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COVID-19 Pandemic and Impact on Research Publications in Critical Care. COVID-19 大流行及其对重症监护研究出版物的影响。
Q4 Medicine Pub Date : 2024-06-05 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001103
Syrus Razavi, Arjun Sharma, Cassidy Lavin, Ali Pourmand, Norma Smalls, Quincy K Tran

Objectives: The COVID-19 pandemic precipitated a significant transformation of scientific journals. Our aim was to determine how critical care (CC) journals and their impact may have evolved during the COVID-19 pandemic. We hypothesized that the impact, as measured by citations and publications, from the field of CC would increase.

Design: Observational study of journal publications, citations, and retractions status.

Setting: All work was done electronically and retrospectively.

Subjects: The top 18 CC journals broadly concerning CC, and the top 5 most productive CC journals on the SCImago list.

Interventions: None.

Measurements and main results: For the top 18 CC journals and specifically Critical Care Medicine (CCM), time series analysis was used to estimate the trends of total citations, citations per publication, and publications per year by using the best-fit curve. We used PubMed and Retraction Watch to determine the number of COVID-19 publications and retractions. The average total citations and citations per publication for all journals was an upward quadratic trend with inflection points in 2020, whereas publications per year spiked in 2020 before returning to prepandemic values in 2021. For CCM total publications trend downward while total citations and citations per publication generally trend up from 2017 onward. CCM had the lowest percentage of COVID-related publications (15.7%) during the pandemic and no reported retractions. Two COVID-19 retractions were noted in our top five journals.

Conclusions: Citation activity across top CC journals underwent a dramatic increase during the COVID-19 pandemic without significant retraction data. These trends suggest that the impact of CC has grown significantly since the onset of COVID-19 while maintaining adherence to a high-quality peer-review process.

目的:COVID-19 大流行引发了科学期刊的重大变革。我们的目的是确定危重症护理 (CC) 期刊及其影响力在 COVID-19 大流行期间是如何演变的。我们的假设是,以引用次数和出版物数量衡量,危重症护理领域的影响力将会增加:设计:对期刊论文的发表、引用和撤稿情况进行观察研究:所有工作均以电子方式回顾性完成:干预措施:无:测量和主要结果对于排名前 18 位的 CC 期刊,特别是《重症医学》(CCM),我们采用时间序列分析法,通过最佳拟合曲线估算总引用次数、每篇论文引用次数和每年发表论文次数的变化趋势。我们使用 PubMed 和 Retraction Watch 来确定 COVID-19 的出版物和撤稿数量。所有期刊的总引用次数和每篇论文的平均引用次数均呈上升的二次曲线趋势,2020 年出现拐点,而每年的论文数在 2020 年激增,2021 年恢复到流行前的数值。中药学》的总发表量呈下降趋势,而总被引频次和每篇被引频次从 2017 年起总体呈上升趋势。在大流行期间,中药学与 COVID 相关的论文比例最低(15.7%),且没有撤稿报告。在我们排名前五的期刊中,有两篇COVID-19撤稿:结论:在 COVID-19 大流行期间,顶级 CC 期刊的引文活动急剧增加,但没有显著的撤稿数据。这些趋势表明,自 COVID-19 爆发以来,在坚持高质量同行评审流程的同时,CC 的影响力也显著增加。
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引用次数: 0
An Exploratory Analysis of Sociodemographic Factors Associated With Physical Functional Impairment in ICU Survivors. 与重症监护室幸存者身体功能损伤相关的社会人口因素的探索性分析。
Q4 Medicine Pub Date : 2024-06-05 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001100
Megan A Watson, Marie Sandi, Johanna Bixby, Grace Perry, Patrick J Offner, Ellen L Burnham, Sarah E Jolley

Importance: Physical functional impairment is one of three components of postintensive care syndrome (PICS) that affects up to 60% of ICU survivors.

Objectives: To explore the prevalence of objective physical functional impairment among a diverse cohort of ICU survivors, both at discharge and longitudinally, and to highlight sociodemographic factors that might be associated with the presence of objective physical functional impairment.

Design, setting, and participants: This was a secondary analysis of 37 patients admitted to the ICU in New Orleans, Louisiana, and Denver, Colorado between 2016 and 2019 who survived with longitudinal follow-up data.

Main outcomes and measures: Our primary outcome of physical functional impairment was defined by handgrip strength and the short physical performance battery. We explored associations between functional impairment and sociodemographic factors that included race/ethnicity, sex, primary language, education status, and medical comorbidities.

Results: More than 75% of ICU survivors were affected by physical functional impairment at discharge and longitudinally at 3- to 6-month follow-up. We did not see a significant difference in the proportion of patients with physical functional impairment by race/ethnicity, primary language, or education status. Impairment was relatively higher in the follow-up period among women, compared with men, and those with comorbidities. Among 18 patients with scores at both time points, White patients demonstrated greater change in handgrip strength than non-White patients. Four non-White patients demonstrated diminished handgrip strength between discharge and follow-up.

