Critical care explorations最新文献

Objectives: Anemia has been associated with an increased risk of both cardiac arrest and stroke, frequent complications of COVID-19. The effect of hemoglobin level at ICU admission on a composite outcome of cardiac arrest or stroke in an international cohort of COVID-19 patients was investigated.

Design: Retrospective analysis of prospectively collected database.

Setting: A registry of COVID-19 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with cardiac arrest or stroke up to 30 days after ICU admission. Anemia was defined as: normal (hemoglobin ≥ 12.0 g/dL for women, ≥ 13.5 g/dL for men), mild (hemoglobin 10.0-11.9 g/dL for women, 10.0-13.4 g/dL for men), moderate (hemoglobin ≥ 8.0 and < 10.0 g/dL for women and men), and severe (hemoglobin < 8.0 g/dL for women and men).

Patients: Patients older than 18 years with acute COVID-19 infection in the ICU.

Interventions: None.

Measurements and main results: Of 6926 patients (median age = 59 yr, male = 65%), 760 patients (11.0%) experienced stroke (2.0%) and/or cardiac arrest (9.4%). Cardiac arrest or stroke was more common in patients with low hemoglobin, occurring in 12.8% of patients with normal hemoglobin, 13.3% of patients with mild anemia, and 16.7% of patients with moderate/severe anemia. Time to stroke or cardiac arrest by anemia status was analyzed using Cox proportional hazards regression with death as a competing risk. Covariates selected through clinical knowledge were age, sex, comorbidities (diabetes, hypertension, obesity, and cardiac or neurologic conditions), pandemic era, country income, mechanical ventilation, and extracorporeal membrane oxygenation. Moderate/severe anemia was associated with a higher risk of cardiac arrest or stroke (hazard ratio, 1.32; 95% CI, 1.05-1.67).

Conclusions: In an international registry of ICU patients with COVID-19, moderate/severe anemia was associated with increased hazard of cardiac arrest or stroke.

Importance: Persistent hypothermia after cardiopulmonary bypass (CPB) in neonates with congenital heart defects (CHD) has been historically considered benign despite lack of evidence on its prognostic significance.

Objectives: Examine associations between the magnitude and pattern of unintentional postoperative hypothermia and odds of complications in neonates with CHD undergoing CPB.

Design: Retrospective cohort study.

Setting: Single northeastern U.S., urban pediatric quaternary care center with an established cardiac surgery program.

Participants: Population-based sample of neonates greater than or equal to 34 weeks gestation undergoing their first CPB between 2015 and 2019.

Interventions: None.

Main outcomes and measurements: Hourly temperature measurements for the first 48 postoperative hours were extracted from inpatient medical records, and clinical characteristics and outcomes were accessed through the local patient registry. Group-based trajectory modeling (GBTM) identified latent temporal temperature trajectories. Associations of trajectories with outcomes were assessed using multivariable binary logistic regression. Outcomes (postoperative complications) were manually adjudicated by experts or were predefined by the patient registry.

Results: Four hundred fifty neonates met inclusion criteria. Their mean (sd) gestational age was 38 weeks (1.3), mean (sd) birth weight was 3.19 kilograms (0.55), median (interquartile range) surgical age was 4.7 days (3.3-7.0), 284 of 450 (63%) were male, and 272 of 450 (60%) were White. GBTM identified three distinct curvilinear temperature trajectories: persistent hypothermia (n = 38, 9%), resolving hypothermia (n = 233, 52%), and normothermia (n = 179, 40%). Compared with the normothermic group, those with persistent hypothermia had significantly higher odds of cardiac arrest, actionable arrhythmia, delayed first successful extubation, prolonged cardiac ICU length of stay, very poor weight gain, and 30-day hospital mortality. The persistent hypothermia group was characterized by greater odds of having a lower gestational age, more prevalent neurologic abnormalities, more unplanned reoperations, and a low surgical mortality risk assessment.

Conclusions: Persistent postoperative hypothermia in neonates after CPB is independently associated with having greater odds of complications. Recovery patterns from postoperative hypothermia may be a clinically useful marker to identify patient instability in neonates. Additional research is needed for causal modeling and prospective validation before clinical adoption.

Objectives: To evaluate the effectiveness of ICU rounding checklists on outcomes.

Data sources: Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar) were searched from inception to May 10, 2024.

Study selection: Cohort studies, case-control studies, and randomized controlled trials comparing the use of rounding checklists to no checklists were included. Other article types were excluded.

Data extraction: The primary outcome was in-hospital mortality. Secondary outcomes included ICU and 30-day mortality; hospital and ICU length of stay (LOS); duration of mechanical ventilation; and frequency of catheter-associated urinary tract infections, central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia. Additional outcomes included healthcare provider perceptions of checklists.

