Critical care explorations最新文献

Objectives: Survival following severe acute neurologic injury (SANI) is increasing. The complexities of caring for these patients are vast and gaps have been highlighted in post-acute care follow-up. While the development of post-ICU follow-up clinics have been increasing in popularity there is limited literature describing the landscape of post-neuroICU/NeuroRecovery clinics. We sought to describe the current landscape and identify benefits and barriers to clinic development in the United States.

Design: We developed a 19-question cross-sectional survey study.

Setting and subjects: The survey was disseminated to clinicians working in neurocritical care units throughout the United States and open for completion from August 2023 to December 2023. Responses were characterized by descriptive statistics.

Interventions: None.

Measurements and main results: Two hundred eighteen unique individuals responded to our survey. Post-neuroICU and/or NeuroRecovery clinics were uncommon and operational at only 69 of 215 respondents' institutions (32.1%). Forty-two percent reported an interest in engaging with a post-neuroICU clinic and an additional 39% showed interest but had identified other obligations preventing participation. Among the identified potential benefits of a clinic for survivors of SANI mitigating gaps in care, identifying differences between predicted and actual outcome, and reassessment of communication/prognosis ranked highest.

Conclusions: Few post-neuroICU/NeuroRecovery clinics exist in the United States but interest in participating in this aspect of care is common within the neurocritical care community. The identification of gaps in care, obstacles to continued recovery, and potential to adjudicate differences between actual and predicted outcomes ranked among the most important potential benefits for extending the current neurocritical care paradigm to the clinic setting.

Importance: Current approaches for bringing critical care expertise to hospital floors to support deteriorating patients are limited by intensivist availability, costs, and scalability. Using existing tele-critical care clinicians to perform consultations on deteriorating patients at risk for ICU admission may overcome these limitations.

Objectives: To characterize clinician perspectives on tele-critical care consultation during an initial small-scale implementation.

Design, setting, and participants: An on-demand tele-critical care consultation service was implemented on selected medical and surgical floors at a large academic medical center, with options for tele-intensivist recommendations only, time-limited monitoring by tele-nurses ± intensivist co-management, or assistance with immediate ICU transfer. To characterize perspectives of both bedside and telemedicine physicians and nurses who participated in consultations, a survey including the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure was performed. Some clinicians also participated in semi-structured interviews.

Analysis: Each survey component was described using median and interquartile range. Interviews were transcribed and analyzed using a thematic analysis approach. Open coding was performed independently by two investigators, followed by identification of themes and iterative team discussion until consensus was reached.

Results: Over 1 year, 65 consultations were performed. Across 43 surveys, the median score was 4 of 5 for each of the validated measures. In the 12 interviews, consistently positive themes included excellent quality of care, support for night shift, and reassurance to patients and families. Themes with mixed feedback included effectiveness in time-critical situations, impact on clinician workload, and communication and collaboration between teams. Opportunities for improvement included increased awareness, issues related to mobile carts, and expansion throughout the hospital.

Conclusions: Telemedicine can be used to deliver critical care consultations to hospitalized floor patients who are deteriorating. Bedside and telemedicine clinicians were highly satisfied with the consultation service.

Objectives: To examine the financial burden of critical care (CC), primary cost drivers, and clinical outcomes associated with CC delivery in low- and middle-income countries (LMICs).

Perspective: CC accounts for a significant cost of global health expenditure. LMICs, where the burden of critical illness is high and access remains inequitable, data on CC's financial impact are scarce, undermining efforts to strengthen capacity, optimize delivery, and guide resource allocation.

Setting: ICU at Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Tertiary Hospital in Nigeria.

Methods: An observational cross-sectional study was conducted. Patients were recruited via a convenient sampling method. Data were collected within the first 24 hours of admission.

Results: A total of 96 patients were analyzed. The average daily cost of a CC bed was ₦4,780.49 (U.S. dollar [USD] 2.99) without mechanical ventilation (MV) and ₦21,255.56 (USD 13.28) with MV. The mean expenditure within the first 24 hours of admission was ₦144,928.00 (USD 90.58). The mortality rate was 23.96%, with higher ASA scores (III and IV) and age over 40 years associated with increased costs and poorer outcomes. Higher CC costs and lower household income are strongly associated with increased mortality.