Conclusions and relevance: In this exploratory analysis, we saw that the prevalence of objective physical functional impairment among ICU survivors was high and persisted after hospital discharge. Our findings suggest a possible relationship between race/ethnicity and physical functional impairment. These exploratory findings may inform future investigations to evaluate the impact of sociodemographic factors on functional recovery.

重要性:身体功能障碍是重症监护后综合征(PICS)的三个组成部分之一,多达 60% 的重症监护室幸存者会受到影响:目的:探讨不同群体的 ICU 幸存者在出院时和纵向客观身体功能障碍的发生率,并强调可能与客观身体功能障碍相关的社会人口因素:这是对2016年至2019年期间路易斯安那州新奥尔良市和科罗拉多州丹佛市重症监护室收治的37名患者进行的二次分析,这些患者存活下来,并提供了纵向随访数据:我们的主要结果是肢体功能障碍,由手握强度和短期体能表现电池定义。我们探讨了功能障碍与社会人口学因素(包括种族/民族、性别、主要语言、教育状况和医疗合并症)之间的关联:结果:超过 75% 的重症监护室幸存者在出院时和 3 至 6 个月的纵向随访中受到身体功能障碍的影响。不同种族/民族、主要语言或教育程度的患者身体功能受损的比例没有明显差异。与男性和合并症患者相比,女性患者在随访期间的功能受损程度相对较高。在两个时间点均有得分的 18 名患者中,白人患者的手握力变化比非白人患者更大。四名非白人患者在出院和随访期间的手握力有所减弱:在这项探索性分析中,我们发现 ICU 幸存者中客观身体功能障碍的发生率很高,并且在出院后仍持续存在。我们的研究结果表明,种族/民族与身体功能障碍之间可能存在关系。这些探索性发现可为今后评估社会人口因素对功能恢复的影响提供参考。
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引用次数: 0
What Is the Potential Value of a Randomized Trial of Different Thresholds to Initiate Invasive Ventilation? A Health Economic Analysis. 对启动侵入性通气的不同阈值进行随机试验的潜在价值是什么?健康经济学分析。
Q4 Medicine Pub Date : 2024-06-04 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001098
Christopher J Yarnell, Kali Barrett, Anna Heath, Margaret Herridge, Robert A Fowler, Lillian Sung, David M Naimark, George Tomlinson

Objectives: To estimate the expected value of undertaking a future randomized controlled trial of thresholds used to initiate invasive ventilation compared with usual care in hypoxemic respiratory failure.

Perspective: Publicly funded healthcare payer.

Setting: Critical care units capable of providing invasive ventilation and unconstrained by resource limitations during usual (nonpandemic) practice.

Methods: We performed a model-based cost-utility estimation with individual-level simulation and value-of-information analysis focused on adults, admitted to critical care, receiving noninvasive oxygen. In the primary scenario, we compared hypothetical threshold A to usual care, where threshold A resulted in increased use of invasive ventilation and improved survival compared with usual care. In the secondary scenario, we compared hypothetical threshold B to usual care, where threshold B resulted in decreased use of invasive ventilation and similar survival compared with usual care. We assumed a willingness-to-pay of 100,000 Canadian dollars (CADs) per quality-adjusted life year.

Results: In the primary scenario, threshold A was cost-effective compared with usual care due to improved hospital survival (78.1% vs. 75.1%), despite more use of invasive ventilation (62% vs. 30%) and higher lifetime costs (86,900 vs. 75,500 CAD). In the secondary scenario, threshold B was cost-effective compared with usual care due to similar survival (74.5% vs. 74.6%) with less use of invasive ventilation (20.2% vs. 27.6%) and lower lifetime costs (71,700 vs. 74,700 CAD). Value-of-information analysis showed that the expected value to Canadian society over 10 years of a 400-person randomized trial comparing a threshold for invasive ventilation to usual care in hypoxemic respiratory failure was 1.35 billion CAD or more in both scenarios.

Conclusions: It would be highly valuable to society to identify thresholds that, in comparison to usual care, either increase survival or reduce invasive ventilation without reducing survival.

目标: 对低氧血症呼吸衰竭患者启动有创通气的阈值与常规护理相比,估算未来开展随机对照试验的预期价值:估算未来开展随机对照试验的预期价值,该试验将对低氧血症呼吸衰竭患者启动有创通气的阈值与常规护理进行比较:背景:有能力提供有创通气的重症监护病房:环境:能够提供有创通气且在常规(非大流行)实践中不受资源限制的重症监护病房:我们进行了基于模型的成本效用估算,并进行了个体层面的模拟和信息价值分析,重点关注接受无创吸氧的重症监护成人。在主要方案中,我们将假设阈值 A 与常规护理进行了比较,与常规护理相比,阈值 A 导致有创通气的使用增加,并提高了存活率。在次要情景中,我们将假设阈值 B 与常规护理进行了比较,与常规护理相比,阈值 B 可减少有创通气的使用,并提高存活率。我们假设每个质量调整生命年的支付意愿为 100,000 加拿大元(CADs):在主要方案中,阈值 A 与常规护理相比具有成本效益,因为住院生存率提高(78.1% 对 75.1%),尽管有创通气使用率更高(62% 对 30%),终生成本更高(86,900 加元对 75,500 加元)。在次要方案中,阈值 B 与常规护理相比具有成本效益,因为两者的存活率相似(74.5% 对 74.6%),有创通气使用率较低(20.2% 对 27.6%),终生成本较低(7.17 万加元对 7.47 万加元)。信息价值分析表明,在两种情况下,对低氧血症呼吸衰竭患者进行有创通气阈值与常规护理比较的 400 人随机试验在 10 年内对加拿大社会的预期价值为 13.5 亿加元或更多:结论:与常规治疗相比,确定可提高存活率或在不降低存活率的情况下减少有创通气的阈值对社会极具价值。
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引用次数: 0
Comparison of Central and Peripheral Arterial Blood Pressure Gradients in Critically Ill Patients: A Systematic Review and Meta-Analysis. 重症患者中心和外周动脉血压梯度的比较:系统综述与元分析》。
Q4 Medicine Pub Date : 2024-05-24 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001096
Daisuke Hasegawa, Ryota Sato, Abhijit Duggal, Mary Schleicher, Kazuki Nishida, Ashish K Khanna, Siddharth Dugar

