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Evaluation of Vancomycin Dose Needed to Achieve 24-Hour Area Under the Concentration-Time Curve to Minimum Inhibitory Concentration Ratio Greater Than or Equal to 400 Using Pharmacometric Approaches in Pediatric Intensive Care Patients. 使用药物计量学方法评估万古霉素在儿科重症监护患者中达到 24 小时浓度-时间曲线下面积与最低抑制浓度之比大于或等于 400 时所需的剂量。
Q4 Medicine Pub Date : 2024-10-01 DOI: 10.1097/CCE.0000000000001159
Dawoon Jung, Omayma A Kishk, Adnan T Bhutta, Ginny E Cummings, Hana M El Sahly, Manpreet K Virk, Brady S Moffett, Jennifer L Morris Daniel, Amy Watanabe, Nicholas Fishbane, Karen L Kotloff, Kenan Gu, Varduhi Ghazaryan, Jogarao V S Gobburu, Ayse Akcan-Arikan, James D Campbell

Objectives: To investigate which independent factor(s) have an impact on the pharmacokinetics of vancomycin in critically ill children, develop an equation to predict the 24-hour area under the concentration-time curve from a trough concentration, and evaluate dosing regimens likely to achieve a 24-hour area under the concentration-time curve to minimum inhibitory concentration ratio (AUC24/MIC) greater than or equal to 400.

Design: Prospective population pharmacokinetic study of vancomycin.

Setting: Critically ill patients in quaternary care PICUs.

Patients: Children 90 days old or older to younger than 18 years who received IV vancomycin treatment, irrespective of the indication for use, in the ICUs at the University of Maryland Children's Hospital and Texas Children's Hospital were enrolled.

Interventions: Vancomycin was prescribed at doses and intervals chosen by the treating clinicians.

Measurements and main results: A median of four serum levels of vancomycin per patient were collected along with other variables for up to 7 days following the first administration. These data were used to characterize vancomycin pharmacokinetics and evaluate the factors affecting the variability in achieving AUC24/MIC ratio greater than or equal to 400 in PICU patients who are not on extracorporeal therapy. A total of 302 children with a median age of 6.0 years were enrolled. A two-compartment model described the pharmacokinetics of vancomycin with the clearance of 2.76 L/hr for a typical patient weighing 20 kg. The glomerular filtration rate estimated using either the bedside Schwartz equation or the chronic kidney disease in children equation was the only statistically significant predictor of clearance among the variables evaluated, exhibiting equal predictive performance. The trough levels achieving AUC24/MIC = 400 were 5.6-10.0 μg/mL when MIC = 1 μg/mL. The target of AUC24/MIC greater than or equal to 400 was achieved in 60.4% and 36.5% with the typical dosing regimens of 15 mg/kg every 6 and 8 hours (q6h and q8h), respectively.

Conclusions: The pharmacokinetics of vancomycin in critically ill children were dependent on the estimated glomerular filtration rate only. Trough concentrations accurately predict AUC24. Typical pediatric vancomycin dosing regimens of 15 mg/kg q6h and q8h will often lead to AUC24/MIC under 400.

目的:研究哪些独立因素会影响重症儿童万古霉素的药代动力学:研究哪些独立因素会影响重症患儿体内万古霉素的药代动力学,建立从谷浓度预测24小时浓度-时间曲线下面积的方程,并评估可能实现24小时浓度-时间曲线下面积与最小抑制浓度比值(AUC24/MIC)大于或等于400的给药方案:万古霉素的前瞻性群体药代动力学研究:环境: 四级护理 PICU 的重症患者:马里兰大学儿童医院和德克萨斯儿童医院重症监护病房接受万古霉素静脉注射治疗的 90 天或以上至 18 岁以下的儿童,无论其使用指征如何:干预措施:万古霉素的剂量和间隔由主治临床医生决定:在首次用药后的长达 7 天内,收集了每位患者万古霉素血清浓度的中位数,以及其他变量。这些数据用于描述万古霉素的药代动力学特征,并评估影响未接受体外疗法的重症监护病房患者达到 AUC24/MIC 比值大于或等于 400 的变异性因素。共有 302 名中位数年龄为 6.0 岁的儿童参与了这项研究。两室模型描述了万古霉素的药代动力学,体重 20 公斤的典型患者的清除率为 2.76 升/小时。使用床旁施瓦茨方程或儿童慢性肾脏病方程估算的肾小球滤过率是所评估变量中唯一具有统计学意义的清除率预测指标,其预测效果相当。当 MIC = 1 μg/mL 时,达到 AUC24/MIC = 400 的谷值水平为 5.6-10.0 μg/mL。采用每 6 小时和 8 小时 15 毫克/千克(q6h 和 q8h)的典型给药方案,分别有 60.4% 和 36.5% 的患者达到 AUC24/MIC 大于或等于 400 的目标:万古霉素在重症儿童中的药代动力学仅取决于估计的肾小球滤过率。低浓度可准确预测 AUC24。典型的小儿万古霉素给药方案为 15 mg/kg q6h 和 q8h,其 AUC24/MIC 通常低于 400。
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引用次数: 0
Thromboembolic Complications in Continuous Versus Interrupted Anticoagulation During Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Study. 静脉体外膜氧合过程中持续抗凝与间断抗凝的血栓栓塞并发症:一项多中心研究。
Q4 Medicine Pub Date : 2024-09-25 eCollection Date: 2024-10-01 DOI: 10.1097/CCE.0000000000001155
William Miller, Jacob Braaten, Anna Rauzi, Jillian Wothe, Kristiana Sather, Angela Phillips, Danika Evans, Ramiro Saavedra-Romero, Matthew Prekker, Melissa E Brunsvold