Data synthesis: Pooled estimates were obtained using an inverse-variance random-effects meta-analysis model. Certainty of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation. There were 30 included studies (including > 32,000 patients) in the review. Using an ICU rounding checklist was associated with reduced in-hospital mortality (risk ratio [RR] 0.80; 95% CI, 0.70-0.92; 12 observational studies; 17,269 patients; I2 = 48%; very low certainty of evidence). The use of an ICU rounding checklist was also associated with reduced ICU mortality (8 observational studies, p = 0.006), 30-day mortality (2 observational studies, p < 0.001), hospital LOS (11 observational studies, p = 0.02), catheter-associated urinary tract infections (CAUTI) (6 observational studies, p = 0.01), and CLABSI (6 observational studies, p = 0.02). Otherwise, there were no significant differences with using ICU rounding checklists on other patient-related outcomes. Healthcare providers' perceptions of checklists were generally positive.

Conclusions: The use of an ICU rounding checklist may improve in-hospital mortality, as well as other important patient-related outcomes. However, well-designed randomized studies are necessary to increase the certainty of evidence and determine which elements should be included in an ICU rounding checklist.

Context: Sepsis leads to multiple organ dysfunction and negatively impacts patient outcomes. Skeletal muscle disuse is a significant comorbidity in septic patients during their ICU stay due to prolonged immobilization.

Hypothesis: Combination of sepsis and muscle disuse will promote a unique proteomic signature in skeletal muscle in comparison to disuse and sepsis separately.

Methods and models: Following cecal ligation and puncture (CLP) or Sham surgeries, mice were subjected to hindlimb suspension (HLS) or maintained normal ambulation (NA). Tibialis anterior muscles from 24 C57BL6/J male mice were harvested for proteomic analysis. Proteomic profiles were assessed using nano-liquid chromatography with tandem mass spectrometry, followed by data analysis including Partial Least Squares Discriminant Analysis (PLS-DA), to compare the differential protein expression across groups.

Results: A total of 2876 differentially expressed proteins were identified, with marked differences between groups. In mice subjected to CLP and HLS combined, there was a distinctive proteomic signature characterized by a significant decrease in the expression of proteins involved in mitochondrial function and muscle metabolism, alongside a marked increase in proteins related to muscle degradation pathways. The PLS-DA demonstrated a clear separation among experimental groups, highlighting the unique profile of the CLP/HLS group. This suggests an important interaction between sepsis-induced inflammation and disuse atrophy mechanisms in sepsis-induced myopathy.

Interpretations and conclusions: Our findings reveal a complex proteomic landscape in skeletal muscle exposed to sepsis and disuse, consistent with an exacerbation of muscle protein degradation under these combined stressors. The identified proteins and their roles in cellular stress responses and muscle pathology provide potential targets for intervention to mitigate muscle dysfunction in septic conditions, highlighting the importance of addressing both sepsis and disuse concurrently in clinical and experimental settings.

Objectives background: This study aimed to assess the impact of race on pulse oximetry reliability, taking into account Spo₂ ranges, COVID-19 diagnosis, and ICU admission.

Design: Retrospective cohort study covering admissions from January 2020 to April 2024.

Setting: National COVID Cohort Collaborative (N3C) database, consisting of electronic health records from 80 U.S. institutions.

Patients/subjects: Patients were selected from the N3C database based on the availability of data on self-identified race and both pulse oximetry estimated Spo₂ and Sao₂. Subgroups included patients in ICU and non-ICU settings, with or without a diagnosis of COVID-19 disease.

Interventions: None.

Measurements and main results: The agreement between Spo₂ and Sao₂ was assessed across racial groups (American Indian or Alaska Native, Asian, Black, Hispanic or Latino, Pacific Islander, and White). Each patient's initial Sao₂ measurement was matched with the closest Spo₂ values recorded within the preceding 10-minute time frame. The risk of hidden hypoxemia (Spo₂ ≥ 88% but Sao₂ < 88%) was determined for various Spo₂ ranges, races, and clinical scenarios. We used a generalized logistic mixed-effects model to evaluate the impact of relevant variables, such as COVID-19, ICU admission, age, sex, race, and Spo₂, on the risk of hidden hypoxemia, while accounting for the random effects within each hospital. A total of 80,541 patients were included, consisting of 596 American Indian or Alaska Native, 2,729 Asian, 11,889 Black, 13,154 Hispanic or Latino, 221 Pacific Islander, and 51,952 White individuals. Discrepancies between Spo₂ and Sao₂ were observed across all racial groups, with the most pronounced bias in Black patients. Hidden hypoxemia rates were higher in Black patients across all Spo₂ subgroups, for all clinical scenarios. The odds of hidden hypoxemia were higher for Black and Hispanic or Latino patients and for those with COVID-19 disease.

