CHEST critical care最新文献

Background

Sepsis is one of the most common reasons for ICU admission and a leading cause of mortality worldwide. More than one-half of survivors experience significant physical, psychological, or cognitive impairments, often termed post-intensive care syndrome (PICS). Sepsis is recognized increasingly as being associated with a risk of adverse cardiovascular events that is comparable with other major cardiovascular risk factors. It is plausible that sepsis survivors may be at risk of unidentified cardiovascular disease, and this may play a role in functional impairments seen after ICU discharge.

Research Question

What is the prevalence of myocardial dysfunction after an ICU admission with sepsis and to what extent might it be associated with physical impairments in PICS?

Study Design and Methods

Characterisation of Cardiovascular Function in ICU Survivors of Sepsis (CONDUCT-ICU) is a prospective, multicenter, pilot study characterizing cardiovascular function and functional impairments in survivors of sepsis taking place in the west of Scotland. Survivors of sepsis will be recruited at ICU discharge and followed up 6 to 10 weeks after hospital discharge. Biomarkers of myocardial injury or dysfunction (high sensitivity troponin and N-terminal pro B-type natriuretic peptide) and systemic inflammation (C-reactive protein, IL-1β, IL-6, IL-10, and tumor necrosis factor alpha) will be measured in 69 patients at recruitment and at follow-up. In addition, a cardiovascular magnetic resonance substudy will be performed at follow-up in 35 patients. We will explore associations between cardiovascular magenetic resonance indexes of cardiac function, biomarkers of cardiac dysfunction and inflammation, and patient-reported outcome measures.

Interpretation

CONDUCT-ICU will provide data regarding the cause and prevalence of cardiac dysfunction in survivors of sepsis and will explore associations with functional impairment. It will provide feasibility data and operational learning for larger studies investigating mechanisms of functional impairment after ICU admission and the association between sepsis and adverse cardiovascular events.

Trial Registry

ClinicalTrials.gov; No.: NCT05633290; URL: www.clinicaltrials.gov

Background

Convalescent plasma increases SARS-CoV-2 clearance in COVID-19, especially in patients lacking preexisting antibodies.

Research Question

In hospitalized patients with COVID-19 receiving convalescent plasma, does conversion to a positive SARS-CoV-2 IgG status provide mortality benefit in patients who lacked SARS-CoV-2 IgG?

Study Design and Methods

This observational study included consecutive hospitalized patients with COVID-19 who received convalescent plasma under the Expanded Access Program from April through August 2020. SARS-CoV-2 N-based IgG antibody enzyme-linked immunosorbent assay measurements before and after transfusion were recorded. Outcomes of patients without preexisting antibodies who demonstrated seroconversion immediately after receipt of convalescent plasma were compared with those who did not show seroconversion. Hospital mortality was the primary outcome.

Results

Two hundred seventy-five hospitalized patients received convalescent plasma during the study period. SARS-CoV-2 IgG was collected from 234 patients. One hundred ten patients (47%) showed seropositive findings and 124 patients (53%) showed seronegative findings before transfusion. Among the seronegative group, 63 patients (50.8%) demonstrated seroconversion after plasma transfusion, whereas 61 patients (49.2%) continued to show seronegative findings despite transfusion. Age, sex, BMI, Sequential Organ Failure Assessment score, and receipt of high-titer plasma were similar across all subgroups. Seroconversion after transfusion was not associated with survival at hospital discharge (OR, 1.9; 95% CI, 0.7-4.9; P = .17).

Interpretation

Serologic response after transfusion of convalescent plasma was not shown to be associated with hospital survival in patients with COVID-19 without preexisting SARS-CoV2 IgG antibodies.

Background

Venous air embolism (VAE) is an understudied entity. Herein, we summarize VAE case reports and small case series reported in the literature.

Research Question

What are the clinical features, diagnostic approaches, and clinical outcomes of VAE and how do surgery-related VAEs compare with non-surgery-related VAEs?

Study Design and Methods

Using the search terms air, gas, venous, and embolism, 437 articles were identified. After applying predetermined exclusion criteria, we included the 164 articles describing cases of isolated VAE. We extracted data pertaining to patient demographics and clinical presentations; VAE characteristics, for example, cause and clinical context; diagnostic testing and time to diagnosis; and clinical management and outcomes. We used the Shapiro-Wilk test to assess data distribution (ie, normally vs nonnormally distributed), the Pearson χ² test for categorical variables, and the Mann-Whitney U test and t test for continuous variables.

Results

We collated 174 patients; 108 patients (62.1%) were male. Most VAE episodes (n = 160 [92%]) were iatrogenic. Eighty-two patients (47%) experienced respiratory, cardiac, or neurologic symptoms, or a combination thereof, whereas 15 patients (8.6%) were asymptomatic; the remaining patients (n = 77 [44.3%]) had collapsed or been intubated before VAE diagnosis. Most patients (56.9%) were hemodynamically unstable on presentation. Diagnostic and management approaches varied considerably across reports. Of management strategies, oxygen supplementation (Fio₂ = 1.0) and body repositioning were implemented most frequently. Seventy-nine patients (45%) received ICU level of care, 13 patients (7.5%) underwent endotracheal intubation, 39 patients (22.4%) received inotropic support, and 32 patients (18.4%) died. Compared with patients with non-surgery-related VAEs, those with surgery-related VAEs underwent end-tidal CO₂ measurement more frequently (50% vs 3%; P < .001) and showed lower all-cause mortality (11.2% vs 24.5%; P = .01). Time to diagnosis was nonsignificantly shorter in surgery-related episodes. Publication bias is one of our study's limitations.

