Pub Date : 2024-03-05eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001043
Daniel J Tan, Joseph M Plasek, Peter C Hou, Rebecca M Baron, Benjamin J Atkinson, Li Zhou
Importance and objectives: COVID-19-related acute respiratory distress syndrome (ARDS) is associated with high mortality and often necessitates invasive mechanical ventilation (IMV). Previous studies on non-COVID-19 ARDS have shown driving pressure to be robustly associated with ICU mortality; however, those studies relied on "static" driving pressure measured periodically and manually. As "continuous" automatically monitored driving pressure is becoming increasingly available and reliable with more advanced mechanical ventilators, we aimed to examine the effect of this "dynamic" driving pressure in COVID-19 ARDS throughout the entire ventilation period.
Design setting and participants: This retrospective, observational study cohort study evaluates the association between driving pressure and ICU mortality in patients with concurrent COVID-19 and ARDS using multivariate joint modeling. The study cohort (n = 544) included all adult patients (≥ 18 yr) with COVID-19 ARDS between March 1, 2020, and April 30, 2021, on volume-control mode IMV for 12 hours or more in a Mass General Brigham, Boston, MA ICU.
Measurements and main results: Of 544 included patients, 171 (31.4%) died in the ICU. Increased dynamic ΔP was associated with increased risk in the hazard of ICU mortality (hazard ratio [HR] 1.035; 95% credible interval, 1.004-1.069) after adjusting for other relevant dynamic respiratory biomarkers. A significant increase in risk in the hazard of death was found for every hour of exposure to high intensities of driving pressure (≥ 15 cm H2O) (HR 1.002; 95% credible interval 1.001-1.003).
Conclusions: Limiting patients' exposure to high intensities of driving pressure even while under lung-protective ventilation may represent a critical step in improving ICU survival in patients with COVID-19 ARDS. Time-series IMV data could be leveraged to enhance real-time monitoring and decision support to optimize ventilation strategies at the bedside.
{"title":"Investigating the Association Between Dynamic Driving Pressure and Mortality in COVID-19-Related Acute Respiratory Distress Syndrome: A Joint Modeling Approach Using Real-Time Continuously-Monitored Ventilation Data.","authors":"Daniel J Tan, Joseph M Plasek, Peter C Hou, Rebecca M Baron, Benjamin J Atkinson, Li Zhou","doi":"10.1097/CCE.0000000000001043","DOIUrl":"10.1097/CCE.0000000000001043","url":null,"abstract":"<p><strong>Importance and objectives: </strong>COVID-19-related acute respiratory distress syndrome (ARDS) is associated with high mortality and often necessitates invasive mechanical ventilation (IMV). Previous studies on non-COVID-19 ARDS have shown driving pressure to be robustly associated with ICU mortality; however, those studies relied on \"static\" driving pressure measured periodically and manually. As \"continuous\" automatically monitored driving pressure is becoming increasingly available and reliable with more advanced mechanical ventilators, we aimed to examine the effect of this \"dynamic\" driving pressure in COVID-19 ARDS throughout the entire ventilation period.</p><p><strong>Design setting and participants: </strong>This retrospective, observational study cohort study evaluates the association between driving pressure and ICU mortality in patients with concurrent COVID-19 and ARDS using multivariate joint modeling. The study cohort (<i>n</i> = 544) included all adult patients (≥ 18 yr) with COVID-19 ARDS between March 1, 2020, and April 30, 2021, on volume-control mode IMV for 12 hours or more in a Mass General Brigham, Boston, MA ICU.</p><p><strong>Measurements and main results: </strong>Of 544 included patients, 171 (31.4%) died in the ICU. Increased dynamic ΔP was associated with increased risk in the hazard of ICU mortality (hazard ratio [HR] 1.035; 95% credible interval, 1.004-1.069) after adjusting for other relevant dynamic respiratory biomarkers. A significant increase in risk in the hazard of death was found for every hour of exposure to high intensities of driving pressure (≥ 15 cm H<sub>2</sub>O) (HR 1.002; 95% credible interval 1.001-1.003).</p><p><strong>Conclusions: </strong>Limiting patients' exposure to high intensities of driving pressure even while under lung-protective ventilation may represent a critical step in improving ICU survival in patients with COVID-19 ARDS. Time-series IMV data could be leveraged to enhance real-time monitoring and decision support to optimize ventilation strategies at the bedside.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10917137/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140051342","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-28eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001055
Sarah Harris-Kober, Alyssa Motzel, Scott Grant, Brian Berman, Lauren Yagiela
Objectives: The majority of PICU general follow-up occurs with primary care providers. Our objective was to investigate primary care pediatricians': 1) comfort with and barriers to caring for children after a PICU admission, 2) knowledge of and screening for post-intensive care syndrome in pediatrics (PICS-P), and 3) resource needs.
Design: Pilot cross-sectional survey study.
