Critical care explorations最新文献

Objective: To train and test supervised machine learning (ML) models to predict low cardiac output syndrome (LCOS) within the first 48 postoperative hours in neonates undergoing cardiothoracic surgery.

Design: Retrospective observational study. An efficient tree-based gradient-boosting algorithm (LightGBM) ML models were developed to predict LCOS occurrence at 2-, 4-, 6-, and 12-hour forecasting horizons, incorporating data from the prediction time and the two preceding hours. SHapley Additive exPlanations (SHAP) analyses were used for feature importance analyses.

Setting: Single center, January 2012 to April 2023.

Patients: Neonates 28 days old or younger who underwent cardiothoracic surgery.

Interventions: None.

Measurements and main results: A total of 181 neonates were included, with 14.9% experiencing LCOS. A multivariate time-series dataset was constructed using hourly clinical and laboratory variables recorded during the first 48 postoperative hours. The LightGBM ML models achieved area under the receiver operating characteristic curve values ranging from 0.91 to 0.98 and area under the precision-recall curve values ranging from 0.60 to 0.80 for LCOS prediction across 2-, 4-, 6-, and 12-hour forecasting horizons. SHAP analyses identified higher vasoactive inotrope score, lower urine output, and higher serum lactate as the most influential predictors.

Conclusions: This study demonstrates that the supervised machine learning models can accurately predict LCOS in neonates, offering high interpretability. The findings support further validation in multicenter settings and integration into clinical workflows to enhance postoperative critical cardiac care neonates.

Objective: To train and test supervised machine learning (ML) models to predict low cardiac output syndrome (LCOS) within the first 48 postoperative hours in neonates undergoing cardiothoracic surgery.

Design: Retrospective observational study. An efficient tree-based gradient-boosting algorithm (LightGBM) ML models were developed to predict LCOS occurrence at 2-, 4-, 6-, and 12-hour forecasting horizons, incorporating data from the prediction time and the two preceding hours. SHapley Additive exPlanations (SHAP) analyses were used for feature importance analyses.

Setting: Single center, January 2012 to April 2023.

Patients: Neonates 28 days old or younger who underwent cardiothoracic surgery.

Interventions: None.

Measurements and main results: A total of 181 neonates were included, with 14.9% experiencing LCOS. A multivariate time-series dataset was constructed using hourly clinical and laboratory variables recorded during the first 48 postoperative hours. The LightGBM ML models achieved area under the receiver operating characteristic curve values ranging from 0.91 to 0.98 and area under the precision-recall curve values ranging from 0.60 to 0.80 for LCOS prediction across 2-, 4-, 6-, and 12-hour forecasting horizons. SHAP analyses identified higher vasoactive inotrope score, lower urine output, and higher serum lactate as the most influential predictors.

Conclusions: This study demonstrates that the supervised machine learning models can accurately predict LCOS in neonates, offering high interpretability. The findings support further validation in multicenter settings and integration into clinical workflows to enhance postoperative critical cardiac care neonates.

The impact of common hemoglobinopathies, such as sickle cell trait (SCT), on outcomes in adults requiring extracorporeal membrane oxygenation (ECMO) remains understudied. Extracorporeal Life Support Organization registry data was analyzed to assess outcomes of adults with SCT or sickle cell disease (SCD) who underwent venoarterial or venovenous ECMO. Among 215 patients identified, 49 had SCT and 166 had SCD. The prevalence of SCT appeared grossly underestimated. Age-adjusted survival rates for SCT patients were favorable compared with those with SCD for venoarterial (43.5% vs. 19.5%; p = 0.04) and venovenous (73.3% vs. 44.8%; p = 0.11) ECMO. Bleeding and thrombotic event rates and renal complications in SCT patients were comparable to those with SCD and similar to reported rates in general adult ECMO populations. While our findings suggest that ECMO may be safely used in patients with SCT, further investigation is essential to determine the clinical impact of sickle cell and other hemoglobinopathies on ECMO therapy.

Background: Sepsis-induced cardiomyopathy (SICM) is prevalent yet remains difficult to diagnose using conventional echocardiography primarily due to its dependence on loading conditions, the dynamic nature of sepsis, and varied cardiovascular phenotypes. Recent advancements in noninvasive myocardial work (MW) analysis, particularly through left ventricle pressure-strain loop (LV PSL), offer a promising strategy for evaluating myocardial function by combining strain imaging with blood pressure data. This technique may address the limitations inherent in traditional measures such as ejection fraction, which can be influenced by fluctuating hemodynamics in sepsis and may not accurately reflect underlying myocardial function.

Case summary: This report presents three cases wherein patients exhibited either preserved or only mildly reduced left ventricular systolic function based on ejection fraction (LVEF), but were found to have diminished MW indices, including global work index, global constructive work, and global work efficiency along with low flow by left ventricle outflow-tract.

Conclusions: Relying solely on LVEF for diagnosing SICM is problematic due to numerous confounding variables. MW parameters constitute innovative, noninvasive echocardiographic indicators that have demonstrated value across a spectrum of cardiac disorders. Although these parameters appear promising as bedside assessment tools, their application within the context of sepsis warrants further investigation.

