Critical care explorations最新文献

Intermediate care (IC) is prevalent nationwide, but little is known about how to best organize this level of care. Using a 99-item cross-sectional survey assessing four domains (hospital and physical IC features, provider and nurse staffing, monitoring, and interventions/services), we describe the organizational heterogeneity of IC within a five-hospital healthcare system. Surveys were completed by nurse managers from 12 (86%) of 14 IC settings. Six IC settings (50%) were embedded within acute care wards, four (33%) were stand-alone units, and two (17%) were embedded within an ICU. All had a nurse-to-patient ratio of 1:3, provided continuous cardiac telemetry, continuous pulse oximetry, high-flow nasal oxygen, and bedside intermittent hemodialysis. Most (> 50%) permitted arterial lines, frequent nursing assessments (every 2 hr), and noninvasive ventilation or mechanical ventilation via a tracheostomy. Vasopressors were less often permitted (< 25% of settings). Models of IC vary greatly within a single healthcare system.

Objectives: The COVID-19 pandemic gave rise to uncertainty concerning potential sequelae related to a severe acute respiratory syndrome coronavirus 2 infection. This landscape is currently unfolding with studies reporting sequelae on various domains (physical, cognitive, and psychosocial), although most studies focus on adults or only one domain. We sought to investigate concurrent sequelae on multiple domains 1 year after PICU admission for Multisystem Inflammatory Syndrome in Children (MIS-C).

Design: Prospective cohort study.

Setting: Two academic, tertiary referral hospitals in The Netherlands and Belgium.

Patients: Patients (< 18 yr, n = 58) seen in-person 1-year after PICU admission for MIS-C.

Interventions: None.

Measurements and main results: Seventy MIS-C patients (62% male; median age, 10.0 [interquartile range, 7.4-13.0]) were admitted to the PICU, mostly (86%) due to (imminent) circulatory failure. The majority received IV immunoglobulins (95%), steroids (83%), and vasopressors and/or inotropes (72%). Invasive respiratory support and extracorporeal membrane oxygenation were necessary in 7% and 2%, respectively. All patients survived. Fifty-eight patients (83%) attended 1-year follow-up. Although most patients had normal functional performance scores (Pediatric Cerebral Performance Category, Pediatric Overall Performance Category, and Functional Status Score), 62% still experienced physical sequelae: fatigue (40%), headaches (27%), and decreased exercise tolerance (19%). Cognitive, behavioral, and psychological problems were reported in 14%, 13%, and 23%, respectively. This resulted in 22% requiring ongoing healthcare utilization, 9% not being able to return to full-time school attendance and cessation of hobbies in 7%.

Conclusions: This is the first 1-year outcome study of MIS-C PICU patients to include both physical and psychosocial characteristics. One year after PICU admission, most children had normalized functional performance as measured by three validated performance scores. However, many still reported a variety of multidimensional sequelae at 1-year follow-up impacting daily life. This emphasizes the importance of continued investigative efforts and multidisciplinary follow-up programs to better understand pathophysiology and contributing factors to the MIS-C disease trajectory and initiate patient-specific interventions to improve outcome and social participation.

Intermediate care (IC) is prevalent nationwide, but little is known about how to best organize this level of care. Using a 99-item cross-sectional survey assessing four domains (hospital and physical IC features, provider and nurse staffing, monitoring, and interventions/services), we describe the organizational heterogeneity of IC within a five-hospital healthcare system. Surveys were completed by nurse managers from 12 (86%) of 14 IC settings. Six IC settings (50%) were embedded within acute care wards, four (33%) were stand-alone units, and two (17%) were embedded within an ICU. All had a nurse-to-patient ratio of 1:3, provided continuous cardiac telemetry, continuous pulse oximetry, high-flow nasal oxygen, and bedside intermittent hemodialysis. Most (> 50%) permitted arterial lines, frequent nursing assessments (every 2 hr), and noninvasive ventilation or mechanical ventilation via a tracheostomy. Vasopressors were less often permitted (< 25% of settings). Models of IC vary greatly within a single healthcare system.