Setting: Metropolitan Detroit, Michigan from September 2022 to March 2023.
Subjects: Primary care pediatricians.
Measurement and main results: The survey included 15 questions on provider demographics, comfort with and barriers to caring for children after a PICU admission, knowledge of and screening practices for PICS-P, and resource needs. The median values for continuous data and frequencies for categorical data were calculated. The survey response rate was 17% (26/152). The median age was 38.5 years (interquartile range 34-52 yr) and 19 of 26 (73%) were female. In case studies, 26 of 26 (100%) were "very comfortable" resuming care for a patient with a straightforward bronchiolitis PICU admission while 8 of 26 participants (31%) were "somewhat uncomfortable" and 1 of 26 (4%) was "not at all comfortable" with caring for a patient after a complex acute respiratory distress syndrome PICU admission. Seven of 26 participants (27%) were familiar with the term "post-intensive care syndrome in pediatrics." Over 50% screened for four of five PICS-P domains. Key barriers were care coordination with specialists, discomfort or difficulties with managing new home equipment, and inadequate or missing documentation.
Conclusions: In this pilot study, approximately one-third of primary care pediatricians had knowledge of PICS-P. Participants experienced numerous care barriers. Our findings suggest future research could engage improved study methods and designs, and focus on interventions to support primary care-provided PICU follow-up.
{"title":"Impression of Primary Care Follow-Up After a PICU Admission: A Pilot Survey of Primary Care Pediatricians.","authors":"Sarah Harris-Kober, Alyssa Motzel, Scott Grant, Brian Berman, Lauren Yagiela","doi":"10.1097/CCE.0000000000001055","DOIUrl":"10.1097/CCE.0000000000001055","url":null,"abstract":"<p><strong>Objectives: </strong>The majority of PICU general follow-up occurs with primary care providers. Our objective was to investigate primary care pediatricians': 1) comfort with and barriers to caring for children after a PICU admission, 2) knowledge of and screening for post-intensive care syndrome in pediatrics (PICS-P), and 3) resource needs.</p><p><strong>Design: </strong>Pilot cross-sectional survey study.</p><p><strong>Setting: </strong>Metropolitan Detroit, Michigan from September 2022 to March 2023.</p><p><strong>Subjects: </strong>Primary care pediatricians.</p><p><strong>Measurement and main results: </strong>The survey included 15 questions on provider demographics, comfort with and barriers to caring for children after a PICU admission, knowledge of and screening practices for PICS-P, and resource needs. The median values for continuous data and frequencies for categorical data were calculated. The survey response rate was 17% (26/152). The median age was 38.5 years (interquartile range 34-52 yr) and 19 of 26 (73%) were female. In case studies, 26 of 26 (100%) were \"very comfortable\" resuming care for a patient with a straightforward bronchiolitis PICU admission while 8 of 26 participants (31%) were \"somewhat uncomfortable\" and 1 of 26 (4%) was \"not at all comfortable\" with caring for a patient after a complex acute respiratory distress syndrome PICU admission. Seven of 26 participants (27%) were familiar with the term \"post-intensive care syndrome in pediatrics.\" Over 50% screened for four of five PICS-P domains. Key barriers were care coordination with specialists, discomfort or difficulties with managing new home equipment, and inadequate or missing documentation.</p><p><strong>Conclusions: </strong>In this pilot study, approximately one-third of primary care pediatricians had knowledge of PICS-P. Participants experienced numerous care barriers. Our findings suggest future research could engage improved study methods and designs, and focus on interventions to support primary care-provided PICU follow-up.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10904095/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139998593","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-27eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001057
Ryan Ruiyang Ling, William Bonavia, Mallikarjuna Ponnapa Reddy, David Pilcher, Ashwin Subramaniam
Objectives: A nontrivial number of patients in ICUs experience persistent critical illness (PerCI), a phenomenon in which features of the ICU course more consistently predict mortality than the initial indication for admission. We aimed to describe PerCI among patients with critical illness caused by COVID-19, and these patients' short- and long-term outcomes.
Design: Multicenter retrospective cohort study.
Setting: Australian and New Zealand Intensive Care Society Adult Patient Database of 114 Australian ICUs between January 1, 2020, and March 31, 2022.
Patients: Patients 16 years old or older with COVID-19, and a documented ICU length of stay.
Exposure: The presence of PerCI, defined as an ICU length of stay greater than or equal to 10 days.
Measurements: We compared the survival time up to 2 years from ICU admission using time-varying robust-variance estimated Cox proportional hazards models. We further investigated the impact of PerCI in subgroups of patients, stratifying based on whether they survived their initial hospitalization.
