Critical care explorations最新文献

Objectives: High velocity therapy (HVT), a form of high-flow oxygen therapy, utilizing a small-bore nasal cannula has been widely used in acute care settings. A new dual-prong (newDP) cannula made using more comfortable material and a single-prong (SP) cannula were evaluated to compare comfort and functionality as measured by relief of dyspnea of patients with chronic obstructive pulmonary disease (COPD) receiving HVT therapy.

Design: Randomized crossover evaluation.

Setting: Outpatient and in patient critical care setting.

Patients: Patients with hypercapnic COPD presenting with dyspnea above baseline.

Interventions: HVT therapy was provided using an existing HVT dual-prong nasal cannula (traditional) to determine the most efficacious flow rate. Patients were then randomized to receive either the newDP cannula, or the SP cannula, and retitrated for optimal flow rate. During each session of therapy, Rated Perceived Dyspnea (RPD) scores, vital signs, transcutaneous carbon dioxide partial pressure (PTCco2) levels, and clinician/ patient perceptions were documented.

Measurements and main results: Of 31 enrolled, 26 patients completed the trial. The median flow rate that relieved dyspnea for the traditional, newDP, and SP cannulas were 25 L/min (20-30 L/min), 25 L/min (19.1-30 L/min), and 15 L/min (13-17 L/min), respectively. The change in RPD from baseline for traditional, newDP, and SP were -1 (-1 to 0), -1 (-2 to -1), and -1 (-2 to -1). Change in RPD from baseline for newDP and SP compared with the traditional cannula was significantly different (p = 0.044 and p = 0.01, respectively). Changes in vital signs and PTCco2 were similar between the three cannula types compared with baseline. The SP cannula provided comparable therapeutic efficacy at significantly lower flow rates (traditional vs. SP; p < 0.0001 and newDP vs. SP; p < 0.0001).

Conclusions: The new cannula designs provided comparable relief of dyspnea. The single-prong cannula provided comparable efficacy at significantly lower flow rates (traditional vs. SP; p < 0.0001 and newDP vs. SP; p < 0.0001). The use of a single-prong cannula with HVT warrants further study.

Objectives: Malignant pertussis, the most severe manifestation of Bordetella pertussis infection, is characterized by multiple organ failure and a high mortality rate despite advanced intensive care measures. Hyperleukocytosis is the hallmark of malignant pertussis and necessitates urgent and aggressive interventions. Among the therapeutic options, leukoreduction via whole blood exchange (BE) transfusion has been associated with significant procedural risks and potential clinical deterioration. Hydroxyurea was recently proposed as a pharmacological alternative for leukoreduction. This study reports our clinical experience with hydroxyurea as an alternative to BE in managing infants with malignant pertussis admitted to a PICU.

Design: Prospective case series.

Setting: A referral PICU in France.

Patients: Critically ill infants (n = 27) with severe pertussis infection.

Interventions: Hydroxyurea therapy or BE transfusion.

Measurements and main results: We reviewed all critically ill infants admitted to our unit for severe pertussis between January 2017 and July 2024. The primary outcome was 28-day survival, and the secondary outcome was the efficacy of hydroxyurea on blood leukocyte count reduction. Among the 27 infants admitted for severe pertussis, 12 exhibited features of malignant pertussis. Of these, seven were treated with hydroxyurea and five with BE. The majority of infants were term and under 3 months old. All patients required ventilatory support, with eight on invasive mechanical ventilation and three receiving extracorporeal membrane oxygenation therapy. Overall mortality was three of 12 (25%). Hydroxyurea was administered at a dose of 20 mg/kg/d for a median duration of 12 days. Hyperleukocytosis was successfully reduced within 7 days.

Conclusions: Hydroxyurea is an alternative therapy for malignant pertussis infection that can efficiently address hyperleukocytosis with limited mortality.