Objectives: Continuous, therapeutic anticoagulation is the standard of care for patients on extracorporeal membrane oxygenation (ECMO). The risks of hemorrhage exacerbated by anticoagulation must be weighed with the thrombotic risks associated with ECMO. We hypothesized increased thrombotic events in patients who had interrupted (vs. continuous) anticoagulation during venovenous ECMO.

Design: This is a retrospective, observational study.

Setting: Enrollment of individuals took place at three adult ECMO centers in Minnesota from 2013 to 2022.

Patients: This study consists of 346 patients supported with venovenous ECMO.

Interventions: Anticoagulation administration was collected from electronic health records, including frequency and duration of anticoagulation interruptions (IAs) and timing and type of thrombotic events, and data were analyzed using descriptive statistics.

Measurements and main results: A total of 156 patients had IA during their ECMO run and 190 had continuous anticoagulation. Risk adjusted logistic regression demonstrated that individuals in the IA group were not statistically more likely to experience a thrombotic complication (odds ratio [OR], 0.69; 95% CI, 0.27-1.70) or require ECMO circuit change (OR, 1.36; 95% CI, 0.52-3.49). Subgroup analysis demonstrated greater frequency of overall thrombotic events with increasing frequency and duration of anticoagulation being interrupted (p = 0.001).

Conclusions: Our multicenter analysis found a similar frequency of thrombotic events in patients on ECMO when anticoagulation was interrupted vs. administered continuously. Further investigation into the impact of the frequency and duration of these interruptions is warranted.

目的:持续治疗性抗凝是体外膜氧合(ECMO)患者的标准护理方法。必须权衡抗凝加重出血的风险和与 ECMO 相关的血栓风险。我们假设在静脉 ECMO 期间间断(与持续)抗凝的患者血栓事件会增加:这是一项回顾性观察研究:2013年至2022年期间,明尼苏达州的三家成人ECMO中心招募了患者:本研究包括 346 名接受静脉 ECMO 支持的患者:从电子健康记录中收集抗凝管理,包括抗凝中断(IAs)的频率和持续时间以及血栓事件的时间和类型,并使用描述性统计对数据进行分析:共有 156 名患者在 ECMO 运行期间发生过 IA,190 名患者进行了持续抗凝治疗。风险调整后的逻辑回归显示,IA 组患者发生血栓并发症(几率比 [OR],0.69;95% CI,0.27-1.70)或需要更换 ECMO 电路(OR,1.36;95% CI,0.52-3.49)的可能性并不高。亚组分析表明,随着抗凝治疗中断频率和持续时间的增加,血栓事件的发生频率也会增加(P = 0.001):我们的多中心分析发现,ECMO 患者中断抗凝与持续抗凝发生血栓事件的频率相似。我们有必要进一步研究这些中断的频率和持续时间的影响。
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引用次数: 0
Antiseizure Medications in Adult Patients With Traumatic Brain Injury: A Systematic Review and Bayesian Network Meta-Analysis. 创伤性脑损伤成人患者的抗癫痫药物治疗:系统回顾与贝叶斯网络元分析》。
Q4 Medicine Pub Date : 2024-09-25 eCollection Date: 2024-10-01 DOI: 10.1097/CCE.0000000000001160
Federico Angriman, Shaurya Taran, Natalia Angeloni, Catherine Devion, Jong Woo Lee, Neill K J Adhikari

Objectives: We sought to evaluate the effectiveness of any antiseizure medication on the incidence of early post-traumatic seizures among adult patients with traumatic brain injury.

