Critical care explorations最新文献

Objectives: Patients who survive critical illness navigate arduous and disparate recovery pathways that include referrals and participation in community-based rehabilitation services. Examining rehabilitation pathways during recovery is crucial to understanding the relationship on patient-centered outcomes. Furthermore, an understanding of social determinants of health (SDOH) in relation to outcomes and rehabilitation use will help ensure equitable access for future care. Therefore, there is a need to define and understand patient care pathways, specifically rehabilitation after discharge, through a SDOH lens after surviving a critical illness to improve long-term outcomes.

Data sources: MEDLINE, PubMed, Web of Science Core Collection (Clarivate), the CINAHL, and the Physiotherapy Evidence Database.

Study selection and data extraction: A systematic review of the literature was completed examining literature from inception to March 2024. Articles were included if post-hospital rehabilitation utilization was reported in adult patients who survived critical illness. Discharge disposition was examined as a proxy for rehabilitation pathways. Patients were grouped by patient diagnosis for grouped analysis and reporting of data. Two independent researchers reviewed manuscripts for inclusion and data were extracted by one reviewer using Covidence. Both reviewers used the Newcastle-Ottawa Scale to assess risk of bias.

Data synthesis: Of 72 articles included, only four articles reported detailed rehabilitation utilization. The majority of the studies included were cohort studies (91.7%) with most articles using a retrospective design (56.9%). The most common patient population was acute respiratory diagnoses (51.4%). Most patients were discharged directly home from the hospital (75.4%). Race/ethnicity was the most frequently reported SDOH (43.1%) followed by insurance status (13.9%) and education (13.9%).

Conclusions: The small number of articles describing rehabilitative utilization allows for limited understanding of rehabilitation pathways following critical illness. The reporting of detailed rehabilitation utilization and SDOH are limited in the literature but may play a vital role in the recovery and outcomes of survivors of critical illness.

Importance: Sepsis, a leading cause of death in the hospital, is a heterogeneous syndrome without a defined or specific set of symptoms.

Objectives: We conducted a survey of clinicians in practice to understand which clinical findings they tend to associate with sepsis.

Design, setting, and participants: A survey was distributed to physicians and advanced practice providers across a multihospital health system during April 2022 and May 2022 querying likelihood of suspecting sepsis and initiating sepsis care in response to various normal and abnormal clinical findings.

Analysis: Strength of association between clinical findings and suspicion of sepsis were based on median and interquartile range of complete responses. Comparisons between individual questions were performed using Wilcoxon rank-sum testing.

Results: Among 179 clinicians who opened the survey, 68 (38%) completed all questions, including 53 (78%) attending physicians representing six different hospitals. Twenty-nine respondents (43%) worked primarily in the ICU, and 16 (24%) worked in the emergency department. The clinical findings most strongly associated with suspicion of sepsis were hypotension, tachypnea, coagulopathy, leukocytosis, respiratory distress, and fever. The abnormal clinical findings least likely to prompt suspicion for sepsis were elevated bilirubin, elevated troponin, and abdominal examination suggesting ileus. On average, respondents were more likely to suspect sepsis with high temperature than with low temperature (p = 0.008) and with high WBC count than with low WBC count (p = 0.003).

Conclusions: Clinicians in practice tend to associate the diagnosis of sepsis with signs of severe illness, such as hypotension or respiratory distress, and systemic inflammation, such as fever and leukocytosis. Except for coagulopathy, nonspecific laboratory indicators of organ dysfunction have less influence on decision-making.

Importance: Receipt of fluid and vasopressors, common treatments in septic shock, may affect cardiac function.

Objectives: We sought to determine whether a liberal or restrictive fluid resuscitation strategy was associated with changes in cardiac function.

Design: We prospectively studied a subset of patients enrolled in the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial, performing echocardiography at baseline and at 24 hours after randomization. Among patients who had an echocardiogram performed at 24 hours, we measured left ventricular global longitudinal strain (LV GLS) and right ventricular free-wall longitudinal strain (RVFWLS). We performed linear regressions with dependent variables of LV GLS, change in LV GLS (ΔLV GLS), and RVFWLS using treatment assignment as an independent variable. We adjusted for ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity, mean arterial pressure, and history of congestive heart failure and myocardial infarction.

Setting: Emergency department and ICUs.

Patients: Adults with sepsis enrolled in the CLOVERS trial.

Main outcomes and measures: We enrolled 180 patients. Our analytic cohort comprised 131 patients with an echocardiogram performed at 24 hours. We observed no differences between treatment arms with respect to demographic, clinical, or echocardiographic data at baseline. We observed no association between restrictive fluid assignment and LV GLS (coefficient, 1.22; p = 0.23), ΔLV GLS (-1.97; p = 0.27), or RVFWLS (2.33; p = 0.19).