A prerequisite for accurate invasive arterial pressure measurement is familiarity with measurement principles and pitfalls. Using an electronic survey, we assessed knowledge about invasive arterial pressure monitoring and current invasive arterial pressure monitoring practices in the ICU. The questionnaire was sent to nurses and physicians who are members of the French Intensive Care Society and the Réseau Européen de Recherche en Ventilation Artificielle network. Three hundred nine nurses and 76 physicians responded. We identified considerable gaps in knowledge and differences in practices that can significantly impact the reliability of invasive arterial pressure measurement, mainly the confusion between zeroing and leveling the transducer and the heterogeneity in external landmarks choice for the phlebostatic axis. In modern critical care, where mean arterial pressure targets are recommended and where patients are awake and/or frequently mobilized, standardized invasive arterial pressure monitoring is required.

A prerequisite for accurate invasive arterial pressure measurement is familiarity with measurement principles and pitfalls. Using an electronic survey, we assessed knowledge about invasive arterial pressure monitoring and current invasive arterial pressure monitoring practices in the ICU. The questionnaire was sent to nurses and physicians who are members of the French Intensive Care Society and the Réseau Européen de Recherche en Ventilation Artificielle network. Three hundred nine nurses and 76 physicians responded. We identified considerable gaps in knowledge and differences in practices that can significantly impact the reliability of invasive arterial pressure measurement, mainly the confusion between zeroing and leveling the transducer and the heterogeneity in external landmarks choice for the phlebostatic axis. In modern critical care, where mean arterial pressure targets are recommended and where patients are awake and/or frequently mobilized, standardized invasive arterial pressure monitoring is required.

Objectives: This study aimed to investigate the impact of obesity on the use of analgesics and sedatives, rates of iatrogenic withdrawal syndrome (IWS), and outcomes in mechanically ventilated pediatric patients. Additionally, it sought to assess whether a nurse-implemented sedation protocol would be equally effective for children with and without obesity.

Design: Secondary analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) pediatric multicenter clinical trial.

Setting: Thirty-one U.S. PICUs.

Patients: Children 1-17 years old, categorized as with or without obesity according to World Health Organization and Centers for Disease Control and Prevention criteria.

Interventions: None.

Measurements and main results: The study assessed various factors including medication exposure, adequacy of pain and sedation management, IWS rates, and clinical outcomes. Obesity occurred in 22% of patients. Obesity did not influence choice of opiate, but it led to extended exposure to these medications. There were no differences in dosing per kilogram of admission weight, resulting in significantly higher daily and cumulative doses in those with obesity. In the protocolized sedation arm, patients with obesity received significantly higher median opiate doses compared with the nonobesity protocolized sedation group. IWS rates did not differ; however, protocolized sedation obesity patients experienced more instances of inadequate sedation, longer time to extubation readiness, longer duration of mechanical ventilation and PICU stay, and higher 28-day in-hospital mortality than the protocolized sedation nonobesity group. These weight-based differences were not noted in the usual care arm.

Conclusions: This study underscores the significance of accounting for body habitus when selecting and dosing opiates in children with acute respiratory failure. Obesity had substantial impact on medication exposure and clinical outcomes, particularly within a structured, protocolized sedation regimen. Further research is warranted to explore the intricate relationship between medication dosing and clinical outcomes in children with obesity.

Objectives: To explore the breadth of social, demographic, and economic (SDE) factors reported in critical illness survivorship research, with a focus on how they impact survivorship outcomes.

Data sources: We obtained articles from Medline, Embase, PsycInfo, and CINAHL, as well as reference list reviews of included articles and relevant reviews captured by searches.

Study selection: SDE factors were defined as any nonmedical factor that can influence outcomes. We included primary studies published in English that explored SDE factors as an independent variable or as an outcome in post-ICU survivorship of adults. Two authors independently assessed each study for inclusion in duplicate, and conflicts were resolved by consensus. Our searches returned 7151 records, of which 83 were included for data extraction and final review.

Data extraction: We used a standardized data collection form to extract data, focusing on the characteristics of each study (i.e., year and country of publication), SDE factors explored, how the factors were measured, the impacts of SDE factors on post-ICU survivorship outcomes, and the impacts of ICU admission on SDE outcomes.

