Annals of Intensive Care最新文献

Background: Sepsis-associated acute kidney injury (SA-AKI) is strongly associated with increased mortality in critical patients. The early detection of SA-AKI is crucial for clinical intervention. This study aims to integrate multiple metabolomics data related to SA-AKI to identify and validate novel metabolic markers.

Methods: Real-time glomerular filtration rate (RT-GFR) measurement was adopted to establish SA-AKI mice. Untargeted metabolomics sequencing was performed on SA-AKI mice renal tissue (Control-LPS-8 h-LPS-24 h, N = 4) and urine samples (Control group vs. LPS-24 h group, N = 6). Time series analysis and random forest algorithm were employed to identify key metabolic molecule. Subsequently, renal spatiotemporal metabolomics was used to explore the specific distribution of key molecule. Eventually, a clinical cohort (20 healthy volunteers vs. 30 sepsis patients vs. 45 SA-AKI patients) urine quantitative metabolomic analysis was carried out to validate it as a biomarker and construct a diagnostic model via logistic regression (LR).

Results: Forty-two key renal metabolites and top fifty urinary metabolites were determined through multidimensional metabolomics study of SA-AKI mice. Urinary 3-Methylhistidine (3-MH) was charactered as a potential biomarker. The distribution of 3-MH increased in collecting ducts through renal spatiotemporal metabolomics sequencing. Then, we recruited 95 urine samples to validate its diagnostic performance (AUC = 0.86, 95% CI 0.77-0.95) and its role as an independent predictive factor for SA-AKI (OR = 0.21, 95% CI: 0.05-0.84, p < 0.05). Ultimately, a diagnostic model combined urinary 3-MH with clinical variables was constructed to identify SA-AKI (AUC = 0.89, 95% CI 0.74-1.00).

Conclusions: We proposed that urinary 3-Methylhistidine has potential diagnostic value for SA-AKI screening. Future studies will focus on its performance in other clinical populations to comprehensively evaluate its diagnostic role.

Background: Pre-clinical studies have suggested the benefits of therapeutic hypothermia in cardiogenic shock (CS). However, current evidence on its efficacy and safety in CS remains limited.

Methods: We performed a systematic review and meta-analysis to assess efficacy/safety of hypothermia in CS. PUBMED/EMBASE/Cochrane/Scopus/Web of Science were searched from inception to December 31, 2024, for studies evaluating outcomes of hypothermia in CS. Efficacy outcome was all-cause mortality. Safety outcomes included pneumonia, sepsis, and bleeding.

Results: Seven studies including 695 patients were analyzed. Acute myocardial infarction (AMI)-related CS was the primary etiology in 363 patients (52.2%). Hypothermia was not associated with a significant reduction in all-cause mortality at 30 days (OR 0.83 [0.54-1.26] or at the longest available follow-up (IRR 0.85 [0.72-1.01]). No significant differences were observed for pneumonia (OR 1.44 [0.42-4.87]), sepsis (OR 0.61 [0.01-46.80]), or bleeding (OR 1.36 [0.65-2.89]). Meta-regression suggested that hypothermia may be less beneficial and riskier in patients with AMI-CS, whereas greater benefit was observed in those with mechanical circulatory support. Trial sequential analysis indicated that the cumulative Z-curve for hypothermia did not cross the boundary for benefit, nor the futility boundary, suggesting that current evidence remains inconclusive and underpowered.

Conclusion: In this meta-analysis, therapeutic hypothermia appeared safe but failed to show a significant reduction in all-cause mortality in patients with CS, albeit with very low certainty of evidence. Larger RCTs are warranted to clarify its clinical utility.

Background: Postoperative pulmonary complications (PPCs) after major upper abdominal surgery are an important cause of morbidity and mortality. However, existing preoperative risk models inadequately address perioperative factors. Although diaphragmatic ultrasonography offers real-time assessment of respiratory muscle function, its predictive utility for PPCs remains underexplored. This study aimed to evaluate the predictive value of diaphragmatic ultrasound parameters for PPCs and to identify the optimal index among them.

Methods: This prospective observational cohort study included patients aged ≥ 50 years who underwent elective upper abdominal surgery under general anesthesia. Right-sided diaphragmatic ultrasound evaluations were performed on preoperative day 1 (PreD1) and on postoperative day 1 (POD1), and measured diaphragm thickening fraction (DTF) and diaphragmatic excursion (DE) during quiet, deep, and sniff breathing. Patients were followed up for 14 days after surgery to assess the incidence of PPCs. Receiver operating characteristic (ROC) analysis and multivariate logistic regression were used to evaluate predictive performance and adjust for confounders.