Conclusions and relevance: In a subset of patients enrolled in CLOVERS, we observed no association between receipt of fluid and vasopressors and short-term changes in cardiac function. Decreased enrollment may limit inferences.

Objectives: To explore older patients' ICU admission preferences and their next-of-kins' ability to predict these preferences.

Design: Self-administered survey.

Setting: Three outpatient clinics, urban tertiary teaching hospital, Norway.

Patients: Purposive sample of outpatients 80 years old or older regarded as potential ICU candidates and their next-of-kins.

Interventions: None.

Measurements and main results: We asked about the patients' ICU admission preferences in three hypothetical scenarios of acute critical illness. Next-of-kin respondents were asked to make a proxy statement regarding the older respondents' wishes regarding ICU admission. For each treatment choice, all respondents could provide their level of confidence. Additionally, we sought to identify demographic and healthcare-related characteristics that potentially influenced ICU admission preferences and proxy accuracy. Of 202 outpatients 80 years old or older, equal proportions opted for (39%; CI, 33-45%) and against (40%; CI, 34-46%) ICU admission, and one in five (21%; CI, 17-26%) did not wish to engage decision-making. Male gender, religiosity, and prior ICU experience increased the likelihood of older respondents opting for ICU admission. Although next-of-kins' proxy statements only weakly agreed with the older respondents' true ICU admission preferences (52%; CI, 45-59%), they agreed with the next-of-kins' own ICU admission preferences (79%; CI, 73-84%) to a significantly higher degree. Decisional confidence was high for both the older and the next-of-kin respondents.

Conclusions: In this purposive sample of Norwegian potential ICU candidates 80 years old or older, we found substantial variation in the ICU admission preferences of very old patients. The next-of-kins' proxy statements did not align with the ICU admission preferences of the older respondents in half of the pairs, but next-of-kins' and older respondents' confidence levels in rendering these judgments were high.

Background: Acute illness states with increased metabolic demand can precipitate severe thiamine deficiency if physiologic needs exceed endogenous stores and supplementation. Patients with preexisting risk factors such as parenteral nutrition (PN) dependence, eating disorders, gastrointestinal disorders, or surgeries are especially vulnerable.

Case summary: A 9-year-old girl with short bowel syndrome receiving long-term PN, including standard thiamine supplementation, presented with refractory shock following aspiration. Profound hyperlactatemia, cardiac dysfunction, and vasoactive requirements persisted despite extracorporeal membrane oxygenation and resolved only after treatment with parenteral thiamine.

Conclusions: Hemodynamic collapse due to thiamine deficiency (Shoshin beriberi) may occur during acute illness in children with nutritional risk factors and should be considered in refractory hyperlactatemia. Timely treatment with parenteral thiamine can support dramatic hemodynamic recovery. Treatment of suspected thiamine deficiency should not be delayed for laboratory confirmation as current thiamine reference ranges correlate poorly with clinical severity, and functional testing may not be readily available.

Objectives: Accumulating basic science data, early clinical findings and various feasibility considerations have provided rationales for administering ketamine as a proposed rescue medication for midazolam-resistant status epilepticus (SE) in the logistically challenging prehospital environment. This report details the multiyear experience of paramedics managing midazolam-resistant SE following the introduction of a ketamine-rescue protocol.

Design: A 7-year, population-based, observational study was conducted to evaluate outcomes of patients treated with IV, intraosseous, intramuscular, or intranasal ketamine for SE despite sufficient midazolam dosings. Tracked outcomes included: 1) rapid/sustained termination of clinical seizures in adults while under paramedics' care; 2) corresponding evaluations in children/adolescents; 3) any concerning observations regarding need for assisted ventilation, intubation, or other active interventions post-ketamine; and 4) any identifiable associations between outcomes and circumstances, demographics, or medical history.

Setting: Emergency response 9-1-1 system serving a large, diverse U.S. county (jurisdictional population, 961,000/1,769 sq miles).

Patients: Those receiving ketamine from paramedics for persistent seizures.

Interventions: Adults and adolescents: 100 mg ketamine IV/intraosseous/intramuscular/intranasal; children: 1 mg/kg intramuscular/intranasal.

Measurements and main results: Among 81 total cases, 57 involved adults (18-86 yr old) receiving the SE-midazolam + ketamine protocol. Ketamine rapidly terminated convulsions in 56 (98.2%) without recurrence during prehospital and hospital arrival phases. For approved reasons, paramedics administered ketamine directly (no midazolam) in eight adults and one child, terminating convulsions in every case. Among 15 childhood/adolescent cases treated per protocol, ketamine rapidly terminated SE activity in 11, but only mitigated it in four, including two retrospectively judged to involve nonseizure activity and two involving intranasal administration. Among all 81 ketamine-treated cases, there were no identifiable clinically significant complications attributable to ketamine, particularly the need for any additional active interventions.