High-flow nasal cannula (HFNC) is a common noninvasive respiratory therapy for respiratory failure, offering positive airway pressure and dead space clearance. In critically ill patients, additional nasal tubes for feeding or monitoring are often required, but their effect on HFNC performance is not well understood. This bench study evaluated the impact of nasal tube placement on dead space clearance, nasopharyngeal pressure, and airway resistance using standard and asymmetrical cannulas. Inserting a 5-Fr tube with a standard cannula had very little effect, whereas bigger sizes (12-Fr and 16-Fr) slightly increased airway pressure and reduce Co2 clearance. An asymmetrical cannula exhibited variable effects depending on the side of the tube placement. Higher pressure and better clearance were achieved with a tube placed in the smaller cannula side. However, if occlusion of the two nares becomes excessive with the tube in place, downsizing the cannula might be recommended.

Objective: The objective of this systematic review was to characterize adverse event detection methods in the ICU setting, including neonatal, pediatric, and adult ICUs, to summarize the evidence of their performance characteristics.

Data sources: Ovid MEDLINE, Ovid Embase, CINAHL, the Cochrane Library, and Google Scholar.

Study selection: Title and abstract screening, as well as full text review, were performed by two reviewers independently using Covidence software. Articles were included if they consisted of original research in a peer-reviewed journal with implementation of an adverse event detection method and reported the total number or category of adverse events, level of harm, or implementation of quality improvement (QI).

Data extraction: Data were extracted by two reviewers with 20% in duplicate. Extracted data included the study type and period/date, the adverse event detection method, the setting (location and type of ICU), ICU bed base, and the data of interest outlined above in study selection.

Data synthesis: Fifty-nine studies in neonatal, pediatric, and adult ICUs were included. Every category of adverse event detection was represented, including incident reporting (IR) (38 studies), trigger tool use (14 studies), trained observation (TO; 11 studies), and structured review (10 studies). TO identified the most adverse events per 100 patient days (57.3), and IR the least (6.4). Only 12 studies (20%) described QI initiatives.

Conclusions: Detection methods likely need to be used in combination for comprehensive results. Definitions of adverse events and associated harms need to be standardized to facilitate future comparison and better understanding of the performance of individual methods of detection. In addition, more emphasis needs to be placed on the dissemination of practice change in response to detection. These will be important steps to better characterize high rates of adverse events in the ICU, thereby fueling patient safety initiatives.

Objectives: Guidelines recommend hydrocortisone as an adjunctive treatment in septic shock, but the optimal dosing regimen is unknown. A national shortage of hydrocortisone in 2023 prompted a change in institutional practice for hydrocortisone administration from 50 mg every 6 hours to 100 mg every 12 hours in an effort to reduce waste and conserve vials, creating an opportunity to evaluate the comparative effectiveness of these two regimens. The primary efficacy outcome was time to shock resolution, and secondary outcomes evaluated in this study were mortality, renal replacement therapy (RRT), medication costs, and maximum vasopressor dose attained.

Design: Single-center, retrospective cohort study.

Setting: ICUs in a quaternary academic medical center.

Patients: Adult patients admitted to an ICU with septic shock, defined by mean arterial pressure less than 65 mm Hg despite adequate fluid resuscitation and need for vasopressor infusion, who were treated with hydrocortisone for shock between October 24, 2022, and October 12, 2023.

Interventions: Treatment with hydrocortisone 50 mg every 6 hours or 100 mg every 12 hours.

Measurements and main results: One hundred thirty-eight patients were included in this retrospective chart review from October 24, 2022, to October 12, 2023. Data for 61 patients in the 50 mg every 6 hours group and 77 patients in the 100 mg every 12 hours group were collected and analyzed. In adjusted competing risk models, hydrocortisone regimen was not associated with differences in time to shock resolution (sub-hazard ratio [sub-HR] 0.95 [95% CI, 0.59-1.54]), ICU mortality (sub-HR 1.59; 95% CI, 0.89-2.84), in-hospital mortality (1.35; 95% CI, 0.81-2.26), or time to RRT (sub-HR 1.01; 95% CI, 0.45-2.31). In addition, the hydrocortisone dose regimen was not associated with differences in maximum vasopressor dose attained (mean difference in norepinephrine equivalent, 0.16 µg/kg/min; 95% CI, -0.26 to 0.58 µg/kg/min). The less frequent dosing resulted in cost savings of $446.10 (95% CI, 253.95-638.25) per patient treated with the more intensive but less frequent hydrocortisone dosing regimen.

Conclusions: A less frequent hydrocortisone dosing regimen was not associated with differences in time to shock resolution. Studies of the comparative effectiveness of different corticosteroid dosing regimens for septic shock are needed.

Background: The management of refractory status epilepticus (SE) remains an area of low evidence with varying management strategies. Treatment in the ICU is often postponed due to potential complications from sedation, and it is unknown if its efficacy is superior to additional treatment attempts with IV anti-seizure medications (ASMs). The Fast Acute Sedation at Intensive Care vs. High-Dose IV Anti-Seizure Medication for Treatment of Non-Convulsive Status Epilepticus (FAST) trial aims to compare the efficacy of rapid sedation in the ICU vs. add-on high-dose IV ASM alone for the treatment of refractory SE.