Main results: We included 4961 patients in the final analysis, and 882 patients (17.8%) had PerCI. ICU mortality was 23.4% in patients with PerCI and 6.5% in those without PerCI. Patients with PerCI had lower 2-year (70.9% [95% CI, 67.9-73.9%] vs. 86.1% [95% CI, 85.0-87.1%]; p < 0.001) survival rates compared with patients without PerCI. Patients with PerCI had higher mortality (adjusted hazards ratio: 1.734; 95% CI, 1.388-2.168); this was consistent across several sensitivity analyses. When analyzed as a nonlinear predictor, the hazards of mortality were inconsistent up until 10 days, before plateauing.
Conclusions: In this multicenter retrospective observational study patients with PerCI tended to have poorer short-term and long-term outcomes. However, the hazards of mortality plateaued beyond the first 10 days of ICU stay. Further studies should investigate predictors of developing PerCI, to better prognosticate long-term outcomes.
{"title":"Persistent Critical Illness and Long-Term Outcomes in Patients With COVID-19: A Multicenter Retrospective Cohort Study.","authors":"Ryan Ruiyang Ling, William Bonavia, Mallikarjuna Ponnapa Reddy, David Pilcher, Ashwin Subramaniam","doi":"10.1097/CCE.0000000000001057","DOIUrl":"10.1097/CCE.0000000000001057","url":null,"abstract":"<p><strong>Objectives: </strong>A nontrivial number of patients in ICUs experience persistent critical illness (PerCI), a phenomenon in which features of the ICU course more consistently predict mortality than the initial indication for admission. We aimed to describe PerCI among patients with critical illness caused by COVID-19, and these patients' short- and long-term outcomes.</p><p><strong>Design: </strong>Multicenter retrospective cohort study.</p><p><strong>Setting: </strong>Australian and New Zealand Intensive Care Society Adult Patient Database of 114 Australian ICUs between January 1, 2020, and March 31, 2022.</p><p><strong>Patients: </strong>Patients 16 years old or older with COVID-19, and a documented ICU length of stay.</p><p><strong>Exposure: </strong>The presence of PerCI, defined as an ICU length of stay greater than or equal to 10 days.</p><p><strong>Measurements: </strong>We compared the survival time up to 2 years from ICU admission using time-varying robust-variance estimated Cox proportional hazards models. We further investigated the impact of PerCI in subgroups of patients, stratifying based on whether they survived their initial hospitalization.</p><p><strong>Main results: </strong>We included 4961 patients in the final analysis, and 882 patients (17.8%) had PerCI. ICU mortality was 23.4% in patients with PerCI and 6.5% in those without PerCI. Patients with PerCI had lower 2-year (70.9% [95% CI, 67.9-73.9%] vs. 86.1% [95% CI, 85.0-87.1%]; <i>p</i> < 0.001) survival rates compared with patients without PerCI. Patients with PerCI had higher mortality (adjusted hazards ratio: 1.734; 95% CI, 1.388-2.168); this was consistent across several sensitivity analyses. When analyzed as a nonlinear predictor, the hazards of mortality were inconsistent up until 10 days, before plateauing.</p><p><strong>Conclusions: </strong>In this multicenter retrospective observational study patients with PerCI tended to have poorer short-term and long-term outcomes. However, the hazards of mortality plateaued beyond the first 10 days of ICU stay. Further studies should investigate predictors of developing PerCI, to better prognosticate long-term outcomes.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10904098/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139998594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-26eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001038
Nibras F Bughrara, Maegan R Neilson, Stephanie Jones, Lorna Workman, Amit Chopra, Aliaksei Pustavoitau
Objectives: We assessed the efficacy of 1-day training in echocardiography assessment using subxiphoid-only (EASy) followed by supervised image interpretation and decision-making during patient rounds as a novel approach to scaling up the use of point-of-care ultrasound (POCUS) in critically ill patients.
Design: Retrospective analysis of medical records and EASy examination images.
Setting: Tertiary care academic hospital.
Patients: A total of 14 adults (> 18 yr old) with COVID-19-associated respiratory failure under the care of Albany Medical Center's surge response team from April 6-17, 2020 who received at least one EASy examination.
Interventions: Residents (previously novice sonographers) were trained in EASy examination using 1 day of didactic and hands-on training, followed by independent image acquisition and supervised image interpretation, identification of hemodynamic patterns, and clinical decision-making facilitated by an echocardiography-certified physician during daily rounds.
Measurements and main results: We recorded the quality of resident-obtained EASy images, scanning time, and frequency with which the supervising physician had to repeat the examination or obtain additional images. A total of 63 EASy examinations were performed; average scanning time was 4.3 minutes. Resident-obtained images were sufficient for clinical decision-making on 55 occasions (87%), in the remaining 8 (13%) the supervising physician obtained further images.
Conclusions: EASy examination is an efficient, valuable tool under conditions of scarce resources. The educational model of 1-day training followed by supervised image interpretation and decision-making allows rapid expansion of the pool of sonographers and implementation of bedside echocardiography into routine ICU patient management.