Data synthesis: We summarized the relationships between SDE factors and ICU survivorship in table format and performed a narrative synthesis. We identified 16 unique SDE factors explored in the current literature. We found that generally, higher education, income, and socioeconomic status were associated with better outcomes post-ICU; while non-White race, public insurance status, and social vulnerability were associated with poorer outcomes.

Conclusions: Various SDE factors have been explored in the critical illness survivorship literature and many are associated with post-ICU outcomes with varying effect sizes. There remains a gap in understanding longitudinal outcomes, mechanisms of how SDE factors interact with outcomes, and of the complexity and interconnectedness of these factors, all of which will be instrumental in guiding interventions to improve post-ICU survivorship.

Importance: A review of the study processes and protocols afterward by the researchers themselves is scarce.

Objectives: The present study aimed to evaluate the study design and the process of data collection of the Maastricht Intensive Care COVID (MaastrICCht) cohort during the COVID-19 pandemic. This evaluation provides information about the quality of the predefined questions and contributes to transparency in science.

Design, setting, and participants: Critical appraisal of studies using data from the MaastrICCht cohort.

Main outcomes and measures: Evaluation of the process of study design and data collection during the COVID-19 pandemic, focusing on the research process and results.

Results: From March 2020 to April 2023, all patients diagnosed with COVID-19 admitted to the ICU at Maastricht University Medical Center + (n = 544) were included in the MaastrICCht cohort. In total, 37 studies were carried out until April 2024. Fifteen studies addressed 11 of the 13 predetermined research questions, whereas 22 additional studies were performed based on the initial research questions described in the design. Furthermore, 10 studies were conducted with other researchers in national and international collaboration as a response to new arising questions based on evidence that appeared relevant during the pandemic.

Conclusions and relevance: Our critical appraisal indicated that using a study protocol enabled many publications and (inter)national collaborations, although formulating pertinent research questions in the context of a novel disease appeared daunting. Despite this, most questions were successfully addressed, whereas few were resolved by other researchers or lost importance due to the expanding body of knowledge.

Context: COVID-19 has been associated with features of a cytokine storm syndrome with some patients sharing features with the hyperinflammatory disorder, secondary hemophagocytic lymphohistiocytosis (sHLH).

Hypothesis: We hypothesized that proteins associated with sHLH from other causes will be associated with COVID-sHLH and that subjects with fatal COVID-sHLH would have defects in immune-related pathways.

Methods and models: We identified two cohorts of adult patients presenting with COVID-19 at two tertiary care hospitals in Seattle, Washington in 2020 and 2021. In this observational study, we assessed clinical laboratory values and plasma proteomics. Subjects identified as having sHLH (ferritin > 1000 plus cytopenias in two or more lineages [WBC < 5000 odds ratio [OR] ANC (absolute neutrophil count) < 1000, hemoglobin < 9 or hematocrit < 27, platelets < 100,000], and elevated transaminases [either AST (aspartate aminotransferase) or ALT (alanine aminotransferase) > 30] OR subjects with a ferritin > 3000) were compared with those with COVID-19 without sHLH. We identified 264 patients with COVID-19 of whom 24 met our sHLH definition. Eight patients who died of COVID-sHLH underwent genomic sequencing to identify variants in immune-related genes.

Results: Nine percent of enrolled COVID-19 subjects met our defined criteria for sHLH (n = 24/264). Using broad serum proteomic approaches (O-link and SomaScan), we identified three proteins increased in subjects with COVID-19-associated sHLH (soluble PD-L1 [sPD-L1], tumor necrosis factor-R1, and interleukin [IL]-18BP, p < 0.05 for O-link and false discovery rate < 0.05 for SomaScan), supporting a role for proteins previously associated with other forms of sHLH (IL-18BP and soluble tumor necrosis factor receptor 1). We also identified candidate proteins and pathways associated with COVID-sHLH, including sPD-L1 and the syntaxin pathway. We detected pathogenic variants in DOCK8 and TMPRSS15 in deceased individuals with COVID-sHLH, further suggesting that alterations in immune-related processes may contribute to hyperinflammation and fatal outcomes in COVID-19.