Conclusions: The financial burden of CC far exceeds Nigeria's monthly minimum wage of ₦70,000.00 (USD 43.75), highlighting the urgent need for health policy and resource allocation strategies to improve timely and equitable CC outcomes in LMICs.

Objectives: Tracheal intubation in critically ill patients is associated with significant morbidity and mortality. Point-of-care ultrasound (POCUS) may help with hemodynamic optimization and customization of management plans to the patient's tenuous physiology to prevent cardiopulmonary collapse. We report the integration of POCUS in the emergency airway management (EAM) of critically ill patients at a tertiary care academic medical center.

Design: Our study is a retrospective, exploratory research project. We evaluated the feasibility of using Echocardiography Assessment using Subcostal-only-view in Physiologically Difficult Airway (EASy-PDA) protocol to prevent peri-intubation hemodynamic compromise during EAM.

Setting: This study took place at a tertiary academic medical center where requests for EAM were answered by anesthesiologists.

Subjects: The EASy-PDA protocol was performed on 30 patients with PDA outside of the operating room in need of EAM.

Interventions: The EASy-PDA protocol included the acquisition of subcostal four-chamber (SC4C) and inferior vena cava (IVC) images, supplemented by focused lung and gastric ultrasonography. Trained anesthesiology residents performed EASy-PDA examinations before airway management, and subsequently assigned hemodynamic phenotypes based on qualitative assessment of biventricular chamber size, myocardial wall thickness and function, and IVC size and collapsibility. Management was then tailored based on hemodynamic phenotyping.

Measurements and main results: The mean time to complete the EASy-PDA examination was 2.40 minutes. SC4C image could not be obtained in one patient due to severe abdominal pain. Images obtained solely via the EASy-PDA examination were sufficient to inform further patient management in 26 patients (86.7%), with one patient requiring emergent pericardial window creation and two patients requiring gastric decompression before intubation based on examination findings.

Conclusions: We were able to show the feasibility of integrating the EASy-PDA protocol into the management of emergent airways. In our case series, we observed that the EASy-PDA examination findings guided hemodynamic optimization before EAM in critically ill patients. This approach may help reduce intubation-associated morbidity and mortality. Further studies are needed to assess the impact of integration of EASy protocol during EAM on patient outcomes.

Objectives: To determine if common antimicrobials (n = 11) are sequestered or degraded during a pediatric extracorporeal membrane oxygenation (ECMO) simulation.

Design: An ex vivo model of a closed ECMO circuit was established to simulate the treatment of a 3 kg infant. A control was used to quantify spontaneous antimicrobial degradation.

Setting: University research laboratory.

Participants: None.

Main outcomes and measures: The ECMO circuit was primed and maintained at physiologic pH and temperature for 7 hours. After baseline sampling, the antimicrobials were administered as a single bolus into the circuit. Eight plasma samples were taken from the controls and ECMO circuits over 7 hours. Antimicrobial concentrations were measured using validated high-performance liquid chromatography-tandem mass spectrometry methodology. The antimicrobial recovery was compared with baseline. Each simulation was performed in triplicate to assess simulation variability.

Results: The recovery mean (%) in ECMO at 7 hours for ampicillin 78%, cefotaxime 92%, flucloxacillin 72%, meropenem 81%, micafungin 72%, piperacillin 84%, and voriconazole 42% was significantly different from the baseline (p < 0.05). The recovery in the control at 7 hours for ampicillin 83%, cefotaxime 76%, flucloxacillin 90%, gentamicin 85%, meropenem 76%, piperacillin 92%, and tazobactam 93% was also significantly different from the baseline (p < 0.05). A significant relationship was identified in the ECMO model between the antimicrobial recovery (%) and the log partition coefficient (log p) of the studied antimicrobials (R2 = 0.52; p = 0.01). No significant relationship was identified between the protein binding and antimicrobial recovery (R2 = 0.23; p = 0.13).

Conclusions and relevance: The lipophilicity of an antimicrobial is a predictor of antimicrobial recovery in ECMO. Concentrations were significantly reduced at 7 hours for greater than 60% of the study antimicrobials in the ECMO models. Clinical studies are required for children receiving ECMO to determine if the current dosing regimens for antimicrobials provide therapeutic concentrations.