Objective: Composite primary outcomes (CPO) (incorporating both mortality and non-mortality outcomes) offer several advantages over mortality as an outcome for critical care research. Our objective was to explore and map the literature to report on CPO evaluated in critical care research.

Data sources: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Cochrane Library from January 2000 to January 2024.

Study selection: All studies (both non-randomized controlled trial [RCT] and RCT) conducted in ICUs treating adult patients (18 yr old or older) that described CPOs and their definitions, were included for mapping, reporting, and analyzing CPOs without any restrictions.

Data extraction: Independent double-screening of abstracts/full texts and data extraction was performed using a pilot-tested extraction template. The data collected included characteristics of CPO, definitions, trends, and death handling techniques used while reporting the CPO.

Data synthesis: Seventeen CPOs were extracted from 71 studies, predominantly reported in the setting of pharmaceutical studies (48/71, 67.6%), used RCT methodology (60/71, 84.5%), and were mostly single-center studies (55/71, 77.5%). Ventilator-free days were the most commonly reported CPO (29/71, 40.8%) with marked variability in the definition used and death handling (0 d in 33 studies and -1 d in 7 studies). The most common statistical paradigm used was frequentist (63/71, 88.7%) and the study follow-up time was 90 days with 28 studies using this timeline (28/71, 39.4%). Narrative synthesis highlighted the variability in defining CPO.

Conclusions: CPOs are an emerging set of outcomes increasingly reported in critical care research. There was significant heterogeneity in definitions used, follow-up times, and reporting trends.

Background: Accurate assessment of oxygen delivery relative to oxygen demand is crucial in the care of a critically ill patient. The central venous oxygen saturation (Svo₂) enables an estimate of cardiac output yet obtaining these clinical data requires invasive procedures and repeated blood sampling. Interpretation remains subjective and vulnerable to error. Recognition of patient's evolving clinical status as well as the impact of therapeutic interventions may be delayed.

Objective: The predictive analytics algorithm, inadequate delivery of oxygen (IDo₂) index, was developed to noninvasively estimate the probability of a patient's Svo₂ to fall below a preselected threshold.

Derivation cohort: A retrospective multicenter cohort study was conducted using data temporally independent from the design and development phase of the IDo₂ index.

Validation cohort: A total of 20,424 Svo₂ measurements from 3,018 critically ill neonates, infants, and children were retrospectively analyzed. Collected data included vital signs, ventilator data, laboratory data, and demographics.

Prediction model: The ability of the IDo₂ index to predict Svo₂ below a preselected threshold (30%, 40%, or 50%) was evaluated for discriminatory power, range utilization, and robustness.

Results: Area under the receiver operating characteristic curve (AUC) was calculated for each index threshold. Datasets with greater amounts of available data had larger AUC scores. This was observed across each configuration. For the majority of thresholds, Svo₂ values were observed to be significantly lower as the IDo₂ index increased.

Conclusions: The IDo₂ index may inform decision-making in pediatric cardiac critical care settings by providing a continuous, noninvasive assessment of oxygen delivery relative to oxygen demand in a specific patient. Leveraging predictive analytics to guide timely patient care, including support for escalation or de-escalation of treatments, may improve care delivery for patients and clinicians.

Importance: The current definition of central line-associated bloodstream infection (CLABSI) may overestimate the true incidence of CLABSI as it is often unclear whether the bloodstream infection (BSI) is secondary to the central line or due to another infectious source.

Objectives: We aimed to assess the prevalence and outcomes of central CLABSI at our institution, to identify opportunities for improvement, appropriately direct efforts for infection reduction, and identify gaps in the CLABSI definition and its application as a quality measure.

Design setting and participants: Retrospective cross-sectional study of patients identified to have a CLABSI in the period 2018-2022 cared for at the value-based purchasing (VBP) units of a 1200-bed tertiary care hospital located in Cleveland, OH. Each CLABSI episode was assessed for relationship with central venous catheter (CVC), suspected secondary source of BSI, mortality associated with the CLABSI hospital encounter, and availability of infectious disease physician or primary physician documentation of infectious source.