Interpretations and conclusions: Proteins increased in COVID-19-associated sHLH, such as sPD-L1, and pathways, such as the syntaxin pathway, suggest important roles for the immune response in driving sHLH in the context of COVID-19.

Importance: While corticosteroid administration in septic shock has been shown to result in faster shock reversal and lower short-term mortality, the role of corticosteroids in the management of cardiogenic shock (CS) remains unexplored.

Objectives: Determine the impact of corticosteroid administration on 90-day mortality (primary outcome) in patients admitted to a critical care unit with CS.

Design, setting, and participants: In this retrospective cohort study, we used the critical care database of Medical Information Mart for Intensive Care-IV, and included all adult patients diagnosed with CS excluding repeated admissions, patients with adrenal insufficiency, those receiving baseline corticosteroids, and those requiring extracorporeal life support. We considered exposure based on receiving systemic corticosteroids from 6 hours before to 24 hours post-critical care admission.

Main outcomes and measures: We calculated Cox proportional hazards using multivariate analysis for 90-day mortality (primary outcome). We also explored the association of corticosteroid use with hospital length of stay, ventilator-free days (VFDs), vasopressor-free days, ventilator-associated pneumonia, central-line-associated bloodstream infections, and hyperglycemia.

Results: We included 2000 eligible patients, with 143 (7.2%) receiving systemic corticosteroids. Corticosteroid-treated patients were younger (67.7 vs. 71.2 yr; p = 0.006), had higher Sequential Organ Failure Assessment scores at baseline (9.4 vs. 7.8; p < 0.001), and more often required vasopressors (78% vs. 63%; p < 0.001), and invasive mechanical ventilation (73% vs. 45%; p < 0.001). Corticosteroid use was associated with increased 90-day mortality in multivariate analysis (hazard ratio, 1.60; 95% CI, 1.25-2.05) and fewer VFDs (2.8 d fewer; 95% CI, 0.35-5.26) with no effect on other secondary outcomes.

Conclusions and relevance: Use of corticosteroids may be associated with increased mortality and a reduction in VFDs in patients admitted to critical care with CS. These findings suggesting potential harm of corticosteroids in CS might reflect unmeasured confounding and require corroboration through additional observational studies and ultimately randomized clinical trials.

Objectives: Sepsis is a life-threatening medical emergency, with a profound healthcare burden globally. Its pathophysiology is complex, heterogeneous and temporally dynamic, making diagnosis challenging. Medical management is predicated on early diagnosis and timely intervention. Transcriptomics is one of the novel "-omics" technologies being evaluated for recognition of sepsis. Our objective was to evaluate the performance of host gene expression biosignatures for the diagnosis of all-cause sepsis in adults.

Data sources: PubMed/Ovid Medline, Ovid Embase, and Cochrane databases from inception to June 2023.

Study selection: We included studies evaluating the performance of host gene expression biosignatures in adults who were diagnosed with sepsis using existing clinical definitions. Controls where applicable were patients without clinical sepsis.

Data extraction: Data including population demographics, sample size, study design, tissue specimen, type of transcriptome, health status of comparator group, and performance of transcriptomic biomarkers were independently extracted by at least two reviewers.

Data synthesis: Meta-analysis to describe the performance of host gene expression biosignatures for the diagnosis of sepsis in adult patients was performed using the random-effects model. Risk of bias was assessed according to the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 117 studies (n = 17,469), comprising 132 separate patient datasets, were included in our final analysis. Performance of transcriptomics for the diagnosis of sepsis against pooled controls showed area under the receiver operating characteristic curve (AUC, 0.86; 95% CI, 0.84-0.88). Studies using healthy controls showed AUC 0.87 (95% CI, 0.84-0.89), while studies using controls with systemic inflammatory response syndrome (SIRS) had AUC 0.84 (95% CI, 0.78-0.90). Transcripts with excellent discrimination against SIRS controls include UrSepsisModel, a 210 differentially expressed genes biosignature, microRNA-143, and Septicyte laboratory.

Conclusions: Transcriptomics is a promising approach for the accurate diagnosis of sepsis in adults and demonstrates good discriminatory ability against both healthy and SIRS control subjects.