Data sources: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, and LILACS were searched from inception to October 2023.

Study selection: We included randomized trials of adult patients with traumatic brain injury evaluating any antiseizure medication compared with either placebo or another agent.

Data extraction: Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Our main outcome of interest was the occurrence of early seizures (i.e., within 7 d); secondary outcomes included late-seizures and all-cause mortality.

Data synthesis: Bayesian network meta-analyses were used to derive risk ratios (RRs) alongside 95% credible intervals (CrIs). We used Grading of Recommendations Assessment, Development, and Evaluation methodology to rate the certainty in our findings. Overall, ten individual randomized controlled trials (1851 participants) were included. Compared with placebo, phenytoin (RR, 0.28; 95% CrI, 0.13-0.57; moderate certainty) and levetiracetam (RR, 0.20; 95% CrI, 0.07-0.60; moderate certainty) were associated with a reduction in the risk of early seizures. Carbamazepine may be associated with a reduced risk of early seizures, but the evidence is very uncertain (RR, 0.41; 95% CrI, 0.12-1.27; very low certainty). Valproic acid may result in little to no difference in the risk of early seizures, but the evidence is very uncertain (RR, 0.97; 95% CrI, 0.16-9.00; very low certainty). The evidence is very uncertain about the impact of any antiseizure medication on the risk of late seizures or all-cause mortality at longest reported follow-up time.

Conclusions: Phenytoin or levetiracetam reduce the risk of early seizures among adult patients with traumatic brain injury. Further research is needed to evaluate required duration of therapy and long-term safety profiles.

研究目的我们试图评估任何抗癫痫药物对成年脑外伤患者创伤后早期癫痫发作的有效性:数据来源:检索了从开始到 2023 年 10 月的 MEDLINE、Embase、PubMed、Cochrane Central Register of Controlled Trials 和 LILACS:我们纳入了针对成年脑外伤患者的随机试验,这些试验评估了任何抗癫痫药物与安慰剂或其他药物的比较:两名审稿人独立提取单个研究数据,并使用 Cochrane 偏倚风险工具评估研究的偏倚风险。我们关注的主要结果是早期癫痫发作的发生率(即 7 d 内);次要结果包括晚期癫痫发作和全因死亡率:采用贝叶斯网络荟萃分析法得出风险比(RRs)和 95% 可信区间(CrIs)。我们采用建议分级评估、发展和评价方法来评定研究结果的确定性。总共纳入了十项随机对照试验(1851 名参与者)。与安慰剂相比,苯妥英(RR,0.28;95% CrI,0.13-0.57;中等确定性)和左乙拉西坦(RR,0.20;95% CrI,0.07-0.60;中等确定性)与早期癫痫发作风险的降低有关。卡马西平可能与降低早期癫痫发作风险有关,但证据非常不确定(RR,0.41;95% CrI,0.12-1.27;极低确定性)。丙戊酸可能导致早期癫痫发作风险几乎没有差异,但证据非常不确定(RR,0.97;95% CrI,0.16-9.00;确定性很低)。在报告的最长随访时间内,任何抗癫痫药物对晚期癫痫发作或全因死亡风险的影响都很不确定:结论:苯妥英或左乙拉西坦能降低成年脑外伤患者早期癫痫发作的风险。还需要进一步的研究来评估所需的治疗时间和长期安全性。
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引用次数: 0
Statistical Power and Performance of Strategies to Analyze Composites of Survival and Duration of Ventilation in Clinical Trials. 临床试验中分析存活率和通气时间复合值策略的统计能力和性能。
Q4 Medicine Pub Date : 2024-09-20 eCollection Date: 2024-10-01 DOI: 10.1097/CCE.0000000000001152
Ziming Chen, Michael O Harhay, Eddy Fan, Anders Granholm, Daniel F McAuley, Martin Urner, Christopher J Yarnell, Ewan C Goligher, Anna Heath

Background: Patients with acute hypoxemic respiratory failure are at high risk of death and prolonged time on the ventilator. Interventions often aim to reduce both mortality and time on the ventilator. Many methods have been proposed for analyzing these endpoints as a single composite outcome (days alive and free of ventilation), but it is unclear which analytical method provides the best performance. Thus, we aimed to determine the analysis method with the highest statistical power for use in clinical trials.