Main outcomes and measures: CLABSI episodes were classified as CVC related, CVC unrelated, and CVC relationship unclear. Mortality during the same encounter as the CLABSI event was assessed as an outcome measure. Descriptive statistics were performed.

Results: A total of 340 CLABSI episodes occurred in adult patients in VBP units. Majority of the CLABSI, 77.5% (266), occurred in the ICU. Of the CLABSI analyzed, 31.5% (107) were classified as unrelated to the CVC; 25.0% (85) had an unclear source; 43% (148) were classified as CVC related. For CVC-related cases, Staphylococcus and Candida were the predominant organisms. For the CVC unrelated and unclear groups Enterococcus was most prevalent. The mortality rate was lowest among patients classified with a CVC-related BSI. The positive predictive value (PPV) of the Centers for Disease Control and Prevention CLABSI definition to predict a true CVC-related infection was found to be 58.0%.

Conclusions and relevance: The definition of CLABSI as a surrogate for catheter-related BSI is inadequate, with a PPV of 58.0% (43.1-67.6%). Efforts should be redirected toward revising the CLABSI definition and possibly reevaluating its criteria. Resources should be assigned to further investigate and systematically prevent BSIs from secondary sources while adhering to existing CLABSI prevention bundles.

Objectives: To investigate the prevalence of pulmonary embolism (PE) in children admitted to critical care diagnosed with COVID-19 infection.

Design: Retrospective database study.

Setting: Data reported to the Virtual Pediatric Systems, 2018-2021.

Patients: Patients 28 days to younger than 18 years old, admitted to a PICU with either PE or COVID-19 diagnoses.

Interventions: None.

Measurements and main results: Among the PE-positive subgroups, from January 2020 to December 2021, 78 patients (14%) had an acute COVID-19 infection. The prevalence of PE pre-pandemic period (2018-2019) was 0.19% and for pandemic period (2020-2021) was 0.26% (p < 0.001). During the pandemic period, the prevalence of PE for COVID-negative patients was 0.21% and for COVID-positive patients was 1.01% (p < 0.001). The result shows that the chance to develop PE for COVID-positive patients is 4.8 times that for COVID-negative patients during the pandemic. In the subgroup of the PE-positive patients, 55.1% were Black or African American in the COVID-positive group and 19% in the COVID-negative group (p < 0.001). A multivariable logistic regression showed that race was an independent risk factor for COVID in PE-positive patients.

Conclusions: Our study demonstrates a significant increase in the prevalence of PE among pediatric patients admitted to PICUs during the COVID-19 pandemic compared with pre-pandemic. Our study indicates that COVID-positive patients are 4.8 times more likely to develop PE than COVID-negative patients. Additionally, the study highlights substantial racial disparities in the prevalence of PE, with Black or African American patients being disproportionately affected.

Importance: Recent studies have found an association between COVID-19 infection and deeper sedation in mechanically ventilated patients, raising concerns about the impact of the COVID-19 pandemic on pain, agitation, and delirium (PAD) management practices overall.

Objectives: This study aimed to assess differences in PAD management in patients without COVID-19 infection in pre- and peri-COVID-19 pandemic timeframes.

Design, setting, and participants: This was a single-center, retrospective, pre-/post-cohort analysis of mechanically ventilated adult patients without COVID-19 infection admitted to an ICU in Boston, MA. The "pre" and "post" groups enrolled patients in 2019 and 2021, respectively. All PAD data during the first 7 days of mechanical ventilation (MV) were collected.

Main outcomes and measures: The primary outcome was ventilator-free days (VFDs) during the first 28 days. A multivariable linear regression analysis was performed to assess VFD while controlling for confounders. Secondary outcomes included depth of sedation, total dose of sedatives, and in-hospital mortality.

Results: There were 339 patients included in the final analysis. There was no difference in VFD between the pre- and post-groups (22.2 vs. 22.6 d; p = 0.92); this was confirmed by multivariable linear regression (p = 0.91). Patients in the post-group experienced significantly deeper levels of sedation compared with the pre-group (58% vs. 53%; p < 0.01) within the first 48 hours of MV. The median number of Richmond Agitation-Sedation Scale assessments per 24-hour period was greater in the pre-group (13 vs. 12 assessments; p = 0.02) within the first 48 hours of MV. There were no significant differences in total cumulative dose of sedatives or in-hospital mortality between the two groups.