Objectives: Measurement of blood pressure taken from different anatomical sites, are often perceived as interchangeable, despite them representing different parts of the systemic circulation. We aimed to perform a systematic review and meta-analysis on blood pressure differences between central and peripheral arterial cannulation in critically ill patients.

Data sources: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase from inception to December 26, 2023, using Medical Subject Headings (MeSH) terms and keywords.

Study selection: Observation study of adult patients in ICUs and operating rooms who underwent simultaneous central (femoral, axillary, or subclavian artery) and peripheral (radial, brachial, or dorsalis pedis artery) arterial catheter placement in ICUs and operating rooms.

Data extraction: We screened and extracted studies independently and in duplicate. We assessed risk of bias using the revised Quality Assessment for Studies of Diagnostic Accuracy tool.

Data synthesis: Twenty-four studies that enrolled 1598 patients in total were included. Central pressures (mean arterial pressure [MAP] and systolic blood pressure [SBP]) were found to be significantly higher than their peripheral counterparts, with mean gradients of 3.5 and 8.0 mm Hg, respectively. However, there was no statistically significant difference in central or peripheral diastolic blood pressure (DBP). Subgroup analysis further highlighted a higher MAP gradient during the on-cardiopulmonary bypass stage of cardiac surgery, reperfusion stage of liver transplant, and in nonsurgical critically ill patients. SBP or DBP gradient did not demonstrate any subgroup specific changes.

Conclusions: SBP and MAP obtained by central arterial cannulation were higher than peripheral arterial cannulation; however, clinical implication of a difference of 8.0 mm Hg in SBP and 3.5 mm Hg in MAP remains unclear. Our current clinical practices preferring peripheral arterial lines need not change.

目的:从不同的解剖部位测量血压通常被认为是可以互换的,尽管它们代表了全身循环的不同部位。我们旨在对重症患者中心动脉插管和外周动脉插管的血压差异进行系统回顾和荟萃分析:我们使用医学主题词表(MeSH)术语和关键词检索了从开始到 2023 年 12 月 26 日的 MEDLINE、Cochrane Central Register of Controlled Trials 和 Embase:对重症监护室和手术室中同时接受中心(股动脉、腋动脉或锁骨下动脉)和外周(桡动脉、肱动脉或足背动脉)动脉导管置入术的成年患者进行观察研究:我们独立筛选并提取了一式两份的研究报告。我们使用修订后的诊断准确性研究质量评估工具评估了偏倚风险:共纳入了 24 项研究,共计 1598 名患者。研究发现,中心血压(平均动脉压 [MAP] 和收缩压 [SBP])明显高于外周血压,平均梯度分别为 3.5 毫米汞柱和 8.0 毫米汞柱。不过,中心或外周舒张压(DBP)在统计学上没有明显差异。亚组分析进一步突出表明,在心脏手术的心肺旁路阶段、肝移植的再灌注阶段以及非手术重症患者中,MAP阶差较高。SBP或DBP梯度未显示出任何亚组特异性变化:通过中心动脉插管获得的 SBP 和 MAP 均高于外周动脉插管;但是,SBP 相差 8.0 mm Hg 和 MAP 相差 3.5 mm Hg 的临床意义仍不明确。我们目前首选外周动脉插管的临床实践无需改变。
{"title":"Comparison of Central and Peripheral Arterial Blood Pressure Gradients in Critically Ill Patients: A Systematic Review and Meta-Analysis.","authors":"Daisuke Hasegawa, Ryota Sato, Abhijit Duggal, Mary Schleicher, Kazuki Nishida, Ashish K Khanna, Siddharth Dugar","doi":"10.1097/CCE.0000000000001096","DOIUrl":"10.1097/CCE.0000000000001096","url":null,"abstract":"<p><strong>Objectives: </strong>Measurement of blood pressure taken from different anatomical sites, are often perceived as interchangeable, despite them representing different parts of the systemic circulation. We aimed to perform a systematic review and meta-analysis on blood pressure differences between central and peripheral arterial cannulation in critically ill patients.</p><p><strong>Data sources: </strong>We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase from inception to December 26, 2023, using Medical Subject Headings (MeSH) terms and keywords.</p><p><strong>Study selection: </strong>Observation study of adult patients in ICUs and operating rooms who underwent simultaneous central (femoral, axillary, or subclavian artery) and peripheral (radial, brachial, or dorsalis pedis artery) arterial catheter placement in ICUs and operating rooms.</p><p><strong>Data extraction: </strong>We screened and extracted studies independently and in duplicate. We assessed risk of bias using the revised Quality Assessment for Studies of Diagnostic Accuracy tool.</p><p><strong>Data synthesis: </strong>Twenty-four studies that enrolled 1598 patients in total were included. Central pressures (mean arterial pressure [MAP] and systolic blood pressure [SBP]) were found to be significantly higher than their peripheral counterparts, with mean gradients of 3.5 and 8.0 mm Hg, respectively. However, there was no statistically significant difference in central or peripheral diastolic blood pressure (DBP). Subgroup analysis further highlighted a higher MAP gradient during the on-cardiopulmonary bypass stage of cardiac surgery, reperfusion stage of liver transplant, and in nonsurgical critically ill patients. SBP or DBP gradient did not demonstrate any subgroup specific changes.</p><p><strong>Conclusions: </strong>SBP and MAP obtained by central arterial cannulation were higher than peripheral arterial cannulation; however, clinical implication of a difference of 8.0 mm Hg in SBP and 3.5 mm Hg in MAP remains unclear. Our current clinical practices preferring peripheral arterial lines need not change.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 6","pages":"e1096"},"PeriodicalIF":0.0,"publicationDate":"2024-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11132324/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141089534","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
Development and Validation of a Prediction Model for 1-Year Mortality in Patients With a Hematologic Malignancy Admitted to the ICU. 重症监护病房血液恶性肿瘤患者 1 年死亡率预测模型的开发与验证。
Q4 Medicine Pub Date : 2024-05-24 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001093
Jan-Willem H L Boldingh, M Sesmu Arbous, Bart J Biemond, Nicole M A Blijlevens, Jasper van Bommel, Murielle G E C Hilkens, Nuray Kusadasi, Marcella C A Muller, Vera A de Vries, Ewout W Steyerberg, Walter M van den Bergh