Conclusions: Race significantly impacts pulse oximetry reliability. Not only Black and Hispanic or Latino patients were at higher risk for hidden hypoxemia, but also those admitted with a COVID-19 diagnosis. Future in-depth explorations into the underlying causes and potential solutions are needed.

Importance: In-hospital cardiac arrest (IHCA) is a significant public health burden. Rates of return of spontaneous circulation (ROSC) have been improving, but the best way to care for patients after the initial resuscitation remains poorly understood, and improvements in survival to discharge are stagnant. Existing North American cardiac arrest databases lack comprehensive data on the postresuscitation period, and we do not know current post-IHCA practice patterns. To address this gap, we developed the Discover IHCA study, which will thoroughly evaluate current post-IHCA care practices across a diverse cohort.

Objectives: Our study collects granular data on post-IHCA treatment practices, focusing on temperature control and prognostication, with the objective of describing variation in current post-IHCA practices.

Design, setting, and participants: This is a multicenter, prospectively collected, observational cohort study of patients who have suffered IHCA and have been successfully resuscitated (achieved ROSC). There are 24 enrolling hospital systems (23 in the United States) with 69 individuals enrolling in hospitals (39 in the United States). We developed a standardized data dictionary, and data collection began in October 2023, with a projected 1000 total enrollments. Discover IHCA is endorsed by the Society of Critical Care Medicine.

Main outcomes and measures: The study collects data on patient characteristics, including prearrest frailty, arrest characteristics, and detailed information on postarrest practices and outcomes. Data collection on post-IHCA practice was structured around current American Heart Association and European Resuscitation Council guidelines. Among other data elements, the study captures postarrest temperature control interventions and postarrest prognostication methods.

Results: The majority of participating hospital systems are large, academic, tertiary care centers serving urban populations. The analysis will evaluate variations in practice and their association with mortality and neurologic function.

Conclusions and relevance: We expect this study, Discover IHCA, to identify variability in practice and outcomes following IHCA and be a vital resource for future investigations into best practices for managing patients after IHCA.

Background: Surrogates, proxies, and clinicians making shared treatment decisions for patients who have lost decision-making capacity often fail to honor patients' wishes, due to stress, time pressures, misunderstanding patient values, and projecting personal biases. Advance directives intend to align care with patient values but are limited by low completion rates and application to only a subset of medical decisions. Here, we investigate the potential of large language models (LLMs) to incorporate patient values in supporting critical care clinical decision-making for incapacitated patients in a proof-of-concept study.

Methods: We simulated text-based scenarios for 50 decisionally incapacitated patients for whom a medical condition required imminent clinical decisions regarding specific interventions. For each patient, we also simulated five unique value profiles captured using alternative formats: numeric ranking questionnaires, text-based questionnaires, and free-text narratives. We used pre-trained generative LLMs for two tasks: 1) text extraction of the treatments under consideration and 2) prompt-based question-answering to generate a recommendation in response to the scenario information, extracted treatment, and patient value profiles. Model outputs were compared with adjudications by three domain experts who independently evaluated each scenario and decision.

Results and conclusions: Automated extractions of the treatment in question were accurate for 88% (n = 44/50) of scenarios. LLM treatment recommendations received an average Likert score by the adjudicators of 3.92 of 5.00 (five being best) across all patients for being medically plausible and reasonable treatment recommendations, and 3.58 of 5.00 for reflecting the documented values of the patient. Scores were highest when patient values were captured as short, unstructured, and free-text narratives based on simulated patient profiles. This proof-of-concept study demonstrates the potential for LLMs to function as support tools for surrogates, proxies, and clinicians aiming to honor the wishes and values of decisionally incapacitated patients.

Objective: Evaluate the consistency and clinical impact of standardized multimodality neuromonitoring (MNM) interpretation and reporting within a system of care for patients with severe traumatic brain injury (sTBI).

Design: Retrospective, observational historical case-control study.

Setting: Single-center academic level I trauma center.

Interventions: Standardized interpretation of MNM data summarized within daily reports.

Measurements main results: Consecutive patients with sTBI undergoing MNM were included. Historical controls were patients monitored before implementation of standardized MNM interpretation; cases were defined as patients with available MNM interpretative reports. Patient characteristics, physiologic data, and clinical outcomes were recorded, and clinical MNM reporting elements were abstracted. The primary outcome was the Glasgow Outcome Scale score 3-6 months postinjury. One hundred twenty-nine patients were included (age 42 ± 18 yr, 82% men); 45 (35%) patients were monitored before standardized MNM interpretation and reporting, and 84 (65%) patients were monitored after that. Patients undergoing standardized interpretative reporting received fewer hyperosmotic agents (3 [1-6] vs. 6 [1-8]; p = 0.04) and spent less time above an intracranial threshold of 22 mm Hg (22% ± 26% vs. 28% ± 24%; p = 0.05). The MNM interpretation cohort had a lower proportion of anesthetic days (48% [24-70%] vs. 67% [33-91%]; p = 0.02) and higher average end-tidal carbon dioxide during monitoring (34 ± 6 mm Hg vs. 32 ± 6 mm Hg; p < 0.01; d = 0.36). After controlling for injury severity, patients undergoing standardized MNM interpretation and reporting had an odds of 1.5 (95% CI, 1.37-1.59) for better outcomes.