Interpretation

Approximately one-half of VAEs are nonsurgical. Diagnostic and management strategies varied widely across reports, reflecting disease heterogeneity and inconsistent clinical approach. All-cause mortality was higher for non-surgery-related episodes than for surgery-related episodes. Considering the comparable age, sex distribution, and comorbidities between these two groups, this finding deserves further study.

Background

Providing analgesia and sedation is an essential component of caring for many mechanically ventilated patients. The selection of analgesic and sedative medications during the COVID-19 pandemic, and the impact of these sedation practices on patient outcomes, remain incompletely characterized.

Research Question

What were the hospital patterns of analgesic and sedative use for patients with COVID-19 who received mechanical ventilation (MV), and what differences in clinical patient outcomes were observed across prevailing sedation practices?

Study Design and Methods

We conducted an observational cohort study of hospitalized adults who received MV for COVID-19 from February 2020 through April 2021 within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. To describe common sedation practices, we used hierarchical clustering to group hospitals based on the percentage of patients who received various analgesic and sedative medications. We then used multivariable regression models to evaluate the association between hospital analgesia and sedation cluster and duration of MV (with a placement of death [POD] approach to account for competing risks).

Results

We identified 1,313 adults across 35 hospitals admitted with COVID-19 who received MV. Two clusters of analgesia and sedation practices were identified. Cluster 1 hospitals generally administered opioids and propofol with occasional use of additional sedatives (eg, benzodiazepines, alpha-agonists, and ketamine); cluster 2 hospitals predominantly used opioids and benzodiazepines without other sedatives. As compared with patients in cluster 2, patients admitted to cluster 1 hospitals underwent a shorter adjusted median duration of MV with POD (β-estimate, –5.9; 95% CI, –11.2 to –0.6; P = .03).

Interpretation

Patients who received MV for COVID-19 in hospitals that prioritized opioids and propofol for analgesia and sedation experienced shorter adjusted median duration of MV with POD as compared with patients who received MV in hospitals that primarily used opioids and benzodiazepines.

Background

Alcohol misuse is overlooked frequently in hospitalized patients, but is common among patients with pneumonia and acute hypoxic respiratory failure. Investigations in hospitalized patients rely heavily on self-report surveys or chart abstraction, which lack sensitivity. Therefore, our understanding of the prevalence of alcohol misuse before and during the COVID-19 pandemic is limited.

Research Question

In critically ill patients with respiratory failure, did the proportion of patients with alcohol misuse, defined by the direct biomarker phosphatidylethanol, vary over a period including the COVID-19 pandemic?

Study Design and Methods

Patients with acute hypoxic respiratory failure receiving mechanical ventilation were enrolled prospectively from 2015 through 2019 (before the pandemic) and from 2020 through 2022 (during the pandemic). Alcohol use data, including Alcohol Use Disorders Identification Test (AUDIT)-C scores, were collected from electronic health records, and phosphatidylethanol presence was assessed at ICU admission. The relationship between clinical variables and phosphatidylethanol values was examined using multivariable ordinal regression. Dichotomized phosphatidylethanol values (≥ 25 ng/mL) defining alcohol misuse were compared with AUDIT-C scores signifying misuse before and during the pandemic, and correlations between log-transformed phosphatidylethanol levels and AUDIT-C scores were evaluated and compared by era. Multiple imputation by chained equations was used to handle missing phosphatidylethanol data.

Results

Compared with patients enrolled before the pandemic (n = 144), patients in the pandemic cohort (n = 92) included a substantially higher proportion with phosphatidylethanol-defined alcohol misuse (38% vs 90%; P < .001). In adjusted models, absence of diabetes, positive results for COVID-19, and enrollment during the pandemic each were associated with higher phosphatidylethanol values. The correlation between health care worker-recorded AUDIT-C score and phosphatidylethanol level was significantly lower during the pandemic.

Interpretation

The higher prevalence of phosphatidylethanol-defined alcohol misuse during the pandemic suggests that alcohol consumption increased during this period, identifying alcohol misuse as a potential risk factor for severe COVID-19-associated respiratory failure. Results also suggest that AUDIT-C score may be less useful in characterizing alcohol consumption during high clinical capacity.

Background

Given the resources and specialized training required to deliver extracorporeal membrane oxygenation (ECMO), the provision of ECMO often is centralized within expert centers. Spurred by recent evidence, the use of ECMO has increased dramatically. However, given the centralized nature of ECMO, it is possible that inequities in access exist.