Results: Among the 223 patients enrolled, 37 (16.6%) developed PPCs. In the entire cohort, all parameters of diaphragmatic ultrasound showed significant postoperative reductions on POD1 compared to preoperative values (P < 0.001). ​A composite index (post-RDS-DE), calculated as the sum of right DEs during deep breathing and sniff breathing on POD1, demonstrated a moderate predictive ability for PPCs (AUC = 0.680, 95% CI: 0.587-0.773). At a cutoff value of post-RDS-DE < 3.55 cm, the negative predictive value reached 90.6%. ​​After multivariable adjustment, post-RDS-DE < 3.55 cm remained an independent predictor of PPCs (adjusted OR = 2.547, 95% CI: 1.067-6.080; P = 0.035).​​ Integration of diaphragmatic ultrasound index (post-RDS-DE < 3.55 cm) with the ARISCAT significantly improved predictive performance (AUC = 0.751 with integrated model vs. 0.643 with ARISCAT alone; DeLong's P = 0.004).

Conclusions: Postoperative maximal inspiratory diaphragmatic ultrasound measurements during deep and sniff breathing (quantified by a composite index, the post-RDS-DE) effectively predict PPCs following upper abdominal surgery. Integration of post-RDS-DE with preoperative ARISCAT markedly enhances predictive accuracy, suggesting diaphragmatic ultrasonography as a bedside tool for perioperative respiratory risk assessment.

Background: Mechanical ventilation is a critical yet labor-intensive medical resource with limited availability. However, population-based data on its utilization and outcomes remain scarce in China. This study aimed to describe the characteristics, frequency, and outcomes of mechanical ventilation at the national level in China.

Methods: In this multicenter cross-sectional study, we retrospectively identified hospitalized patients who received mechanical ventilation using data from the National Data Center for Medical Service. The dataset included information on patient characteristics, length of hospital stays, procedures, diagnoses, and discharge outcomes. The population selected for this study included all mechanically ventilated patients admitted between January 1, 2022 and December 31, 2022. We analyzed the distribution characteristics of patients requiring mechanical ventilation by type of ventilation. Case fatality rates were calculated and further stratified by age, sex, and comorbidity burden.

Results: The study included 1,641,809 admissions from 2,837 hospitals, with all patients receiving mechanical ventilation. The median age of the patients was 66.0 years (interquartile range: 51.0-76.0). Among them, 64.4% received invasive mechanical ventilation (IMV) only, while 29.0% received non-invasive ventilation (NIV) only. The incidence of mechanical ventilation was 186.5 per 100,000 population. Patients receiving IMV only had longer hospital stays and a higher comorbidity burden, compared with those receiving NIV. 41.4% of invasively ventilated patients had a diagnosis of cerebrovascular disease. In contrast, chronic pulmonary disease was the most common comorbidity (57.0%) in NIV patients. The NIV failure rate observed in our study was 7.9%. Overall, 12.8% of mechanically ventilated patients died during hospitalization, with a marked difference in case fatality rate between IMV patients (16.2%) and those receiving NIV only (5.5%). Increasing age and a higher Charlson index were both associated with a stepwise increase in mortality risk.

Conclusions: Significant variations in epidemiological characteristics by age, sex, and comorbidity were observed across different modalities of mechanical ventilation. Mortality rates were markedly higher among patients receiving IMV compared to those receiving NIV, with the differences most pronounced among elderly patients, males, and those with greater comorbidity burden.

Background: As healthcare emerges as the world's fifth-largest carbon emitter, intensive care units (ICUs) represent environmental challenges due to their high resource consumption and energy demands. Reducing greenhouse gas (GHG) emissions is necessary to limit global warming. This study aimed to quantify the carbon footprint of ICU care during the first 24 h of admission for trauma patients. By establishing a baseline "carbon cost" for ICU trauma care, we seek to provide a framework for future studies assessing sustainable care strategies.

Methods: We conducted a prospective observational pilot study in a French trauma ICU, categorizing patients into three standardized care pathways. The GHG emissions have been quantified using a hybrid life cycle assessment approach across various scope categories. Statistical analyses included correlation testing between the different groups and severity scores.

Results: Total carbon footprints ranged from 86 to 248 kg of CO₂e per patient over the first 24 h. Medications, medical devices, and transportation were the primary contributors, while energy and waste represented a smaller portion of the emissions. There was a significant positive correlation between emissions and severity scores.

Conclusion: The carbon footprint of ICU care of a trauma patient during the first 24 h is significant, and it is necessary to conduct assessments in each ICU to identify levers for environmental improvement. The carbon cost should be integrated into the standardization of care and research protocols to enable more sustainable care practices.

Background: Sepsis is the leading cause of Intensive Care Unit (ICU) admissions in kidney transplant recipients (KTRs). However, the optimal immunosuppressive therapy (IST) management in this context is not well-defined. We aimed to evaluate the impact of IST management in the ICU on mortality rates and kidney graft function 6 months after inclusion in KTRs admitted for sepsis.

Methods: We conducted a multicenter, prospective, observational study over 1 year in 11 French ICUs. Inclusion criteria were all KTRs who have been transplanted for at least 3 months, admitted to the ICU for sepsis. All changes of IST (7 days prior to ICU admission or throughout the ICU stay) were collected. The primary outcome was MAKE 180 (Major Adverse Kidney Event), a composite outcome including mortality, kidney graft dysfunction and dialysis requirement at 180 days after inclusion.