Conclusions: Standardized interpretation and reporting of MNM data are a novel approach to provide clinical insight and to guide individualized critical care. In patients with sTBI, independent MNM interpretation and communication to bedside clinical care teams may result in improved intracranial pressure control, fewer medical interventions, and changes in ventilatory management. In this study, the implementation of a system for management, including standardized MNM interpretation, was associated with a significant improvement in outcome.

Objective: Mean arterial pressure (MAP) plays a significant role in regulating tissue perfusion and urine output (UO). The optimal MAP target in critically ill patients remains a subject of debate. We aimed to explore the relationship between MAP and UO.

Design: A retrospective observational study.

Setting: A general ICU in a tertiary medical center.

Patients: All critically ill patients admitted to the ICU for more than 10 hours.

Interventions: None.

Measurements and main results: MAP values and hourly UO were collected in 5,207 patients. MAP levels were categorized into 10 groups of 5 mm Hg (from MAP < 60 mm Hg to MAP > 100 mg Hg), and 656,423 coupled hourly mean MAP and UO measurements were analyzed. Additionally, we compared the UO of individual patients in each MAP group with or without norepinephrine (NE) support or diuretics, as well as in patients with acute kidney injury (AKI).Hourly UO rose incrementally between MAP values of 65-100 mm Hg. Among 2,226 patients treated with NE infusion, mean UO was significantly lower in the MAP less than 60 mm Hg group (53.4 mL/hr; 95% CI, 49.3-57.5) compared with all other groups (p < 0.001), but no differences were found between groups of 75 less than or equal to MAP. Among 2500 patients with AKI, there was a linear increase in average UO from the MAP less than 60 mm Hg group (57.1 mL/hr; 95% CI, 54.2-60.0) to the group with MAP greater than or equal to 100 mm Hg (89.4 mL/hr; 95% CI, 85.7-93.1). When MAP was greater than or equal to 65 mm Hg, we observed a statistically significant trend of increased UO in periods without NE infusion.

Conclusions: Our analysis revealed a linear correlation between MAP and UO within the range of 65-100 mm Hg, also observed in the subgroup of patients treated with NE or diuretics and in those with AKI. These findings highlight the importance of tissue perfusion to the maintenance of diuresis and achieving adequate fluid balance in critically ill patients.

Objectives: Optimal timing of tracheostomy in severe traumatic brain injury (TBI) is unknown due to lack of clinical trials. We emulated a target trial to estimate the effect of early vs. delayed tracheostomy strategy on functional outcome of patients with severe TBI.

Design: Target trial emulation using 1:1 balanced risk-set matching.

Setting: North American hospitals participating in the TBI Hypertonic Saline randomized controlled trial of the Resuscitation Outcomes Consortium.

Patients: The prematching population consisted of patients with TBI and admission Glasgow Coma Scale less than or equal to 8, who were alive and on mechanical ventilation on the fourth day following trial enrollment, and stayed in the ICU for at least 5 days. Patients with absolute indication for tracheostomy and patients who died during the first 28 days with a decision to withdraw care were excluded.

Interventions: We matched patients who received tracheostomy at a certain timepoint (early group) with patients who had not received tracheostomy at the same timepoint but were at-risk of tracheostomy in the future (delayed group). The primary outcome was a poor 6-month functional outcome, defined as Glasgow Outcome Scale-Extended less than or equal to 4.

Measurements and main results: Out of 1282 patients available for analysis, 275 comprised the prematching population, with 75 pairs being created postmatching. Median time of tracheostomy differed significantly in the early vs. the delayed group (7.0 d [6.0-10.0 d] vs. 12.0 d [9.8-18.3 d]; p < 0.001). Only 40% of patients in the delayed group received tracheostomy. There was no statistically significant difference between groups regarding poor 6-month functional outcome (early: 68.0% vs. delayed: 72.0%; p = 0.593).

Conclusions: In a target trial emulation, early as opposed to delayed tracheostomy strategy was not associated with differences in 6-month functional outcome following severe TBI. Considering the limitations of target trial emulations, delaying tracheostomy through a "watchful waiting" approach may be appropriate.