Conclusions: Ketamine appeared to be consistently effective in treating adults with ongoing out-of-hospital seizures that were resistant to sufficient dosings of midazolam. Similar results were observed in children/adolescents.

A growing body of critical care research draws on real-world data from electronic health records (EHRs). The bedside clinician has myriad data sources to aid in clinical decision-making, but the lack of data sharing and harmonization standards leaves much of this data out of reach for multi-institution critical care research. The Society of Critical Care Medicine (SCCM) Discovery Data Science Campaign convened a panel of critical care and data science experts to explore and document unique advantages and opportunities for leveraging EHR data in critical care research. This article reviews and illustrates six organizing topics (data domains and common data elements; data harmonization; data quality; data interoperability and digital infrastructure; data access, sharing, and governance; and ethics and equity) as a data science primer for critical care researchers, laying a foundation for future publications from the SCCM Discovery Data Harmonization and Sharing Guiding Principles Panel.

Objectives: Sepsis is an evolving process and proposed subtypes may change over time. We hypothesized that previously established sepsis subtypes are dynamic, prognostic of outcome, and trajectories are associated with host response alterations.

Design: A secondary analysis of two observational critically ill sepsis cohorts: the Molecular diAgnosis and Risk stratification of Sepsis (MARS) and the Medical Information Mart for Intensive Care-IV (MIMIC-IV).

Setting: ICUs in the Netherlands and United States between 2011-2014 and 2008-2019, respectively.

Participants: Patient admission fulfilling the Sepsis-3 criteria upon ICU admission adjudicated to one of four previously identified subtypes, comprising 2,416 admissions in MARS and 10,745 in MIMIC-IV.

Main outcomes and measures: Subtype stability and the changes per subtype on days 2, 4 and 7 of ICU admission were assessed. Next, the associated between change in clinical subtype and outcome and host response alterations.

Results: In MARS, upon ICU admission, 6% (n = 150) of the patient admissions were α-type, 3% (n = 70) β-type, 55% (n = 1317) γ-type, and 36% (n = 879) δ-type; in MIMIC-IV, this was α = 22% (n = 2398), β = 22% (n = 2365), γ = 31% (n = 3296), and δ = 25% (2686). Overall, prevalence of subtypes was stable over days 2, 4, and 7. However, 28-56% (MARS/MIMIC-IV) changed from α on ICU admission to any of the other subtypes on day 2, 33-71% from β, 57-32% from γ, and 50-48% from δ. On day 4, overall subtype persistence was 33-36%. γ or δ admissions remaining in, or transitioning to, subtype γ on days 2, 4, and 7 exhibited lower mortality rates compared with those remaining in, or transitioning to, subtype δ. Longitudinal host response biomarkers reflecting inflammation, coagulation, and endothelial dysfunction were most altered in the δ-δ group, followed by the γ-δ group, independent of the day or biomarker domain.

Conclusions and relevance: In two large cohorts, subtype change to δ was associated with worse clinical outcome and more aberrant biomarkers reflecting inflammation, coagulation, and endothelial dysfunction. These findings underscore the importance of monitoring sepsis subtypes and their linked host responses for improved prognostication and personalized treatment strategies.

Objectives: Septic shock is a common condition necessitating timely management including hemodynamic support with vasopressors. Despite the high prevalence and mortality, there is limited data characterizing patients who require three or more vasopressors. We sought to define the demographics, outcomes, and prognostic determinants associated with septic shock requiring three or more vasopressors.

Design: This is a multicenter retrospective cohort of two ICU databases, Medical Information Mart for Intensive Care IV (MIMIC-IV) and electronic ICU-Clinical Research Database, which include over 400,000 patients admitted to 342 ICUs.

Patients: Inclusion criteria entailed patients who were: 1) age 18 years old and older, 2) admitted to any ICU, 3) administered at least three vasopressors for at least 2 hours at any time during their ICU stay, and 4) identified to have sepsis based on the Sepsis-3 criteria.

Interventions: None.

Measurements and main results: A total of 3447 patients met inclusion criteria. The median age was 67 years, 60.5% were male, and 96.6% had full code orders at the time of the third vasopressor initiation. Septic shock requiring three or more vasopressors was associated with 57.6% in-hospital mortality. Code status changes occurred in 23.9% of patients following initiation of a third vasopressor. Elevated lactate upon ICU admission (odds ratio [95% CI], 2.79 [2.73-2.85]), increased duration of time between ICU admission and third vasopressor initiation (1.78 [1.69-1.87]), increased serum creatinine (1.61 [1.59-1.62]), and age above 60 years (1.47 [1.41-1.54]) were independently associated with an increased risk of mortality based on analysis of the MIMIC-IV database. Non-White race and Richmond Agitation-Sedation Scale scores were not associated with mortality.

Conclusions: Septic shock requiring three vasopressors is associated with exceptionally high mortality. Knowledge of patients at highest risk of mortality in this population may inform management and expectations conveyed in shared decision-making.