Objectives: To develop and validate a prediction model for 1-year mortality in patients with a hematologic malignancy acutely admitted to the ICU.

Design: A retrospective cohort study.

Setting: Five university hospitals in the Netherlands between 2002 and 2015.

Patients: A total of 1097 consecutive patients with a hematologic malignancy were acutely admitted to the ICU for at least 24 h.

Interventions: None.

Measurements and main results: We created a 13-variable model from 22 potential predictors. Key predictors included active disease, age, previous hematopoietic stem cell transplantation, mechanical ventilation, lowest platelet count, acute kidney injury, maximum heart rate, and type of malignancy. A bootstrap procedure reduced overfitting and improved the model's generalizability. This involved estimating the optimism in the initial model and shrinking the regression coefficients accordingly in the final model. We assessed performance using internal-external cross-validation by center and compared it with the Acute Physiology and Chronic Health Evaluation II model. Additionally, we evaluated clinical usefulness through decision curve analysis. The overall 1-year mortality rate observed in the study was 62% (95% CI, 59-65). Our 13-variable prediction model demonstrated acceptable calibration and discrimination at internal-external validation across centers (C-statistic 0.70; 95% CI, 0.63-0.77), outperforming the Acute Physiology and Chronic Health Evaluation II model (C-statistic 0.61; 95% CI, 0.57-0.65). Decision curve analysis indicated overall net benefit within a clinically relevant threshold probability range of 60-100% predicted 1-year mortality.

Conclusions: Our newly developed 13-variable prediction model predicts 1-year mortality in hematologic malignancy patients admitted to the ICU more accurately than the Acute Physiology and Chronic Health Evaluation II model. This model may aid in shared decision-making regarding the continuation of ICU care and end-of-life considerations.

目的开发并验证血液系统恶性肿瘤患者入住重症监护室后 1 年死亡率的预测模型:设计:一项回顾性队列研究:2002年至2015年期间荷兰的五所大学医院:干预措施:无:无干预措施:我们从 22 个潜在预测因素中创建了一个 13 变量模型。主要预测因素包括活动性疾病、年龄、既往造血干细胞移植、机械通气、最低血小板计数、急性肾损伤、最大心率和恶性肿瘤类型。自举程序减少了过度拟合,提高了模型的普适性。这包括在初始模型中估计乐观程度,并在最终模型中相应缩小回归系数。我们通过中心内部和外部交叉验证来评估模型的性能,并将其与急性生理学和慢性健康评估 II 模型进行比较。此外,我们还通过决策曲线分析评估了临床实用性。研究观察到的 1 年总死亡率为 62%(95% CI,59-65)。我们的 13 变量预测模型在各中心的内部-外部验证中表现出了可接受的校准和区分度(C 统计量 0.70;95% CI,0.63-0.77),优于急性生理学和慢性健康评估 II 模型(C 统计量 0.61;95% CI,0.57-0.65)。决策曲线分析表明,在预测的 1 年死亡率为 60%-100% 的临床相关阈值概率范围内,总体净获益:与急性生理学和慢性健康评估 II 模型相比,我们新开发的 13 变量预测模型能更准确地预测入住 ICU 的血液恶性肿瘤患者的 1 年死亡率。该模型有助于就继续接受重症监护室护理和临终关怀做出共同决策。
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引用次数: 0
Prediction of Readmission Following Sepsis Using Social Determinants of Health. 利用健康的社会决定因素预测败血症后的再入院情况。
Q4 Medicine Pub Date : 2024-05-24 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001099
Fatemeh Amrollahi, Brent D Kennis, Supreeth Prajwal Shashikumar, Atul Malhotra, Stephanie Parks Taylor, James Ford, Arianna Rodriguez, Julia Weston, Romir Maheshwary, Shamim Nemati, Gabriel Wardi, Angela Meier