ICU readmissions remain a critical concern, carrying increased morbidity, mortality, and cost. We examined the epidemiology of unplanned ICU readmissions across 19 hospitals in the Common Longitudinal ICU data Format (CLIF) Consortium from January 2020 to December 2021 and the MIMIC-IV database. The cohort included 185,241 adult ICU admissions, excluding postoperative or post-interventional procedure readmissions. Overall, 8.6% of ICU discharges were readmitted during the same hospitalization. Unplanned readmissions occurred in 1.9% of cases within 24 hours, 3.4% within 48 hours, and 4.5% within 72 hours of discharge. Readmitted patients experienced markedly higher in-hospital mortality (20.6% vs. 2.1%; p < 0.001). Compared with initial ICU stays, readmissions were associated with greater use of respiratory support (42.3% vs. 35.3%) and vasopressors (26.1% vs. 23.1%). Hospitals with stepdown units demonstrated comparable unplanned ICU readmission rates. These findings demonstrate that ICU readmissions remain common, are associated with poor outcomes, and require greater organ support. Improved characterization of high-risk subphenotypes is needed to inform safer discharge processes.

Importance: The alternative complement pathway is a key component of host defense against bacteremia and other infections. However, dysregulated activation can contribute to excessive inflammation and worse clinical outcomes during bacteremia and infectious syndromes such as sepsis.

Objectives: We aim to identify variants in alternative pathway (AP) genes that influence the risk for bacteremia and sepsis.

Design, setting, and participants: We used summary statistics from a Veterans Affairs Million Veteran Program (MVP) genome-wide by phenome-wide association study of more than 600,000 individuals.

Main outcomes and measures: Using seven electronic health record-derived Phecodes for bacteremia or sepsis, we investigated associations with single-nucleotide polymorphisms (SNPs) in genes encoding multiple AP components. We also investigated potential regulatory SNPs near candidate genes based on expression quantitative trait loci (eQTL) data or in silico modeling (Combined Annotation Dependent Depletion and RegulomeDB scores).

Results: In the MVP trans-ancestral meta-analysis, we identified 25 unique lead genic SNPs with a minor allele frequency of greater than 1% that were significantly associated with incidence of sepsis or bacteremia Phecodes. Most were intronic (n = 21), with four exonic variants, including one in C5AR1 (rs4804049) that has novel associations with multiple Phecodes. Outside of AP gene loci, we also identified significant associations in 14 unique SNPs with predicted regulatory effects by in silico modeling and 11 unique SNPs with eQTL data suggesting an impact on AP gene expression. Variants in complement factor B (CFB), complement factor I (CFI), and C5a receptors (C5AR1/C5AR2) accounted for most of the significant genic SNPs, while noncoding functional variants primarily affected CFB, CFD, and the C5a receptor 1 (C5AR1).

Conclusions and relevance: We identified potentially clinically relevant genetic variation in the alternative complement pathway that may contribute to individual susceptibility to bacteremia and sepsis syndromes. Further study is required to understand the mechanisms behind these associations and their clinical impacts.

Importance: Although survival rates in ICUs have improved, ICU length of stay is increasing, particularly among critically ill patients requiring prolonged mechanical ventilation. These patients often face challenges in early rehabilitation. Despite the importance of early mobilization, its implementation is often hindered by the severity of patient conditions. The details of rehabilitation interventions, particularly the element of intervention time, have not been fully examined.

Objectives: This study evaluated the time, content, and effects of rehabilitation during ICU stays.

Design, setting, and participants: This study is a secondary analysis of data from the Japanese Rehabilitation and Risk Factors on the Post-Intensive Care Syndrome (J-RELIFE) prospective multicenter registry, which enrolled critically ill patients across 22 institutions in Japan. From this registry, we identified 423 patients who underwent mechanical ventilation in the ICU for greater than 48 hours. Patients were categorized into three groups based on ICU stay length: short-, medium-, and long-term (199, 157, and 67 patients, respectively).

Main outcomes and measures: The primary variable was rehabilitation intervention time in the ICU, analyzed relative to ICU stay length. Secondary measures included the association between rehabilitation time and the highest Sequential Organ Failure Assessment (SOFA) score, as well as functional outcomes at ICU and hospital discharge.

Results: The long-term group had significantly greater rehabilitation time (p < 0.05). A significant correlation was observed between rehabilitation time and highest SOFA score (r = 0.354; p < 0.001). In the long-term ICU group, even with high illness severity and delayed mobilization, patients' activities of daily living were restored by discharge.