Methods/results: This prospective, randomized, multicenter trial will enroll adult patients with non-convulsive status epilepticus (NCSE) who either meet current EEG criteria or have unambiguous NCSE with minor motor phenomena ("subtle SE") but without ongoing tonic-clonic seizures that are refractory to benzodiazepines and treatment with at least one second-line ASM. Patients will be randomized to receive either rapid deep sedation for 20 hours with propofol and eventually low-dose midazolam or additional high-dose IV anticonvulsant therapy (levetiracetam, valproate, fosphenytoin, lacosamide, or topiramate) in the intermediate care unit. The primary endpoint is treatment failure, either defined as NCSE on EEG 24 hours after randomization or persistent NCSE after 3 hours despite therapy on continuous EEG or clinically. Secondary endpoints include assessment of new-onset neurologic deficits and modified Rankin Scale at discharge, economic analyses, length of hospital stay, in-hospital infections, and survival. Evaluations will be performed at baseline, discharge, and 3, 6, 12, and 24 months. The target sample size is 116 patients; we expect to have to randomize about 140 patients to reach the required number of patients.

Conclusions: The FAST trial is the first randomized clinical trial to investigate refractory NCSE. Regardless of the outcome, the results of this trial protocol will provide new class 1 evidence for the treatment of NCSE and establish the standard of care for this patient population in the future.

Trial registration: EU CT: 2024-515507-18-00/clinicaltrials.gov: NCT05263674.

Objectives: To use 3D imaging modalities to obtain precise measurements of the proximal tibia in pediatric patients and assess the safety of current intraosseous needle lengths (15 and 25 mm).

Design: Retrospective descriptive study.

Setting: University of Minnesota and MHealth Fairview System, Minneapolis, MN.

Patients: Pediatric patients (≤ 16 yr) who underwent full-body positron emission tomography-CT or axial MRI scans of the lower extremities between January 2014 and December 2023.

Interventions: None.

Measurements and main results: A total of 912 scans were initially retrieved; 232 scans were excluded due to osseous diseases, tibial fractures, suboptimal scan quality, or soft-tissue abnormalities, leaving 680 scans for analysis. Scans were stratified into 1-year age groups. Measurements at the proximal tibia included soft-tissue thickness, cortical bone thickness, and medullary canal diameter. Other values, such as the pre-intraosseous space (sum of cortical thickness and soft-tissue depth) and total distance to deep cortex, were calculated. Simulated needle insertions demonstrated that 31.62% of the 15 mm needles were too shallow, failing to reach the medullary canal, whereas 34.85% of the 25 mm needles were too deep, both of which could cause severe complications. A cutoff analysis for needle size based on age rather than weight was also calculated. For the 15 mm needle, 95% CI was not found in any age range, and the highest confidence cutoff was for using the needle in the age range of 0-8 years (91.9%). The 25 mm needle had a 97.8% CI from ages 10-16.

Conclusions: The study reveals significant age-related variability in the proximal tibia's anatomical dimensions, suggesting that standard 15 and 25 mm intraosseous needles may not reliably achieve optimal placement in pediatric patients. Our findings indicate that the current intraosseous needles may not be as safe as previously thought and support the need to develop improved intraosseous needle designs to enhance safety and therapeutic effectiveness in pediatric emergency care.

Objective: To determine the impact of using dynamic measures of fluid responsiveness in guiding the resuscitation of adult patients with sepsis and septic shock.

Data source: We searched MEDLINE, Embase, and unpublished sources from inception to February 3, 2025.

Study selection: We included randomized controlled trials (RCTs) that evaluated the use of dynamic measures of fluid responsiveness to guide resuscitation compared with any other method in patients with sepsis and septic shock.

Data extraction: We collected data regarding study and patient characteristics, definitions of fluid responsiveness, modality for assessing fluid responsiveness, and outcome data. We performed a random-effects meta-analysis and rated the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation framework.

Data synthesis: We included nine eligible RCTs (n = 698 patients). The use of dynamic measures of fluid responsiveness to guide IV fluid (IVF) administration of patients with septic shock probably reduces 28-day mortality (relative risk] 0.61; 95% CI, 0.42-0.90, moderate certainty), may reduce the risk of acute kidney injury (AKI) (RR 0.66; 95% CI, 0.44-0.98, low certainty), and cumulative fluid balance on day 3 (mean difference -1.57L; 95% CI, -2.44 L to -0.69 L, low certainty). The use of dynamic measures of fluid responsiveness has an uncertain effect on ICU mortality, ICU and hospital length of stay, need for and duration of mechanical ventilation, need for renal replacement therapy, vasoactive medication administration, duration of vasopressor use, and IVF administration on day 1.

Conclusions: In adult patients with sepsis and septic shock, using dynamic measures of fluid responsiveness may improve survival and reduce the risk of AKI. Future studies should evaluate the impact of this intervention on other important clinical outcomes and determine the comparative efficacy of specific modalities for assessing fluid responsiveness.