Objectives: To determine the predictive value of social determinants of health (SDoH) variables on 30-day readmission following a sepsis hospitalization as compared with traditional clinical variables.

Design: Multicenter retrospective cohort study using patient-level data, including demographic, clinical, and survey data.

Settings: Thirty-five hospitals across the United States from 2017 to 2021.

Patients: Two hundred seventy-one thousand four hundred twenty-eight individuals in the AllofUs initiative, of which 8909 had an index sepsis hospitalization.

Interventions: None.

Measurements and main results: Unplanned 30-day readmission to the hospital. Multinomial logistic regression models were constructed to account for survival in determination of variables associate with 30-day readmission and are presented as adjusted odds rations (aORs). Of the 8909 sepsis patients in our cohort, 21% had an unplanned hospital readmission within 30 days. Median age (interquartile range) was 54 years (41-65 yr), 4762 (53.4%) were female, and there were self-reported 1612 (18.09%) Black, 2271 (25.49%) Hispanic, and 4642 (52.1%) White individuals. In multinomial logistic regression models accounting for survival, we identified that change to nonphysician provider type due to economic reasons (aOR, 2.55 [2.35-2.74]), delay of receiving medical care due to lack of transportation (aOR, 1.68 [1.62-1.74]), and inability to afford flow-up care (aOR, 1.59 [1.52-1.66]) were strongly and independently associated with a 30-day readmission when adjusting for survival. Patients who lived in a ZIP code with a high percentage of patients in poverty and without health insurance were also more likely to be readmitted within 30 days (aOR, 1.26 [1.22-1.29] and aOR, 1.28 [1.26-1.29], respectively). Finally, we found that having a primary care provider and health insurance were associated with low odds of an unplanned 30-day readmission.

Conclusions: In this multicenter retrospective cohort, several SDoH variables were strongly associated with unplanned 30-day readmission. Models predicting readmission following sepsis hospitalization may benefit from the addition of SDoH factors to traditional clinical variables.

目的与传统的临床变量相比,确定健康的社会决定因素(SDoH)变量对脓毒症住院后 30 天再入院的预测价值:多中心回顾性队列研究,使用患者层面的数据,包括人口统计学、临床和调查数据:2017年至2021年,全美35家医院:干预措施:无:干预措施:无:非计划 30 天再入院。在确定与 30 天再入院相关的变量时,建立了多项式逻辑回归模型以考虑生存率,并以调整后的几率(aORs)表示。在我们队列中的 8909 名脓毒症患者中,21% 的患者在 30 天内发生了计划外再入院。中位年龄(四分位数间距)为 54 岁(41-65 岁),女性 4762 人(53.4%),自述黑人 1612 人(18.09%),西班牙裔 2271 人(25.49%),白人 4642 人(52.1%)。在考虑生存率的多项式逻辑回归模型中,我们发现,由于经济原因(aOR,2.55 [2.35-2.74])而改用非医生医疗服务提供者类型、由于交通不便而延迟接受医疗护理(aOR,1.68 [1.62-1.74])以及无法负担流动医疗护理(aOR,1.59 [1.52-1.66]),在考虑生存率的情况下,与 30 天再入院密切且独立相关。居住在贫困和没有医疗保险的患者比例较高的邮政编码内的患者也更有可能在 30 天内再次入院(aOR,分别为 1.26 [1.22-1.29] 和 aOR,1.28 [1.26-1.29])。最后,我们发现拥有初级保健提供者和医疗保险与30天内非计划再入院的低几率相关:在这个多中心回顾性队列中,几个 SDoH 变量与 30 天非计划再入院密切相关。在传统临床变量的基础上增加 SDoH 因素,可能会对预测脓毒症住院后再入院的模型有所帮助。
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引用次数: 0
Physical Rehabilitation and Mobilization in Patients Receiving Extracorporeal Life Support: A Systematic Review. 体外生命支持患者的身体康复和移动:系统回顾。
Q4 Medicine Pub Date : 2024-05-24 eCollection Date: 2024-06-01 DOI: 10.1097/CCE.0000000000001095
Julian D Rivera, Edward S Fox, Shannon M Fernando, Alexandre Tran, Daniel Brodie, Eddy Fan, Jo-Anne Fowles, Carol L Hodgson, Joseph E Tonna, Bram Rochwerg

Objectives: We planned to synthesize evidence examining the potential efficacy and safety of performing physical rehabilitation and/or mobilization (PR&M) in adult patients receiving extracorporeal life support (ECLS).