Conclusions and relevance: This study suggests that PAD practices, including depth of sedation and frequency of assessment, differed between pre- and post-COVID-19 groups in patients without COVID-19. Outcomes including VFD, mortality, and hospital length of stay were not affected. Further studies are needed to understand the broader impact of the COVID-19 pandemic on PAD management practices.

Objectives: To investigate the prevalence of pulmonary embolism (PE) in children admitted to critical care diagnosed with COVID-19 infection.

Design: Retrospective database study.

Setting: Data reported to the Virtual Pediatric Systems, 2018-2021.

Patients: Patients 28 days to younger than 18 years old, admitted to a PICU with either PE or COVID-19 diagnoses.

Interventions: None.

Measurements and main results: Among the PE-positive subgroups, from January 2020 to December 2021, 78 patients (14%) had an acute COVID-19 infection. The prevalence of PE pre-pandemic period (2018-2019) was 0.19% and for pandemic period (2020-2021) was 0.26% (p < 0.001). During the pandemic period, the prevalence of PE for COVID-negative patients was 0.21% and for COVID-positive patients was 1.01% (p < 0.001). The result shows that the chance to develop PE for COVID-positive patients is 4.8 times that for COVID-negative patients during the pandemic. In the subgroup of the PE-positive patients, 55.1% were Black or African American in the COVID-positive group and 19% in the COVID-negative group (p < 0.001). A multivariable logistic regression showed that race was an independent risk factor for COVID in PE-positive patients.

Conclusions: Our study demonstrates a significant increase in the prevalence of PE among pediatric patients admitted to PICUs during the COVID-19 pandemic compared with pre-pandemic. Our study indicates that COVID-positive patients are 4.8 times more likely to develop PE than COVID-negative patients. Additionally, the study highlights substantial racial disparities in the prevalence of PE, with Black or African American patients being disproportionately affected.

Objectives: To systematically review the safety and efficacy of nonbiological (NBAL) or biological artificial liver support systems (BAL) and whole-organ extracorporeal liver perfusion (W-ECLP) systems, in adults with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF).

Data sources: Eligible NBAL/BAL studies from PubMed/Embase searches were randomized controlled trials (RCTs) in adult patients with ALF/ACLF, greater than or equal to ten patients per group, reporting outcomes related to survival, adverse events, transplantation rate, and hepatic encephalopathy, and published in English from January 2000 to July 2023. Separately, we searched for studies evaluating W-ECLP in adult patients with ALF or ACLF published between January1990 and July 2023.

Study selection and data extraction: Two researchers independently screened citations for eligibility and, of eligible studies, retrieved data related to study characteristics, patients and interventions, outcomes definition, and intervention effects. The Cochrane Risk of Bias 2 tool and Joanna Briggs Institute checklists were used to assess individual study risk of bias. Meta-analysis of mortality at 28-30 days post-support system initiation and frequency of at least one serious adverse event (SAE) generated pooled risk ratios (RRs), based on random (mortality) or fixed (SAE) effects models.

Data synthesis: Of 17 trials evaluating NBAL/BAL systems, 11 reported 28-30 days mortality and five reported frequency of at least one SAE. Overall, NBAL/BAL was not statistically associated with mortality at 28-30 days (RR, 0.85; 95% CI, 0.67-1.07; p = 0.169) or frequency of at least one SAE (RR, 1.15; 95% CI, 0.99-1.33; p = 0.059), compared with standard medical treatment. Subgroup results on ALF patients suggest possible benefit for mortality (RR, 0.67; 95% CI, 0.44-1.03; p = 0.069). From six reports of W-ECLP (12 patients), more than half (58%) of severe patients were bridged to transplantation and survived without transmission of porcine retroviruses.

Conclusions: Despite no significant pooled effects of NBAL/BAL devices, the available evidence calls for further research and development of extracorporeal liver support systems, with larger RCTs and optimization of patient selection, perfusion durability, and treatment protocols.