{"title":"Is 1 Day of Focused Training in Echocardiographic Assessment Using Subxiphoid-Only (EASy) Examination Enough? A Tertiary Hospital Response to the COVID-19 Crisis and the Use of the EASy Examination to Support Unit-Wide Image Acquisition.","authors":"Nibras F Bughrara, Maegan R Neilson, Stephanie Jones, Lorna Workman, Amit Chopra, Aliaksei Pustavoitau","doi":"10.1097/CCE.0000000000001038","DOIUrl":"10.1097/CCE.0000000000001038","url":null,"abstract":"<p><strong>Objectives: </strong>We assessed the efficacy of 1-day training in echocardiography assessment using subxiphoid-only (EASy) followed by supervised image interpretation and decision-making during patient rounds as a novel approach to scaling up the use of point-of-care ultrasound (POCUS) in critically ill patients.</p><p><strong>Design: </strong>Retrospective analysis of medical records and EASy examination images.</p><p><strong>Setting: </strong>Tertiary care academic hospital.</p><p><strong>Patients: </strong>A total of 14 adults (> 18 yr old) with COVID-19-associated respiratory failure under the care of Albany Medical Center's surge response team from April 6-17, 2020 who received at least one EASy examination.</p><p><strong>Interventions: </strong>Residents (previously novice sonographers) were trained in EASy examination using 1 day of didactic and hands-on training, followed by independent image acquisition and supervised image interpretation, identification of hemodynamic patterns, and clinical decision-making facilitated by an echocardiography-certified physician during daily rounds.</p><p><strong>Measurements and main results: </strong>We recorded the quality of resident-obtained EASy images, scanning time, and frequency with which the supervising physician had to repeat the examination or obtain additional images. A total of 63 EASy examinations were performed; average scanning time was 4.3 minutes. Resident-obtained images were sufficient for clinical decision-making on 55 occasions (87%), in the remaining 8 (13%) the supervising physician obtained further images.</p><p><strong>Conclusions: </strong>EASy examination is an efficient, valuable tool under conditions of scarce resources. The educational model of 1-day training followed by supervised image interpretation and decision-making allows rapid expansion of the pool of sonographers and implementation of bedside echocardiography into routine ICU patient management.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10898658/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139984787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-26eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001058
Stephen J Amerson, McKenna Hoffman, Fadi Abouzahr, Mohammad Ahmad, Rachel K Sterling, Hitesh Gidwani, Linda E Sousse, Jeffrey D Dellavolpe
Background: Streptococcal toxic shock syndrome (STSS) is a fulminant complication of predominantly invasive group A streptococcal infections. STSS is often characterized by influenza-like symptoms, including fever, chills, and myalgia that can quickly progress to sepsis with hypotension, tachycardia, tachypnea, and multiple organ failure (kidney, liver, lung, or blood). Mortality can exceed 50% depending on the severity of symptoms.
Case summary: Here, we describe a novel, multi-extracorporeal intervention strategy in a case of severe septic shock secondary to STSS. A 28-year-old woman 5 days after cesarean section developed STSS with respiratory distress, hypotension, and multiple organ failure. Despite conventional therapy with intubation, antibiotics, vasopressors, and fluid resuscitation, her condition worsened. She was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with subsequent initiation of pathogen hemoperfusion using the Seraph 100 blood filter, followed by immunomodulation with the selective cytopheretic device (SCD). No device-related adverse events were observed. The patient's condition gradually stabilized with discontinuation of vasopressors after 4 days, ECMO decannulation after 6 days, evidence of renal recovery after 7 days, and extubation from mechanical ventilation after 14 days. She was transferred to conventional hemodialysis after 13 days and discontinued all kidney replacement therapy 11 days later.
Conclusions: This is the first reported use of VA-ECMO, Seraph 100 hemoperfusion, and cell-directed immunomodulation with SCD. This multimodal approach to extracorporeal support represents a promising therapeutic strategy for the most refractory critical care cases. Further studies are needed to assess the safety and efficacy of this sequential approach.