Data sources: We included any study that compared PR&M to no PR&M or among different PR&M strategies in adult patients receiving any ECLS for any indication and any cannulation. We searched seven electronic databases with no language limitations.

Study selection and data extraction: Two reviewers, independently and in duplicate, screened all citations for eligibility. We used the Cochrane Risk of Bias 2 and Cochrane Risk Of Bias In Non-randomized Studies of Interventions tools to assess individual study risk of bias. Although we had planned for meta-analysis, this was not possible due to insufficient data, so we used narrative and tabular data summaries for presenting results. We assessed the overall certainty of the evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation framework.

Data synthesis: We included 17 studies that enrolled 996 patients. Most studies examined venovenous extracorporeal membrane oxygenation (ECMO) and/or venoarterial ECMO as a bridge to recovery in the ICU. We found an uncertain effect of high-intensity/active PR&M on mortality, duration of mechanical ventilation, ICU length of stay, hospital length of stay, or quality of life compared with low-intensity/passive PR&M in patients receiving ECLS (very low certainty due to very serious imprecision). There was similarly an uncertain effect on safety events including clinically important bleeding, spontaneous intracerebral hemorrhage, limb ischemia, accidental decannulation, or ECLS circuit dysfunction (very low certainty due to very serious risk of bias and imprecision).

Conclusions: Based on the currently available summary of evidence, there is an uncertain effect of high-intensity/active PR&M on patient important outcomes or safety in patients receiving ECLS. Despite indirect data from other populations suggesting potential benefit of high-intensity PR&M in the ICU; further high-quality randomized trials evaluating the benefits and risks of physical therapy and/or mobilization in this population are needed.

目的: 我们计划对接受体外生命支持(ECLS)的成人患者进行物理康复和/或移动(PR&M)的潜在疗效和安全性的证据进行综合分析:我们计划综合研究对接受体外生命支持(ECLS)的成年患者进行物理康复和/或移动(PR&M)的潜在疗效和安全性的证据:我们纳入了所有对接受体外生命支持(ECLS)治疗的成年患者进行物理康复和/或移动(PR&M)与不进行物理康复和/或移动(PR&M)进行比较的研究,这些患者接受过任何适应症和任何插管。我们检索了七个无语言限制的电子数据库:两名审稿人分别独立并重复筛选了所有符合条件的引文。我们使用 Cochrane Risk of Bias 2 和 Cochrane Risk Of Bias In Non-randomized Studies of Interventions 工具来评估各项研究的偏倚风险。虽然我们曾计划进行荟萃分析,但由于数据不足而无法实现,因此我们采用了叙述式和表格式数据摘要来呈现结果。我们采用建议分级评估、发展和评价框架对每项结果的证据的整体确定性进行了评估:我们纳入了 17 项研究,共招募了 996 名患者。大多数研究将静脉体外膜肺氧合(ECMO)和/或静脉动脉 ECMO 作为重症监护病房康复的桥梁。我们发现,在接受 ECLS 的患者中,与低强度/被动 PR&M 相比,高强度/主动 PR&M 对死亡率、机械通气持续时间、重症监护室住院时间、住院时间或生活质量的影响并不确定(由于非常严重的不精确性,确定性很低)。同样,对临床重要出血、自发性脑出血、肢体缺血、意外拔管或 ECLS 电路功能障碍等安全事件的影响也不确定(由于存在非常严重的偏倚和不精确风险,因此确定性很低):根据目前可用的证据摘要,高强度/积极的 PR&M 对接受 ECLS 患者的重要预后或安全性的影响尚不确定。尽管来自其他人群的间接数据表明,在 ICU 中进行高强度 PR&M 可能会带来益处,但仍需进一步开展高质量的随机试验,评估物理治疗和/或动员对该人群的益处和风险。
{"title":"Physical Rehabilitation and Mobilization in Patients Receiving Extracorporeal Life Support: A Systematic Review.","authors":"Julian D Rivera, Edward S Fox, Shannon M Fernando, Alexandre Tran, Daniel Brodie, Eddy Fan, Jo-Anne Fowles, Carol L Hodgson, Joseph E Tonna, Bram Rochwerg","doi":"10.1097/CCE.0000000000001095","DOIUrl":"10.1097/CCE.0000000000001095","url":null,"abstract":"<p><strong>Objectives: </strong>We planned to synthesize evidence examining the potential efficacy and safety of performing physical rehabilitation and/or mobilization (PR&M) in adult patients receiving extracorporeal life support (ECLS).</p><p><strong>Data sources: </strong>We included any study that compared PR&M to no PR&M or among different PR&M strategies in adult patients receiving any ECLS for any indication and any cannulation. We searched seven electronic databases with no language limitations.</p><p><strong>Study selection and data extraction: </strong>Two reviewers, independently and in duplicate, screened all citations for eligibility. We used the Cochrane Risk of Bias 2 and Cochrane Risk Of Bias In Non-randomized Studies of Interventions tools to assess individual study risk of bias. Although we had planned for meta-analysis, this was not possible due to insufficient data, so we used narrative and tabular data summaries for presenting results. We assessed the overall certainty of the evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation framework.</p><p><strong>Data synthesis: </strong>We included 17 studies that enrolled 996 patients. Most studies examined venovenous extracorporeal membrane oxygenation (ECMO) and/or venoarterial ECMO as a bridge to recovery in the ICU. We found an uncertain effect of high-intensity/active PR&M on mortality, duration of mechanical ventilation, ICU length of stay, hospital length of stay, or quality of life compared with low-intensity/passive PR&M in patients receiving ECLS (very low certainty due to very serious imprecision). There was similarly an uncertain effect on safety events including clinically important bleeding, spontaneous intracerebral hemorrhage, limb ischemia, accidental decannulation, or ECLS circuit dysfunction (very low certainty due to very serious risk of bias and imprecision).</p><p><strong>Conclusions: </strong>Based on the currently available summary of evidence, there is an uncertain effect of high-intensity/active PR&M on patient important outcomes or safety in patients receiving ECLS. Despite indirect data from other populations suggesting potential benefit of high-intensity PR&M in the ICU; further high-quality randomized trials evaluating the benefits and risks of physical therapy and/or mobilization in this population are needed.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"6 6","pages":"e1095"},"PeriodicalIF":0.0,"publicationDate":"2024-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11132346/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141089540","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
Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis. 支气管炎患者使用无创正压通气与院内心脏骤停。
Q4 Medicine Pub Date : 2024-05-15 eCollection Date: 2024-05-01 DOI: 10.1097/CCE.0000000000001088
Lindsay N Shepard, Sanjiv Mehta, Kathryn Graham, Martha Kienzle, Amanda O'Halloran, Nadir Yehya, Ryan W Morgan, Garrett P Keim