Methods: Using statistical simulation, we compared multiple methods for analyzing days alive and free of ventilation: the t, Wilcoxon rank-sum, and Kryger Jensen and Lange tests, as well as the proportional odds, hurdle-Poisson, and competing risk models. We compared 14 scenarios relating to: 1) varying baseline distributions of mortality and duration of ventilation, which were based on data from a registry of patients with acute hypoxemic respiratory failure and 2) the varying effects of treatment on mortality and duration of ventilation.

Results and conclusions: All methods have good control of type 1 error rates (i.e., avoid false positive findings). When data are simulated using a proportional odds model, the t test and ordinal models have the highest relative power (92% and 90%, respectively), followed by competing risk models. When the data are simulated using survival models, the competing risk models have the highest power (100% and 92%), followed by the t test and a ten-category ordinal model. All models struggled to detect the effect of the intervention when the treatment only affected one of mortality and duration of ventilation. Overall, the best performing analytical strategy depends on the respective effects of treatment on survival and duration of ventilation and the underlying distribution of the outcomes. The evaluated models each provide a different interpretation for the treatment effect, which must be considered alongside the statistical power when selecting analysis models.

背景:急性低氧血症呼吸衰竭患者死亡风险高,使用呼吸机时间长。干预措施通常旨在降低死亡率和缩短使用呼吸机的时间。将这些终点作为单一综合结果(存活天数和无通气时间)进行分析的方法有很多,但目前还不清楚哪种分析方法性能最佳。因此,我们的目标是确定在临床试验中具有最高统计能力的分析方法:通过统计模拟,我们比较了多种分析存活和无通气天数的方法:t 检验、Wilcoxon 秩和检验、Kryger Jensen 和 Lange 检验,以及比例几率模型、障碍-泊松模型和竞争风险模型。我们对以下 14 种情况进行了比较1)死亡率和通气时间的不同基线分布,这些数据基于急性低氧血症呼吸衰竭患者的登记数据;2)治疗对死亡率和通气时间的不同影响:所有方法都能很好地控制 1 类错误率(即避免出现假阳性结果)。当使用比例几率模型模拟数据时,t 检验和序数模型的相对功率最高(分别为 92% 和 90%),其次是竞争风险模型。当使用生存模型模拟数据时,竞争风险模型的效力最高(100% 和 92%),其次是 t 检验和十类序数模型。当治疗只影响死亡率和通气时间中的一项时,所有模型都很难检测出干预的效果。总的来说,最佳分析策略取决于治疗对存活率和通气时间的影响以及结果的基本分布。所评估的模型对治疗效果的解释各不相同,在选择分析模型时必须同时考虑统计能力。
{"title":"Statistical Power and Performance of Strategies to Analyze Composites of Survival and Duration of Ventilation in Clinical Trials.","authors":"Ziming Chen, Michael O Harhay, Eddy Fan, Anders Granholm, Daniel F McAuley, Martin Urner, Christopher J Yarnell, Ewan C Goligher, Anna Heath","doi":"10.1097/CCE.0000000000001152","DOIUrl":"10.1097/CCE.0000000000001152","url":null,"abstract":"<p><strong>Background: </strong>Patients with acute hypoxemic respiratory failure are at high risk of death and prolonged time on the ventilator. Interventions often aim to reduce both mortality and time on the ventilator. Many methods have been proposed for analyzing these endpoints as a single composite outcome (days alive and free of ventilation), but it is unclear which analytical method provides the best performance. Thus, we aimed to determine the analysis method with the highest statistical power for use in clinical trials.</p><p><strong>Methods: </strong>Using statistical simulation, we compared multiple methods for analyzing days alive and free of ventilation: the t, Wilcoxon rank-sum, and Kryger Jensen and Lange tests, as well as the proportional odds, hurdle-Poisson, and competing risk models. We compared 14 scenarios relating to: 1) varying baseline distributions of mortality and duration of ventilation, which were based on data from a registry of patients with acute hypoxemic respiratory failure and 2) the varying effects of treatment on mortality and duration of ventilation.</p><p><strong>Results and conclusions: </strong>All methods have good control of type 1 error rates (i.e., avoid false positive findings). When data are simulated using a proportional odds model, the t test and ordinal models have the highest relative power (92% and 90%, respectively), followed by competing risk models. When the data are simulated using survival models, the competing risk models have the highest power (100% and 92%), followed by the t test and a ten-category ordinal model. All models struggled to detect the effect of the intervention when the treatment only affected one of mortality and duration of ventilation. Overall, the best performing analytical strategy depends on the respective effects of treatment on survival and duration of ventilation and the underlying distribution of the outcomes. The evaluated models each provide a different interpretation for the treatment effect, which must be considered alongside the statistical power when selecting analysis models.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 10","pages":"e1152"},"PeriodicalIF":0.0,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11419436/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303479","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}
引用次数: 0
The Association Between Vasopressin and Adverse Kidney Outcomes in Children and Young Adults Requiring Vasopressors on Continuous Renal Replacement Therapy. 需要使用血管加压素进行持续肾脏替代治疗的儿童和青少年中,血管加压素与肾脏不良结果之间的关系。
Q4 Medicine Pub Date : 2024-09-20 eCollection Date: 2024-10-01 DOI: 10.1097/CCE.0000000000001156
Denise C Hasson, Katja M Gist, JangDong Seo, Erin K Stenson, Aaron Kessel, Taiki Haga, Sara LaFever, Maria Jose Santiago, Matthew Barhight, David Selewski, Zaccaria Ricci, Nicholas J Ollberding, Natalja L Stanski