{"title":"Sequential Extracorporeal Therapy of Pathogen Removal Followed by Cell-Directed Extracorporeal Therapy in Streptococcal Toxic Shock Syndrome Refractory to Venoarterial Extracorporeal Membrane Oxygenation: A Case Report.","authors":"Stephen J Amerson, McKenna Hoffman, Fadi Abouzahr, Mohammad Ahmad, Rachel K Sterling, Hitesh Gidwani, Linda E Sousse, Jeffrey D Dellavolpe","doi":"10.1097/CCE.0000000000001058","DOIUrl":"10.1097/CCE.0000000000001058","url":null,"abstract":"<p><strong>Background: </strong>Streptococcal toxic shock syndrome (STSS) is a fulminant complication of predominantly invasive group A streptococcal infections. STSS is often characterized by influenza-like symptoms, including fever, chills, and myalgia that can quickly progress to sepsis with hypotension, tachycardia, tachypnea, and multiple organ failure (kidney, liver, lung, or blood). Mortality can exceed 50% depending on the severity of symptoms.</p><p><strong>Case summary: </strong>Here, we describe a novel, multi-extracorporeal intervention strategy in a case of severe septic shock secondary to STSS. A 28-year-old woman 5 days after cesarean section developed STSS with respiratory distress, hypotension, and multiple organ failure. Despite conventional therapy with intubation, antibiotics, vasopressors, and fluid resuscitation, her condition worsened. She was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with subsequent initiation of pathogen hemoperfusion using the Seraph 100 blood filter, followed by immunomodulation with the selective cytopheretic device (SCD). No device-related adverse events were observed. The patient's condition gradually stabilized with discontinuation of vasopressors after 4 days, ECMO decannulation after 6 days, evidence of renal recovery after 7 days, and extubation from mechanical ventilation after 14 days. She was transferred to conventional hemodialysis after 13 days and discontinued all kidney replacement therapy 11 days later.</p><p><strong>Conclusions: </strong>This is the first reported use of VA-ECMO, Seraph 100 hemoperfusion, and cell-directed immunomodulation with SCD. This multimodal approach to extracorporeal support represents a promising therapeutic strategy for the most refractory critical care cases. Further studies are needed to assess the safety and efficacy of this sequential approach.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10898666/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139984788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-23eCollection Date: 2024-03-01DOI: 10.1097/CCE.0000000000001056
Lece V Webb, Jakob Evans, Veronica Smith, Elisabeth Pettibone, Jarod Tofil, Jessica Floyd Hicks, Sherry Green, Ariann Nassel, Jeremy M Loberger
Importance: Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis.
Objective: This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index).
Design setting and participants: This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity.
Main outcomes and measures: The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT).
Results: A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024).
Conclusions and relevance: Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.
重要性:脓毒症是美国发病和死亡的主要原因,尽管脓毒症管理有所改善,但种族/族裔群体之间的治疗效果仍存在差异。这些观察到的差异往往与健康的社会决定因素(SDoH)有关。人们对 SDoH 对小儿败血症治疗结果的影响知之甚少:本研究根据种族/民族和邻里环境(以社会脆弱性指数衡量)对严重败血症患儿的护理提供和结果进行了研究:这项回顾性横断面研究是在一家四级儿童医院完成的。2018年5月1日至2022年2月28日期间入院的18岁或以下患者符合改善儿科脓毒症结果(IPSO)合作组织对严重脓毒症的定义。社会脆弱性、护理服务和临床结果的综合指标按种族/民族进行分层:主要结果和测量方法:主要结果是入住 PICU。次要结果为脓毒症识别和早期目标导向疗法(EGDT):共有 967 名儿童符合 IPSO 定义的严重败血症标准,其中 53.4% 为白人/非西班牙裔。近一半的患儿(48.7%)需要入住重症监护病房。不同种族患者入院时的病情严重程度没有差异(1.01 vs. 1.1,p = 0.18)。非白人种族/西班牙裔与入住 PICU 存在独立关联(几率比 [OR] 1.35 [1.01-1.8],P = 0.04)。虽然社会脆弱性与 PICU 入院并非独立相关(OR 0.95 [0.59-1.53],p = 0.83),但非白人儿童更有可能居住在弱势社区(0.66 vs. 0.38,p < 0.001)。非白人种族与较低的败血症识别率(87.8% vs. 93.6%,p = 0.002)和较低的EGDT依从性(35.7% vs. 42.8%,p = 0.024)有关:结论和相关性:非白人种族/族裔与入住 PICU 有独立关联。同时还发现了护理服务的差异。需要进行前瞻性研究以进一步了解这些发现。
{"title":"Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis.","authors":"Lece V Webb, Jakob Evans, Veronica Smith, Elisabeth Pettibone, Jarod Tofil, Jessica Floyd Hicks, Sherry Green, Ariann Nassel, Jeremy M Loberger","doi":"10.1097/CCE.0000000000001056","DOIUrl":"10.1097/CCE.0000000000001056","url":null,"abstract":"<p><strong>Importance: </strong>Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis.</p><p><strong>Objective: </strong>This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index).</p><p><strong>Design setting and participants: </strong>This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity.</p><p><strong>Main outcomes and measures: </strong>The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT).</p><p><strong>Results: </strong>A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, <i>p</i> = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], <i>p</i> = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], <i>p</i> = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, <i>p</i> < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, <i>p</i> = 0.002) and less EGDT compliance (35.7% vs. 42.8%, <i>p</i> = 0.024).</p><p><strong>Conclusions and relevance: </strong>Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10896474/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139984808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-20eCollection Date: 2024-02-01DOI: 10.1097/CCE.0000000000001050
Kevin Gorsky, Sean Cuninghame, Kesikan Jayaraj, Marat Slessarev, Conall Francoeur, Davinia E Withington, Jennifer Chen, Brian H Cuthbertson, Claudio Martin, Martin Chapman, Saptharishi Lalgudi Ganesan, Nicole McKinnon, Angela Jerath
Objectives: Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients.
