Medicina intensiva最新文献

In patients with spontaneous or traumatic intracranial hemorrhage, hematoma expansion is associated with poorer neurological outcomes and increased mortality. The administration of an antifibrinolytic agent like tranexamic acid (TXA) may potentially improve clinical outcomes in patients with acute brain injury by preventing such intracranial expansion. However, studies on the impact of TXA in these patients have yielded variable results, and its efficacy, appropriate dosing and optimal timing of administration remain unclear. The present review summarizes the clinical evidence regarding the proper use of tranexamic acid in the treatment of intracranial traumatic and non-traumatic hemorrhage, and its implications for clinical practice.

Objective: Evaluate the incidence of hypotension during the weaning phase of vasopressors.

Design: A single-center, open-label randomized clinical trial between May and December 2022.

Setting: a tertiary care academic medical center.

Patients: 91 adult patients over 18 years of age with septic shock (according to Sepsis-3).

Intervention: Patients were divided into two groups: initial reduction of norepinephrine or initial reduction of vasopressin.

Main variables of interest: The primary outcome was the incidence of hypotension within the first 24 h after reducing vasopressors. Additionally, the clinical impact of this hypotension was assessed through mortality, length of hospital stay, duration of vasopressor use, incidence of arrhythmias, and prevalence of hemodialysis.

Results: Out of a total of 91 patients, 78 were included in the analysis: 39 in the norepinephrine group and 39 in the vasopressin group. Despite a numerically significant difference in the incidence of hypotension between the groups (norepinephrine 43.6%, vasopressin 25.6%), there was no statistical difference (p =  0.153, relative risk = 1.7, 95% confidence interval: 0.9-3.2). In this sample, vasopressin withdrawal was predominantly titrated. There were no differences between the groups in terms of the evaluated clinical outcomes.

Conclusion: No differences were detected in the incidence of hypotension when weaning was initiated with norepinephrine or vasopressin, although it was non significantly higher in norepinephrine group. In our sample, vasopressin withdrawal was titrated, which differs from North American practice. Brazilian Clinical Trials Registry (REBEC: RBR-10smbw65).

Clinicaltrials: gov platform (NCT05506319).

Objective: In the present study, we aimed to compare in-hospital mortality and safety of intravenous beta-blockers and amiodarone in septic patients with new-onset atrial fibrillation (NOAF). The null hypothesis is that there is no significant difference in in-hospital mortality and safety of Beta-blocker (BBs) and amiodarone in treating NOAF in patients with sepsis.

Design: We conducted a retrospective analysis based on the MIMIC-IV database. Septic patients with NOAF were screened.

Setting: Patients admitted to adult mixed ICU for septic patients with NOAF.

Patients: A total of 34,789 patients were screened of whom 1394 patients were included for the analysis: 286 in the amiodarone group and 1108 in the BBs group.

Interventions: None.

Main variables of interest: Cox proportional hazard model was used to examine the in-hospital mortality, ventilator-free days and duration of atrial fibrillation in patients receiving either amiodarone or intravenous BBs. Propensity score matching was applied to determine any association.

Results: After Propensity Score (PS) matching, a total of 244 patients were included in both the BB and amiodarone groups. In this cohort, BBs was significantly associated with lower in-hospital mortality [adjusted hazard ratio (HR) of 0.70 (95% CI 0,54-0,91; P = 0.008)]. On the other hand, patients who received amiodarone had a shorter duration of atrial fibrillation (54.17 h vs 72.81 h; P = 0.003). There was no significant difference in ventilator-free days between the BB group and the amiodarone group.

Conclusion: In septic patients with NOAF, patients receiving BBs had lower in-hospital mortality than those who received amiodarone. On the other hand, amiodarone group had a shorter duration of atrial fibrillation. There was no significant difference in ventilator-free days between the BB group and the amiodarone group.

The pharmacological group of immune checkpoint-inhibitors (ICI) has revolutionized the field of oncology in the last ten years. The improvements in the survival of certain cancers thanks to these treatments comes at the cost of an increased morbidity and mortality due to certain immune related adverse events (irAE). This review will concentrate on the irAE that more frequently require intensive care unit (ICU) admission. The infectious burden of patients treated with ICI is also explored, shining light not only on the infections caused by the immunosuppression needed to manage the different irAE, but also on the specific infections arising from a unique immune dysregulation only seen in ICI treated patients.

Objective: The purpose of this study was to analyze the differences in the effectiveness and complications of CPAP versus non-invasive ventilation on bilevel positive airway pressure (BiPAP) in the treatment of COVID-19 associated acute respiratory failure (ARF).

Design: Retrospective observational study.

Setting: ICU.

Patients: All COVID-19 patients, admitted to an ICU between March 2020 and February 2023, who required CPAP or BiPAP were analyzed.

Interventions: Use of CPAP or BiPAP in COVID-19 associated ARF.

Main variables of interest: Initial clinical variables, CPAP and BiPAP failure rate, complications, in-hospital mortality.

Results: 429 patients were analyzed, of whom 328 (76.5%) initially received CPAP and 101 (23.5%) BiPAP. Initial respiratory rate was 30 ± 8 in the CPAP group and 34 ± 9 in BiPAP (p < 0.001), while PaO₂/FiO₂ was 120 ± 26 and 111 ± 24 mmHg (p = 0.001), respectively. The most frequent complication related to the device was claustrophobia/discomfort, 23.2% in CPAP and 25.7% in BiPAP (p = 0.596), while the most frequent complications not related to the device were severe ARDS, 58.6% and 70.1% (p = 0.044), and hyperglycemia, 44.5% and 37.6%, respectively (p = 0.221). After adjusting by propensity score matched analysis, neither failure of the device (OR 1.37, CI 95% 0.72-2.62) nor in-hospital mortality (OR 1.57, CI 95% 0.73-3.42) differed between both groups.

Conclusions: Either non-invasive ventilatory device failure or mortality rate differed in patients initially treated with CPAP versus BiPAP.

Objective: To determine whether the Reverse Shock Index multiplied by the Glasgow Coma Scale (rSIG) is a predictor of in-hospital mortality in patients with traumatic brain injury (TBI).

Design: This is a systematic review and meta-analysis.

Setting: A comprehensive search was conducted in five databases for studies published up to May 22, 2024, using a PECO strategy. Eight studies were identified for quantitative analysis and included in our meta-analysis.

Participants: The participants of the included primary studies.

Interventions: Patients with a low rSIG as a predictor of in-hospital mortality in TBI.

Main variables of interest: rSIG, in-hospital mortality, TBI.

Results: Our meta-analysis evaluated a total of eight observational studies encompassing 430,000 patients with TBI, observing 6,417 deaths (15%). After performing a sensitivity analysis, we found that patients with TBI and a low value of the reverse shock index multiplied by the Glasgow Coma Scale (rSIG) had a 24% higher risk of death (OR 1.24; 95% CI 1.12-1.38; I²: 96%). Furthermore, rSIG values were significantly higher in survivors compared to those who died (MD 7.72; 95% CI 1.86-13.58; I²: 99%).