Results: One hundred and twenty-four patients were included. The main cause of ICU admission was respiratory failure for 78 patients (62.9%). Predominant IST management was mycophenolic acid (MPA) discontinuation for 74 patients (59.7%) and calcineurin inhibitor (CNI) continuation for 63 patients (50.8%). By multivariable analysis, after adjustment for age, non-renal SOFA score at admission, kidney function at admission, sex, and history of cellular rejection we did not find any significant association between MAKE 180 and CNI discontinuation (adjusted OR = 1.05, 95% CI 0.87-1.26, p = 0.6). In contrast, MPA discontinuation was significantly associated with MAKE 180 (adjusted OR = 1.45, 95% CI 1.07-1.96, p = 0.018). No significant association was found between IST discontinuation and ICU-acquired infections (adjusted OR = 1.14, 95% CI 0.95-1.36, p = 0.157). Among ICU survivors, only 2 graft rejections occurred during the year following ICU discharge.

Conclusion: This study is the first prospective investigation to suggest an association between MPA discontinuation and adverse outcomes during sepsis in critically-ill KTRs. These findings must be interpreted with caution given the potential confounding introduced by SARS-Cov-2-specific treatment protocols. Further interventional trials are necessary to optimize immunosuppressive drug strategies in KTRs during sepsis.

The pressure-flow relationship is fundamental to circulatory hemodynamics of any organ. In the kidney, renal perfusion pressure (RPP), defined as the gradient between mean arterial pressure and renal venous pressure or mean systemic filling pressure, serves as the principal driving pressure for renal blood flow (RBF). This concept recognizes that both arterial hypotension and venous congestion can reduce the pressure gradient for renal perfusion, potentially contributing to renal dysfunction or acute kidney injury (AKI). In health, whenever RPP fluctuates, the kidney autoregulates intrarenal vascular resistance to maintain stable RBF and glomerular filtration rate over a range of RPP. However, in critical illness, autoregulatory capacity may be impaired, and the degree of impairment can vary not only between patients but also within the same patient depending on the disease context or stage of illness. Therefore, during critical illness, inadequate RPP tends to overwhelm renal autoregulation capacity earlier than anticipated, leading to tissue hypoperfusion and increased risk of AKI. Relying on standard blood pressure targets to optimize RPP may not account for such inter- or intra-individual variations in autoregulation. Experimental models have shown that AKI can develop without overt macrocirculatory changes, implicating microcirculatory dysfunction as an important contributor too. Dynamic, multi-modal assessment of renal perfusion may offer a more precise approach to renal protection. Additionally, the focus of research has shifted towards providing new insights into individualized perfusion targets and refining RPP-guided strategies to prevent AKI among high-risk patients in ICU. The objective of this review is to describe the role of RPP, implications of dysregulated renal perfusion, approaches to monitoring renal perfusion, and potential therapies targeting RPP on the horizon for critically ill patients.

Background: Pneumocystis jirovecii pneumonia (PjP) is a rising cause of acute respiratory failure in immunocompromised patients, often requiring Intensive Care Unit (ICU) admission. However, optimal ventilatory strategies remain unclear.

Methods: For the present study, we conducted an ancillary analysis of the PRONOCYSTIS study, a large multicenter cohort of PjP patients. Patients admitted to the ICUs were compared according to initial respiratory management (High-Flow Nasal Cannula (HFNC), standard Oxygen (SO) or Non-Invasive Ventilation (NIV). A propensity score adjustment [inverse probability of treatment weighting (IPTW) analysis] was implemented to account for potential confounders. The primary outcome was intubation rate. Univariable and multivariable Cox regressions were also used to assess variables associated with survival.

Results: Over the study period, 248 patients with PjP were included in the present analysis. Of those, 70 were treated by HFNC while 118 and 60 received SO and NIV, respectively. HFNC patients had a decreased intubation rate (28.6% versus 45.0% in NIV and 55.4% in SO patients; p = 0.003). When assessing the impact of respiratory management on intubation by IPTW, HFNC remained an independent protective factor (weighted Hazard Ratio (HR) 0.41 (95% CI 0.24-0.69); p < 0.001). While, NIV was not associated with intubation (HR 0.62 (95% CI 0.37-1.02); p = 0.056). Through adjusted survival analysis, long-term corticosteroids treatment (aHR 4.03 (95% CI 2.01-8.08); p < 0.001), Solid tumor (aHR 3.37 (95% CI 1.45-7.86); p = 0.005) and the Sequential Organ Failure Assessment score (aHR 1.24 (95% CI 1.15-1.35); p < 0.001) were found to be independent predictor for death. Initial respiratory support was not associated with survival either in the Cox multivariable analysis or in the IPTW analysis.

Conclusion: Through this multicenter observational study of severe PjP patients, although oxygenation strategy was not associated with D90 survival, HFNC support appeared to be associated with a lower intubation rate. Further prospective studies are warranted to refine respiratory management in critically ill PjP patients.