Data sources: MEDLINE, Cochrane Central Register of Controlled Trials, and Embase.
Study selection: Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021.
Data extraction: Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case-control studies, and risk-of-bias framework for clinical trials.
Data synthesis: Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1-2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89-95%, pediatric: 80-97%), SE (adults: 54-100%, pediatric: 60-100%), and DS (adults: 60-90%, pediatric: 62-90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol.
Conclusions: Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.
{"title":"Inhaled Volatiles for Status Asthmaticus, Epilepsy, and Difficult Sedation in Adult ICU and PICU: A Systematic Review.","authors":"Kevin Gorsky, Sean Cuninghame, Kesikan Jayaraj, Marat Slessarev, Conall Francoeur, Davinia E Withington, Jennifer Chen, Brian H Cuthbertson, Claudio Martin, Martin Chapman, Saptharishi Lalgudi Ganesan, Nicole McKinnon, Angela Jerath","doi":"10.1097/CCE.0000000000001050","DOIUrl":"10.1097/CCE.0000000000001050","url":null,"abstract":"<p><strong>Objectives: </strong>Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients.</p><p><strong>Data sources: </strong>MEDLINE, Cochrane Central Register of Controlled Trials, and Embase.</p><p><strong>Study selection: </strong>Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021.</p><p><strong>Data extraction: </strong>Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case-control studies, and risk-of-bias framework for clinical trials.</p><p><strong>Data synthesis: </strong>Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1-2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89-95%, pediatric: 80-97%), SE (adults: 54-100%, pediatric: 60-100%), and DS (adults: 60-90%, pediatric: 62-90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol.</p><p><strong>Conclusions: </strong>Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10881088/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139934670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19eCollection Date: 2024-02-01DOI: 10.1097/CCE.0000000000001053
Suvi T Vaara, Ary Serpa Neto, Rinaldo Bellomo, Neill K J Adhikari, Didier Dreyfuss, Martin Gallagher, Stephane Gaudry, Eric Hoste, Michael Joannidis, Ville Pettilä, Amanda Y Wang, Kianoush Kashani, Ron Wald, Sean M Bagshaw, Marlies Ostermann
Objectives: Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant.
Design: Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722).
Setting: One hundred-fifty-three ICUs in 13 countries.
Patients: Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ).
Interventions: None.
Measurements and main results: Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007).
Conclusions: Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.
{"title":"Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis.","authors":"Suvi T Vaara, Ary Serpa Neto, Rinaldo Bellomo, Neill K J Adhikari, Didier Dreyfuss, Martin Gallagher, Stephane Gaudry, Eric Hoste, Michael Joannidis, Ville Pettilä, Amanda Y Wang, Kianoush Kashani, Ron Wald, Sean M Bagshaw, Marlies Ostermann","doi":"10.1097/CCE.0000000000001053","DOIUrl":"10.1097/CCE.0000000000001053","url":null,"abstract":"<p><strong>Objectives: </strong>Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant.</p><p><strong>Design: </strong>Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722).</p><p><strong>Setting: </strong>One hundred-fifty-three ICUs in 13 countries.</p><p><strong>Patients: </strong>Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (<i>p</i> < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (<i>p</i> < 0.001; <i>p</i> < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (<i>p</i> < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (<i>p</i> < 0.001) and hospital discharge (<i>p</i> < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; <i>p</i> < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; <i>p</i> = 0.007).</p><p><strong>Conclusions: </strong>Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10878545/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139914240","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-12eCollection Date: 2024-02-01DOI: 10.1097/CCE.0000000000001052
James T Ross, Anamaria J Robles, Monty B Mazer, Amy C Studer, Kenneth E Remy, Rachael A Callcut
Objectives: Cell-free hemoglobin (CFH) is a potent mediator of endothelial dysfunction, organ injury, coagulopathy, and immunomodulation in hemolysis. These mechanisms have been demonstrated in patients with sepsis, hemoglobinopathies, and those receiving transfusions. However, less is known about the role of CFH in the pathophysiology of trauma, despite the release of equivalent levels of free hemoglobin.
Data sources: Ovid MEDLINE, Embase, Web of Science Core Collection, and BIOSIS Previews were searched up to January 21, 2023, using key terms related to free hemoglobin and trauma.
Data extraction: Two independent reviewers selected studies focused on hemolysis in trauma patients, hemoglobin breakdown products, hemoglobin-mediated injury in trauma, transfusion, sepsis, or therapeutics.
Data synthesis: Data from the selected studies and their references were synthesized into a narrative review.