Objectives: Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults.

Design: Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study.

Setting: Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021.

Patients/subjects: Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1-2), and late (days 3-7).

Interventions: None.

Measurements and main results: Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20-2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17-6.11; p = 0.02) compared with early initiation.

Conclusions: Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.

目的:持续肾脏替代疗法 (CRRT) 和休克都与重症监护病房的高发病率和高死亡率有关。成人数据表明,血管加压素与儿茶酚胺(去甲肾上腺素和肾上腺素)相比具有肾保护作用。我们旨在确定在 CRRT 期间使用血管加压素是否与改善儿童和年轻成人的肾脏预后有关:设计:全球肾脏病肾脏替代治疗结果合作研究(WE-ROCK)的二次分析,这是一项多中心、回顾性队列研究:2015年1月1日至2021年12月31日期间全球34个中心的新生儿、心脏和重症监护病房:因急性肾损伤和/或体液超负荷接受CRRT治疗并需要使用血管加压素的25岁以下患者。接受血管加压素治疗的患者与仅接受去甲肾上腺素/肾上腺素治疗的患者进行了比较。通过将患者分为早期(第0天或之前)、中期(第1-2天)和晚期(第3-7天),评估了血管加压素相对于CRRT开始时间的影响:无干预措施:在 1016 名患者中,有 665 人(65%)在 CRRT 第一周需要使用血管加压药。在这 665 名患者中,248 人(37%)接受了血管加压素治疗,473 人(71%)在 90 天内发生了重大肾脏不良事件(MAKE-90)(死亡、依赖肾脏替代疗法和/或自 CRRT 开始 90 天后血清肌酐较基线升高 > 125%),195 人(29%)在 28 天内首次尝试 CRRT 即脱离了 CRRT。接受血管加压素与更高的 MAKE-90 机率相关(调整后的机率比 [aOR],1.80;95% CI,1.20-2.71;p = 0.005),但与解脱成功率无关。在血管加压素组中,与早期启动相比,中期/晚期启动与更高的MAKE-90几率相关(aOR,2.67;95% CI,1.17-6.11;p = 0.02):近三分之二接受 CRRT 的儿童和青少年需要使用血管加压药,其中超过三分之一的人使用血管加压素。接受血管加压素与更多的 MAKE-90 有关,但接受血管加压素的人更早开始治疗似乎是有益的。需要进行前瞻性研究,以了解使用血管加压素的适当时机、剂量和亚人群。
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引用次数: 0
Erratum: Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum. 勘误:非创伤性成人院内心脏骤停抢救过程中的心包穿刺术、胸导管插入术和针刺胸腔造口术:回顾性队列研究:勘误。
Q4 Medicine Pub Date : 2024-09-17 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001158

[This corrects the article DOI: 10.1097/CCE.0000000000001130.].

