approach to assessment of hemorrhagic and thrombotic risks for each patient. Here, we summarize the underlying contributors to the prothrombotic phenotype in late TIC, including a description of emerging roles for HMGB1, extracellular vesicles, and endogenous inhibitors. Additionally, a general approach to thromboprophylaxis, monitoring, and anticoagulation in this patient population are discussed. Finally, we summarize relevant risk stratification systems and guidelines for clinical management of thromboembolic risk among trauma patients, and highlight limitations in these systems and guidelines as areas for future research.