Conclusions: Free hemoglobin likely plays a role in endothelial dysfunction, organ injury, coagulopathy, and immune dysfunction in polytrauma. This is a compelling area of investigation as multiple existing therapeutics effectively block these pathways.
研究目的游离细胞血红蛋白(CFH)是溶血过程中导致内皮功能障碍、器官损伤、凝血障碍和免疫调节的有效介质。这些机制已在败血症、血红蛋白病和接受输血的患者中得到证实。然而,尽管游离血红蛋白的释放水平相当,但人们对 CFH 在创伤病理生理学中的作用却知之甚少:使用与游离血红蛋白和创伤相关的关键术语检索了截至2023年1月21日的Ovid MEDLINE、Embase、Web of Science Core Collection和BIOSIS Previews:两位独立审稿人筛选出的研究主要涉及创伤患者溶血、血红蛋白分解产物、创伤中血红蛋白介导的损伤、输血、败血症或治疗:结论:游离血红蛋白可能在创伤中发挥着重要作用:游离血红蛋白可能在多发性创伤的内皮功能障碍、器官损伤、凝血功能障碍和免疫功能障碍中发挥作用。这是一个引人注目的研究领域,因为现有的多种疗法可有效阻断这些途径。
{"title":"Cell-Free Hemoglobin in the Pathophysiology of Trauma: A Scoping Review.","authors":"James T Ross, Anamaria J Robles, Monty B Mazer, Amy C Studer, Kenneth E Remy, Rachael A Callcut","doi":"10.1097/CCE.0000000000001052","DOIUrl":"10.1097/CCE.0000000000001052","url":null,"abstract":"<p><strong>Objectives: </strong>Cell-free hemoglobin (CFH) is a potent mediator of endothelial dysfunction, organ injury, coagulopathy, and immunomodulation in hemolysis. These mechanisms have been demonstrated in patients with sepsis, hemoglobinopathies, and those receiving transfusions. However, less is known about the role of CFH in the pathophysiology of trauma, despite the release of equivalent levels of free hemoglobin.</p><p><strong>Data sources: </strong>Ovid MEDLINE, Embase, Web of Science Core Collection, and BIOSIS Previews were searched up to January 21, 2023, using key terms related to free hemoglobin and trauma.</p><p><strong>Data extraction: </strong>Two independent reviewers selected studies focused on hemolysis in trauma patients, hemoglobin breakdown products, hemoglobin-mediated injury in trauma, transfusion, sepsis, or therapeutics.</p><p><strong>Data synthesis: </strong>Data from the selected studies and their references were synthesized into a narrative review.</p><p><strong>Conclusions: </strong>Free hemoglobin likely plays a role in endothelial dysfunction, organ injury, coagulopathy, and immune dysfunction in polytrauma. This is a compelling area of investigation as multiple existing therapeutics effectively block these pathways.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10863949/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139731239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-12eCollection Date: 2024-02-01DOI: 10.1097/CCE.0000000000001054
Mariam Charkviani, Hong Hieu Truong, Nasrin Nikravangolsefid, Jacob Ninan, Larry J Prokop, Swetha Reddy, Kianoush B Kashani, Juan Pablo Domecq Garces
Objectives: Conduct a systematic review and meta-analysis to assess prevalence and timing of acute kidney injury (AKI) development after acute respiratory distress syndrome (ARDS) and its association with mortality.
Data sources: Ovid MEDLINE(R), Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO database, Scopus, and Web of Science thought April 2023.
Study selection: Titles and abstracts were screened independently and in duplicate to identify eligible studies. Randomized controlled trials and prospective or retrospective cohort studies reporting the development of AKI following ARDS were included.
Data extraction: Two reviewers independently extracted data using a pre piloted abstraction form. We used Review Manager 5.4 software (Cochrane Library, Oxford, United Kingdom) and Open Meta software (Brown University, Providence, RI) for statistical analyses.
Data synthesis: Among the 3646 studies identified and screened, 17 studies comprising 9359 ARDS patients met the eligibility criteria and were included in the meta-analysis. AKI developed in 3287 patients (40%) after the diagnosis of ARDS. The incidence of AKI at least 48 hours after ARDS diagnosis was 20% (95% CI, 0.18-0.21%). The pooled risk ratio (RR) for the hospital (or 30-d) mortality among ARDS patients who developed AKI was 1.93 (95% CI, 1.71-2.18). AKI development after ARDS was identified as an independent risk factor for mortality in ARDS patients, with a pooled odds ratio from multivariable analysis of 3.69 (95% CI, 2.24-6.09). Furthermore, two studies comparing mortality between patients with late vs. early AKI initiation after ARDS revealed higher mortality in late AKI patients with RR of 1.46 (95% CI, 1.19-1.8). However, the certainty of evidence for most outcomes was low to very low.