Importance: A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis.

Objectives: We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA.

Design, setting and participants: Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database.

Main outcomes and measures: The primary exposure was NIPPV and the primary outcome was IHCA.

Measurements and main results: Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]).

Conclusions and relevance: Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

重要性:最近的一项研究表明,在患有支气管炎的儿童中,医院层面大量使用无创正压通气(NIPPV)与院内心脏骤停(IHCA)之间存在关联:我们旨在确定支气管炎患儿在患者层面接触无创正压通气是否与 IHCA 相关:在北美一家单中心四级 PICU 进行的回顾性队列研究,包括虚拟儿科系统数据库中国际疾病分类一级或二级诊断为支气管炎的儿童:主要暴露是NIPPV,主要结果是IHCA:在符合条件的 4698 例诊断为支气管炎的 ICU 入院患者中,1.2%(57/4698)发生了 IHCA。IHCA发生时,有创机械通气(IMV)是最常用的呼吸支持方式(65%,37/57),12%(7/57)接受NIPPV。与无 IHCA 的患者相比,IHCA 患者的儿科死亡风险-III 评分更高(3 [0-8] vs. 0 [0-2]; p < 0.001),患有复杂慢性疾病的比例更高(94.7% vs. 46.2%; p < 0.001),死亡率更高(21.1% vs. 1.0%; p < 0.001)。93%(53/57)的IHCA患者实现了自主循环(ROSC)恢复;79%(45/57)的患者存活至出院。七名无慢性疾病且在 IHCA 时有活动性支气管炎症状的患儿全部实现了 ROSC,86%(6/7)的患儿存活至出院。在仅限于接受 NIPPV 或 IMV 的患者的多变量分析中,与 IMV 相比,接受 NIPPV 的患者发生 IHCA 的几率较低(调整后的几率比 [aOR],0.07;95% CI,0.03-0.18)。在评估所有患者分类呼吸支持的二次分析中,与 IMV 相比,NIPPV 与较低的 IHCA 发生几率相关(aOR,0.35;95% CI,0.14-0.87),而最小呼吸支持(无/鼻插管/湿化高流量鼻插管 [aOR,0.56;95% CI,0.23-1.36])则无差异:支气管炎患儿心跳骤停的情况并不常见,仅占支气管炎重症监护病房收治人数的 1.2%。支气管炎患儿使用 NIPPV 可降低 IHCA 的发生几率。
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引用次数: 0
National Emergency Tele-Critical Care in a Pandemic: Barriers and Solutions. 大流行病中的国家紧急远程重症监护:障碍与解决方案。
Q4 Medicine Pub Date : 2024-05-13 eCollection Date: 2024-05-01 DOI: 10.1097/CCE.0000000000001091
Jeremy C Pamplin, Brooke Gray, Matthew T Quinn, Jeanette R Little, Christopher J Colombo, Sanjay Subramanian, Joseph C Farmer, Michael Ries, Benjamin Scott

The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.