[此处更正了文章 DOI:10.1097/CCE.0000000000001130]。
{"title":"Erratum: Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum.","authors":"","doi":"10.1097/CCE.0000000000001158","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001158","url":null,"abstract":"<p><p>[This corrects the article DOI: 10.1097/CCE.0000000000001130.].</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 9","pages":"e1158"},"PeriodicalIF":0.0,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11412716/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303493","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}
引用次数: 0
Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum. 非创伤性成人院内心脏骤停抢救过程中的心包穿刺、胸腔置管和针刺胸腔造口术:回顾性队列研究:勘误。
Q4 Medicine Pub Date : 2024-09-17 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001158
{"title":"Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum.","authors":"","doi":"10.1097/CCE.0000000000001158","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001158","url":null,"abstract":"","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 9","pages":"e1158"},"PeriodicalIF":0.0,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study. 急性呼吸衰竭患者使用限时试验的特点:一项前瞻性单中心观察研究。
Q4 Medicine Pub Date : 2024-09-16 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001148
Joy X Moy, Anica C Law, Lily N Stalter, Michael D Peliska, Geralyn Palmer, Bret M Hanlon, Sean Mortenson, Elizabeth M Viglianti, Douglas A Wiegmann, Jacqueline M Kruser

Importance: A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.

Objectives: To characterize TLT use in patients with acute respiratory failure (ARF).

Design, setting, and participants: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.

Main outcomes and measures: Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.

Results: Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).

Conclusions and relevance: In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

重要性:有时间限制的试验(TLT)是临床医生、患者和家属之间的一项合作计划,在规定的时间内使用维持生命疗法,之后根据患者的反应决定是继续以康复为目标的护理,还是将重点转向舒适。TLT是一种很有前景的方法,有助于应对危重病中的不确定性,但人们对其目前的使用情况知之甚少:描述急性呼吸衰竭(ARF)患者使用 TLT 的情况:美国一家学术医疗中心对接受有创机械通气超过或等于 48 小时的急性呼吸衰竭成人 ICU 患者进行了为期 12 个月的前瞻性队列观察研究:主要暴露是参与 TLT,由患者的 ICU 医生确定。从电子病历中提取患者特征、护理服务要素和住院结果:在 176 名符合条件的患者中,36 人(20.5%)参加了 TLT。在 18 位重症监护室主治医生中,有 9 位(50%)参与了大于或等于 1 次 TLT(频率为所护理患者的 0-39%)。TLT 的中位持续时间为 3.0 天(四分位数间距 [IQR],3.0-4.5 天)。TLT患者的平均年龄较高(67.4 岁 [sd,12.0 岁] vs. 60.0 岁 [sd,16.0 岁];P < 0.01),Charlson合并症指数较高(5.1 [sd,2.2] vs. 3.8[sd,2.6];p < 0.01),与非 TLT 患者相比,器官功能衰竭序列评估评分相似(9.6 [sd, 3.3] vs. 9.5 [sd, 3.7];p = 0.93)。TLT患者更有可能死亡或出院接受临终关怀(80.6% vs. 42.1%;p < 0.05),ICU住院时间更短(中位数,5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d];p < 0.01):在这项研究中,约五分之一的 ARF 患者参加了 TLT。我们的研究结果表明,TLT 主要用于临近生命末期的患者,但医生的使用情况存在很大差异,因此需要证据来指导最佳使用。
{"title":"Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study.","authors":"Joy X Moy, Anica C Law, Lily N Stalter, Michael D Peliska, Geralyn Palmer, Bret M Hanlon, Sean Mortenson, Elizabeth M Viglianti, Douglas A Wiegmann, Jacqueline M Kruser","doi":"10.1097/CCE.0000000000001148","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001148","url":null,"abstract":"<p><strong>Importance: </strong>A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.</p><p><strong>Objectives: </strong>To characterize TLT use in patients with acute respiratory failure (ARF).</p><p><strong>Design, setting, and participants: </strong>Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.</p><p><strong>Main outcomes and measures: </strong>Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.</p><p><strong>Results: </strong>Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).</p><p><strong>Conclusions and relevance: </strong>In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 9","pages":"e1148"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11407817/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303420","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}
引用次数: 0
Utility of Skin Tone on Pulse Oximetry in Critically Ill Patients: A Prospective Cohort Study. 重症患者肤色对脉搏氧饱和度的影响:一项前瞻性队列研究
Q4 Medicine Pub Date : 2024-09-13 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001133
Sicheng Hao, Katelyn Dempsey, João Matos, Christopher E Cox, Veronica Rotemberg, Judy W Gichoya, Warren Kibbe, Chuan Hong, An-Kwok Ian Wong

Objective: Pulse oximetry, a ubiquitous vital sign in modern medicine, has inequitable accuracy that disproportionately affects minority Black and Hispanic patients, with associated increases in mortality, organ dysfunction, and oxygen therapy. Previous retrospective studies used self-reported race or ethnicity as a surrogate for skin tone which is believed to be the root cause of the disparity. Our objective was to determine the utility of skin tone in explaining pulse oximetry discrepancies.