Conclusions: While our findings highlight a significant association between ARDS and subsequent development of AKI, the low to very low certainty of evidence underscores the need for cautious interpretation. This systematic review identified a significant knowledge gap, necessitating further research to establish a more definitive understanding of this relationship and its clinical implications.
目的:对急性呼吸窘迫综合征(ARDS)后急性肾损伤(AKI)的发生率和时间及其与死亡率的关系进行系统回顾和荟萃分析:进行系统综述和荟萃分析,评估急性呼吸窘迫综合征(ARDS)后急性肾损伤(AKI)的发生率、发生时间及其与死亡率的关系:数据来源:Ovid MEDLINE(R)、Ovid Embase、Ovid Cochrane Central Register of Controlled Trials、Ovid Cochrane Database of Systematic Reviews、Ovid PsycINFO 数据库、Scopus 和 Web of Science(认为 2023 年 4 月):对标题和摘要进行一式两份的独立筛选,以确定符合条件的研究。数据提取:两名审稿人使用预先试用的摘要表独立提取数据。我们使用 Review Manager 5.4 软件(英国牛津 Cochrane 图书馆)和 Open Meta 软件(美国罗得岛州普罗维登斯布朗大学)进行统计分析:在已确定和筛选的 3646 项研究中,有 17 项研究(包括 9359 名 ARDS 患者)符合资格标准,并被纳入荟萃分析。3287名患者(40%)在确诊ARDS后发生了AKI。在确诊 ARDS 后至少 48 小时内发生 AKI 的比例为 20%(95% CI,0.18-0.21%)。在发生 AKI 的 ARDS 患者中,住院(或 30 天)死亡率的汇总风险比 (RR) 为 1.93(95% CI,1.71-2.18)。ARDS后发生AKI被认为是导致ARDS患者死亡的一个独立风险因素,多变量分析的汇总风险比为3.69(95% CI,2.24-6.09)。此外,有两项研究比较了 ARDS 后晚期与早期 AKI 患者的死亡率,结果显示晚期 AKI 患者的死亡率更高,RR 为 1.46(95% CI,1.19-1.8)。然而,大多数结果的证据确定性较低或很低:虽然我们的研究结果突显了ARDS与后续发生AKI之间的重要关联,但证据的确定性较低或非常低,这强调了谨慎解释的必要性。本系统综述发现了一个重要的知识缺口,因此有必要开展进一步研究,以更明确地了解这种关系及其临床意义。
{"title":"Temporal Relationship and Clinical Outcomes of Acute Kidney Injury Following Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis.","authors":"Mariam Charkviani, Hong Hieu Truong, Nasrin Nikravangolsefid, Jacob Ninan, Larry J Prokop, Swetha Reddy, Kianoush B Kashani, Juan Pablo Domecq Garces","doi":"10.1097/CCE.0000000000001054","DOIUrl":"10.1097/CCE.0000000000001054","url":null,"abstract":"<p><strong>Objectives: </strong>Conduct a systematic review and meta-analysis to assess prevalence and timing of acute kidney injury (AKI) development after acute respiratory distress syndrome (ARDS) and its association with mortality.</p><p><strong>Data sources: </strong>Ovid MEDLINE(R), Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO database, Scopus, and Web of Science thought April 2023.</p><p><strong>Study selection: </strong>Titles and abstracts were screened independently and in duplicate to identify eligible studies. Randomized controlled trials and prospective or retrospective cohort studies reporting the development of AKI following ARDS were included.</p><p><strong>Data extraction: </strong>Two reviewers independently extracted data using a pre piloted abstraction form. We used Review Manager 5.4 software (Cochrane Library, Oxford, United Kingdom) and Open Meta software (Brown University, Providence, RI) for statistical analyses.</p><p><strong>Data synthesis: </strong>Among the 3646 studies identified and screened, 17 studies comprising 9359 ARDS patients met the eligibility criteria and were included in the meta-analysis. AKI developed in 3287 patients (40%) after the diagnosis of ARDS. The incidence of AKI at least 48 hours after ARDS diagnosis was 20% (95% CI, 0.18-0.21%). The pooled risk ratio (RR) for the hospital (or 30-d) mortality among ARDS patients who developed AKI was 1.93 (95% CI, 1.71-2.18). AKI development after ARDS was identified as an independent risk factor for mortality in ARDS patients, with a pooled odds ratio from multivariable analysis of 3.69 (95% CI, 2.24-6.09). Furthermore, two studies comparing mortality between patients with late vs. early AKI initiation after ARDS revealed higher mortality in late AKI patients with RR of 1.46 (95% CI, 1.19-1.8). However, the certainty of evidence for most outcomes was low to very low.</p><p><strong>Conclusions: </strong>While our findings highlight a significant association between ARDS and subsequent development of AKI, the low to very low certainty of evidence underscores the need for cautious interpretation. This systematic review identified a significant knowledge gap, necessitating further research to establish a more definitive understanding of this relationship and its clinical implications.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10863947/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139731241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}