COVID-19 大流行对美国医疗系统造成了巨大的破坏,在病人大量涌入时,一些医院几乎瘫痪。全国各地有限的重症监护病房床位进一步加剧了这些挑战。远程医疗,特别是远程重症监护 (TCC),可以通过远程专业技术扩展医院的临床能力,并通过将一些监护工作转移到远程团队来提高医疗能力。遗憾的是,远程医疗尤其是远程重症监护的快速部署受到多重障碍的制约。2020 年夏天,为了支持国家紧急远程重症监护网络(NETCCN)的部署,50 多名将远程医疗技术应用于重症监护的国家领导者聚集一堂,就实施国家紧急远程重症监护网络的障碍和克服这些障碍的策略发表了自己的看法。在达成共识后,这些专家编写了白皮书,并以此为基础撰写了本文。在本文中,作者分享了他们的经验,并针对法律、地方政策和文化以及个人观点所带来的障碍,按照最低、较好、最佳的模式,提出了在国家灾难背景下提供远程医疗的多种解决方案。跨州许可和虚拟专家的地方特权被认为是快速部署服务的最大障碍,而完善 TCC 模式以实现最佳结果和定义最佳财务模式则是长期成功的最重要因素。最终,我们得出结论,快速部署全国远程医疗响应系统是可以实现的。
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引用次数: 0
Physiologic Determinants of Near-Infrared Spectroscopy-Derived Cerebral and Tissue Oxygen Saturation Measurements in Critically Ill Patients. 重症患者近红外光谱法得出的大脑和组织血氧饱和度测量值的生理决定因素
Q4 Medicine Pub Date : 2024-05-10 eCollection Date: 2024-05-01 DOI: 10.1097/CCE.0000000000001094
Neil Cody, Ian Bradbury, Ross R McMullan, Gerard Quinn, Aisling O'Neill, Kathryn Ward, Justine McCann, Daniel F McAuley, Jonathan A Silversides

Objectives: Near-infrared spectroscopy (NIRS) is a potentially valuable modality to monitor the adequacy of oxygen delivery to the brain and other tissues in critically ill patients, but little is known about the physiologic determinants of NIRS-derived tissue oxygen saturations. The purpose of this study was to assess the contribution of routinely measured physiologic parameters to tissue oxygen saturation measured by NIRS.

Design: An observational sub-study of patients enrolled in the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomized feasibility trial.

Setting: Two ICUs in the United Kingdom.

Patients: Patients were recruited for the RADAR-2 study, which compared a conservative approach to fluid therapy and deresuscitation with usual care. Those included in this sub-study underwent continuous NIRS monitoring of cerebral oxygen saturations (SctO2) and quadriceps muscle tissue saturations (SmtO2).

Intervention: Synchronized and continuous mean arterial pressure (MAP), heart rate (HR), and pulse oximetry (oxygen saturation, Spo2) measurements were recorded alongside NIRS data. Arterial Paco2, Pao2, and hemoglobin concentration were recorded 12 hourly. Linear mixed effect models were used to investigate the association between these physiologic variables and cerebral and muscle tissue oxygen saturations.

Measurements and main results: Sixty-six patients were included in the analysis. Linear mixed models demonstrated that Paco2, Spo2, MAP, and HR were weakly associated with SctO2 but only explained 7.1% of the total variation. Spo2 and MAP were associated with SmtO2, but together only explained 0.8% of its total variation. The remaining variability was predominantly accounted for by between-subject differences.

Conclusions: Our findings demonstrated that only a small proportion of variability in NIRS-derived cerebral and tissue oximetry measurements could be explained by routinely measured physiologic variables. We conclude that for NIRS to be a useful monitoring modality in critical care, considerable further research is required to understand physiologic determinants and prognostic significance.

目的:近红外光谱(NIRS)是监测重症患者脑部和其他组织供氧是否充足的一种有潜在价值的方法,但人们对 NIRS 导出的组织氧饱和度的生理决定因素知之甚少。本研究的目的是评估常规测量的生理参数对 NIRS 测量的组织氧饱和度的贡献:设计:对参加复苏后积极去复苏作用-2(RADAR-2)随机可行性试验的患者进行观察性子研究:地点:英国两家重症监护室:RADAR-2研究比较了液体疗法和复苏的保守方法与常规护理。参与该子研究的患者接受了连续的近红外血氧饱和度(SctO2)和股四头肌组织饱和度(SmtO2)监测:干预措施:在记录 NIRS 数据的同时,同步连续记录平均动脉压 (MAP)、心率 (HR) 和脉搏血氧仪(血氧饱和度,Spo2)的测量值。每 12 小时记录一次动脉 Paco2、Pao2 和血红蛋白浓度。线性混合效应模型用于研究这些生理变量与大脑和肌肉组织血氧饱和度之间的关系:有 66 名患者参与了分析。线性混合模型显示,Paco2、Spo2、MAP 和 HR 与 SctO2 的关系较弱,但只能解释总变化的 7.1%。Spo2 和 MAP 与 SmtO2 相关,但二者只能解释其总变化的 0.8%。其余的变异主要是由受试者之间的差异造成的:我们的研究结果表明,常规测量的生理变量只能解释一小部分 NIRS 导出的大脑和组织血氧测量的变异性。我们的结论是,要使近红外成像技术成为重症监护中一种有用的监测模式,还需要进行大量的进一步研究,以了解生理决定因素和预后意义。
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引用次数: 0
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Critical care explorations
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