Research Question

Does center of admission impact the likelihood of receiving ECMO among adults with moderate or severe acute hypoxemic respiratory failure (Pao₂ to Fio₂ ratio ≤ 200 mm Hg within 48 h of ventilation).

Study Design and Methods

We performed a retrospective cohort study using data from the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) and Reseau Europeen de Recherche en Ventilation Artificielle (REVA) Influenza A(H1N1) Registry databases. Using modified log-Poisson analysis, we estimated the likelihood of receiving extracorporeal membrane oxygenation (ECMO) (initiation at the admitting hospital or transfer for initiation), adjusting for disease severity over time. To explore unmeasured confounding, we evaluated the association between center of admission on three negative controls: neuromuscular blockade, prone positioning, and dialysis.

Results

Among 1,581 patients (37.7% female patients; mean age, 60.7 years), 76 patients (4.8%) received ECMO. Longitudinal analysis, adjusted for trends in disease severity, demonstrated that patients admitted to ECMO centers were two times more likely to receive ECMO than those admitted to non-ECMO centers (relative risk [RR], 2.00; 95% CI, 1.17-3.41). Patients at ECMO centers received ECMO 2 days earlier than those at non-ECMO centers: median time to initiation was 1 day (interquartile range, 1-5 days) vs 3 days (interquartile range, 2-5 days; P = .04). Center of admission was not associated with neuromuscular blockade (RR, 1.08; 95% CI, 0.90-1.30), prone positioning (RR, 0.93; 95% CI, 0.68-1.28), or dialysis (RR, 1.04; 95% CI, 0.84-1.27).

Interpretation

Adults with hypoxemic respiratory failure admitted to ECMO centers were twice as likely to receive ECMO as those admitted to non-ECMO centers. These finding raise concerns regarding equity in access to care and suggest a potential lower threshold among clinicians at ECMO centers for initiation of ECMO.

The practice of critical care depends not only on the particular patient population served, but also on the context in which critical care is provided, including culture and regional norms and resources. How clinicians interpret and implement new evidence or guideline recommendations is affected by their unique context. In 2023, the Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension (CLOVERS) trial was published. The CLOVERS trial included 1,563 patients and studied early vasopressor initiation vs liberal fluid initiation after an initial fluid bolus for patients with septic shock seeking treatment in the United States. No mortality difference was found between the two treatment arms. In this article, adult and pediatric critical care clinicians from the United States, the United Kingdom, Italy, Rwanda, India, and Brazil describe how CLOVERS has impacted or will impact their practice.

Background

Acute liver failure (ALF) has a mortality rate of approximately 50%. Thus, it is evident that improvements in treatment of ALF are necessary. The Molecular Adsorbent Recirculating System (MARS; Baxter), an extracorporeal liver support system that detoxifies water-soluble and protein-bound toxins, has been available at select centers worldwide for > 2 decades. Although some studies have shown the efficacy of MARS in the management of ALF, the literature remains limited. The objective of this study was to assess the outcomes of patients with ALF who underwent MARS therapy at a single institution using institutionally developed indications based on current best evidence.

Research Question

Is MARS used for selected causes of ALF associated with better survivability than predicted by standardized mortality rates (SMRs)?

Study Design and Methods

This was a single-center, retrospective cohort study of the outcomes of patients with ALF who underwent MARS at the R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center. All patients aged 18 years or older who were admitted to our institution and underwent MARS treatment between July 1, 2013, and February 9, 2021, were included in this study. Data relevant to the study were collected from electronic medical records and were stored in Research Electronic Data Capture tools. From these data, estimated mortality from Model for End-Stage Liver Disease scores were used to calculate SMR. The SMRs then were compared for different institutional indications for MARS. Additional descriptive statistics were applied.

Results

Sixty-one patients underwent MARS treatment during the study period. Overall survival in the cohort was 56%. The SMR was lower than expected for patients who underwent MARS who were transplant candidates (SMR, 0.78; 95% CI, 0.63-0.93). Although no significant differences were found before and after MARS treatment in median ammonia levels (58 Umol/L [interquartile range (IQR), 32-104 Umol/L] vs 39 Umol/L [IQR, 18-57 Umol/L]; P = .44) or norepinephrine doses (0.21 μg/kg/min [IQR, 0.08-0.4 μg/kg/min] vs 0.06 μg/kg/min [IQR, 0.04-0.14 μg/kg/min]; P = .46), significant decreases in median aspartate transferase (3,334 U/L [IQR, 1,174-11,151 U/L] vs 344 U/L [IQR, 196-978 U/L]; P < .001), alanine transaminase (1,410 U/L [IQR, 600-5,505 U/L] vs 347 U/L [IQR, 153-952 U/L]; P < .001), international normalized ratio (3.2 [IQR, 2-4.5] vs 1.5 [IQR, 1.3-1.9]; P < .001), and median lactic acid levels (7.7 mM [IQR, 4.8-13.2 mM] vs 2.4 mM [IQR, 1.7-3.1 mM]; P < .001) were seen.

Interpretation

We report our experience using MARS for institutionally developed indications in a level 1 trauma center and transplant center. These data add to a growing body of literature that support the use of MARS as an extraco