Design: Prospective cohort study.

Setting: Patients were eligible if they had pulse oximetry recorded up to 5 minutes before arterial blood gas (ABG) measurements. Skin tone was measured using administered visual scales, reflectance colorimetry, and reflectance spectrophotometry.

Participants: Admitted hospital patients at Duke University Hospital.

Interventions: None.

Measurements and main results: Sao2-Spo2 bias, variation of bias, and accuracy root mean square, comparing pulse oximetry, and ABG measurements. Linear mixed-effects models were fitted to estimate Sao2-Spo2 bias while accounting for clinical confounders.One hundred twenty-eight patients (57 Black, 56 White) with 521 ABG-pulse oximetry pairs were recruited. Skin tone data were prospectively collected using six measurement methods, generating eight measurements. The collected skin tone measurements were shown to yield differences among each other and overlap with self-reported racial groups, suggesting that skin tone could potentially provide information beyond self-reported race. Among the eight skin tone measurements in this study, and compared with self-reported race, the Monk Scale had the best relationship with differences in pulse oximetry bias (point estimate: -2.40%; 95% CI, -4.32% to -0.48%; p = 0.01) when comparing patients with lighter and dark skin tones.

Conclusions: We found clinical performance differences in pulse oximetry, especially in darker skin tones. Additional studies are needed to determine the relative contributions of skin tone measures and other potential factors on pulse oximetry discrepancies.

目的:脉搏血氧仪是现代医学中无处不在的生命体征,但其准确性不公平,对黑人和西班牙裔少数群体患者的影响尤为严重,死亡率、器官功能障碍和氧疗的相关费用也随之增加。以往的回顾性研究使用自我报告的种族或民族作为肤色的替代物,这被认为是造成差异的根本原因。我们的目标是确定肤色在解释脉搏血氧饱和度差异方面的效用:前瞻性队列研究:在动脉血气 (ABG) 测量前 5 分钟记录脉搏氧饱和度的患者均符合条件。肤色测量采用管理视觉量表、反射比色法和反射分光光度法进行:干预措施:无:测量和主要结果比较脉搏血氧仪和 ABG 测量的 Sao2-Spo2 偏差、偏差变化和准确度均方根。在考虑临床混杂因素的同时,拟合线性混合效应模型以估计 Sao2-Spo2 偏差。采用六种测量方法前瞻性地收集了肤色数据,共产生了八种测量结果。结果显示,所收集的肤色测量值之间存在差异,并与自我报告的种族群体重叠,这表明肤色有可能提供自我报告的种族以外的信息。在本研究的八种肤色测量方法中,与自我报告的种族相比,当比较浅肤色和深肤色患者时,蒙克量表与脉搏氧饱和度偏差差异的关系最好(点估计值:-2.40%;95% CI,-4.32% 至 -0.48%;p = 0.01):我们发现脉搏氧饱和度的临床表现存在差异,尤其是肤色较深的患者。需要进行更多的研究来确定肤色测量和其他潜在因素对脉搏血氧饱和度差异的相对影响。
{"title":"Utility of Skin Tone on Pulse Oximetry in Critically Ill Patients: A Prospective Cohort Study.","authors":"Sicheng Hao, Katelyn Dempsey, João Matos, Christopher E Cox, Veronica Rotemberg, Judy W Gichoya, Warren Kibbe, Chuan Hong, An-Kwok Ian Wong","doi":"10.1097/CCE.0000000000001133","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001133","url":null,"abstract":"<p><strong>Objective: </strong>Pulse oximetry, a ubiquitous vital sign in modern medicine, has inequitable accuracy that disproportionately affects minority Black and Hispanic patients, with associated increases in mortality, organ dysfunction, and oxygen therapy. Previous retrospective studies used self-reported race or ethnicity as a surrogate for skin tone which is believed to be the root cause of the disparity. Our objective was to determine the utility of skin tone in explaining pulse oximetry discrepancies.</p><p><strong>Design: </strong>Prospective cohort study.</p><p><strong>Setting: </strong>Patients were eligible if they had pulse oximetry recorded up to 5 minutes before arterial blood gas (ABG) measurements. Skin tone was measured using administered visual scales, reflectance colorimetry, and reflectance spectrophotometry.</p><p><strong>Participants: </strong>Admitted hospital patients at Duke University Hospital.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Sao2-Spo2 bias, variation of bias, and accuracy root mean square, comparing pulse oximetry, and ABG measurements. Linear mixed-effects models were fitted to estimate Sao2-Spo2 bias while accounting for clinical confounders.One hundred twenty-eight patients (57 Black, 56 White) with 521 ABG-pulse oximetry pairs were recruited. Skin tone data were prospectively collected using six measurement methods, generating eight measurements. The collected skin tone measurements were shown to yield differences among each other and overlap with self-reported racial groups, suggesting that skin tone could potentially provide information beyond self-reported race. Among the eight skin tone measurements in this study, and compared with self-reported race, the Monk Scale had the best relationship with differences in pulse oximetry bias (point estimate: -2.40%; 95% CI, -4.32% to -0.48%; p = 0.01) when comparing patients with lighter and dark skin tones.</p><p><strong>Conclusions: </strong>We found clinical performance differences in pulse oximetry, especially in darker skin tones. Additional studies are needed to determine the relative contributions of skin tone measures and other potential factors on pulse oximetry discrepancies.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 9","pages":"e1133"},"PeriodicalIF":0.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study. 成人长期重症患者质量改进工具的代码设计:改良德尔菲共识研究。
Q4 Medicine Pub Date : 2024-09-12 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001146
Laura Allum, Natalie Pattison, Bronwen Connolly, Chloe Apps, Katherine Cowan, Emily Flowers, Nicholas Hart, Louise Rose