Conclusions and relevance: Our registry-based analysis shows that severely ill ICU patients require extended rehabilitation interventions. This highlights the need for staffing and implementation systems that can ensure sufficient rehabilitation time for severely ill patients.

Objectives: Multimodality monitoring based prognostication in pediatric traumatic brain injury (TBI) relies heavily on the evaluation of instantaneous and easily interpretable monitoring values. Entropy quantifies the level of disorder within a system reflecting overall activity of sensitive closed-loop feedback homeostatic mechanisms. Multiscale entropy (MSE) assesses entropy across different time scales to examine various physiologic systems and processes that operate across different time scales. The current understanding of MSE suggests that low entropy reflects increased rigidity of the various homeostatic control systems, reflecting underperformance of mechanisms such as cerebral autoregulation. This hypothesis-generating retrospective study explores the value of MSE for prognostication after pediatric TBI.

Design: Retrospective analysis of data from an observational multicenter database.

Setting: Ten PICUs across the United Kingdom.

Patients: One hundred thirty-five children with severe pediatric TBI receiving invasive neuromonitoring between 2018 and 2022.

Interventions: None.

Measurements and main results: MSE was calculated based on 10-second time trends of different biosignals (incl. blood pressure, heart rate, intracranial pressure [ICP]). MSE metrics were assessed using univariable and multivariable (logistic regression with backward stepwise elimination and sliding dichotomy) methods. Last, correlation coefficients between MSE and clinical or monitoring metrics were assessed. Decreased MSE of physiologic biosignals were associated with worse outcomes and remained associated with outcomes when added to multivariable analyses. Within multivariable logistic regression analyses (covariates: Injury Severity Score [ISS], Rotterdam score, ICP, pressure reactivity index [PRx]), the resulting odds ratios (ORs) were: MSE arterial blood pressure (abp: OR, 0.83; p = 0.014), MSE cerebral perfusion pressure (cpp: OR, 0.86; p = 0.024), and MSE icp (OR, 0.87; p = 0.029). MSE displayed weak associations with clinical parameters reflecting higher TBI severity (i.e., ISS, Abbreviated Injury Scale, Glasgow Coma Scale, etc.) but moderate correlations with PRx (correlation coefficients: MSE abp, -0.47; MSE cpp, -0.55) and ICP (MSE abp, -0.3).

Conclusions: Biosignal complexity is a promising tool for improving individualized prognostication after pediatric TBI. Our results further underpin the association between MSE and the function of physiologic autoregulatory mechanisms.

Objectives: Sepsis trials likely include patients who vary in response to therapeutic interventions. The optimal approach to identify such differences in treatment response remains unclear. Estimating individualized absolute risk differences (iARDs) to model treatment response at an individual patient level using supervised effect models applied to randomized trial data may be informative. We explored the relationship between two subgrouping approaches and a recently published iARD model for the effect of early goal-directed therapy (EGDT) resuscitation in sepsis.

Design: Secondary analysis of the Protocolized Care for Early Septic Shock (ProCESS) and Australasian Resuscitation in Sepsis Evaluation (ARISE) trials. We applied clinical subtypes (α, β, γ, δ) to 829 ProCESS and 1588 ARISE patients and biologic "hyperinflammatory" and "nonhyperinflammatory" subphenotypes to 363 ProCESS patients with biomarker data using established methods. We predicted iARDs with supervised learning using clinical variables as predictors and 90-day mortality as the primary outcome. We evaluated iARD variability within subgroups.

Setting: Eighty-one sites worldwide.

Patients/subjects: Adults with septic shock.

Interventions: EGDT or usual care.

Measurements and main results: The average treatment effect of EGDT appeared to vary within both clinical and biologic subphenotypes. EGDT appeared potentially beneficial in the β and nonhyperinflammatory subphenotypes but harmful in the γ and hyperinflammatory subphenotypes. However, the predicted iARDs within each subgroup ranged from considerable harm to considerable benefit. For example, for the β-subtype, the average mortality reduction from EGDT was 8.5% (95% CI, -0.4 to 17.5), but the iARDs ranged from a 29% increase to a 16% reduction in mortality, with 39% of patients predicted to be harmed.

Conclusions: Although both clinical and biologic phenotyping may identify subgroups whose average treatment effect is beneficial or harmful, individual risks and benefits within subgroups still vary dramatically, raising concern that phenotyping may not reliably or safely personalize sepsis care.