Objectives: Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.

Design: Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.

Setting: Carried out in the United Kingdom.

Patients/subjects: Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.

Interventions: None.

Measurements and main results: We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted "critically important" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.

Conclusions: Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.

目的:越来越多的患者需要长期接受重症监护。然而,用于提高安全性和规范护理的现有质量改进(QI)工具并不是针对他们的特殊需求而设计的。这可能会导致错失护理机会,并造成更坏的结果。根据基于经验的编码设计流程,我们的目标是就最重要的可操作护理流程达成共识,以便将其纳入针对长期重症成人患者的 QI 工具:设计:从之前的系统性回顾以及对既往患者、其护理伙伴和临床医生的访谈中确定项目。进行了两轮在线改良德尔菲调查,要求参与者对每个项目进行评分,根据其对有效护理的重要性从 1 到 9 分进行评分;其中 1-3 分不重要,4-6 分重要但不关键,7-9 分非常重要,可纳入 QI 工具。然后由一名独立主持人主持召开最后的共识会议,进一步讨论并确定项目的优先次序:患者/研究对象:在英国进行:干预措施:无:测量和主要结果我们招募了 116 名参与者:在德尔菲第一轮中,我们招募了 63 名医护人员(54%)、45 名患者(39%)和 8 名亲属(7%),并在第二轮中保留了 91 人(78%)。在最初确定的 39 个项目中,有 32 个项目被超过 70% 的德尔菲参与者评为 "极其重要",可纳入 QI 工具。在与 15 名重症监护室临床医生、4 名既往患者和 1 名家属举行的共识会议上,这些项目被进一步排序,最终的 QI 工具包含 25 个项目,其中包括促进患者和家属参与决策、提供连续性护理以及结构化呼吸机断奶和康复:通过基于经验的编码设计和严格的建立共识方法,我们确定了针对长期危重症成人患者的 QI 工具的重要内容。了解工具的可接受性和最佳实施策略的工作正在进行中。
{"title":"Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study.","authors":"Laura Allum, Natalie Pattison, Bronwen Connolly, Chloe Apps, Katherine Cowan, Emily Flowers, Nicholas Hart, Louise Rose","doi":"10.1097/CCE.0000000000001146","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001146","url":null,"abstract":"<p><strong>Objectives: </strong>Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.</p><p><strong>Design: </strong>Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.</p><p><strong>Setting: </strong>Carried out in the United Kingdom.</p><p><strong>Patients/subjects: </strong>Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted \"critically important\" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.</p><p><strong>Conclusions: </strong>Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 9","pages":"e1146"},"PeriodicalIF":0.0,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303490","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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Critical care explorations
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