Medicina intensiva最新文献

英文中文

Medicina intensiva

Pub Date : 2024-08-01 DOI: 10.1016/j.medine.2024.07.010

Sara Alcántara Carmona, Héctor Villanueva Fernández

引用次数: 0

Effectiveness of Helmet-CPAP in mild to moderate coronavirus type 2 hypoxemia: An observational study 头盔-CPAP 对轻中度冠状病毒 2 型低氧血症的疗效：一项观察性研究。

Medicina intensiva

Pub Date : 2024-08-01 DOI: 10.1016/j.medine.2024.03.007

Objective

To determine the relative effectiveness of Helmet-CPAP (H_CPAP) with respect to high-flow nasal cannula oxygen therapy (HFNO) in avoiding greater need for intubation or mortality in a medium complexity hospital in Chile during the year 2021.

Design

Cohort analytical study, single center.

Setting

Units other than intensive care units.

Patients

Records of adults with mild to moderate hypoxemia due to coronavirus type 2.

Interventions

None.

Main variables of interest

Need for intubation or mortality.

Results

159 patients were included in the study, with a ratio by support of 2:10 (H_CPAP:HFNO). The 46.5% were women, with no significant differences by sex according to support (p = 0.99, Fisher test). The APACHE II score, for HFNO, had a median of 10.5, 3.5 units higher than H_CPAP (p < 0.01, Wilcoxon rank sum). The risk of intubation in HFNO was 42.1% and in H_CPAP 3.8%, with a significant risk reduction of 91% (95% CI: 36.9%–98.7%; p < 0.01). APACHE II does not modify or confound the support and intubation relationship (p > 0.2, binomial regression); however, it does confound the support and mortality relationship (p = 0.82, RR homogeneity test). Despite a 79.1% reduction in mortality risk with H_CPAP, this reduction was not statistically significant (p = 0.11, binomial regression).

Conclusions

The use of Helmet CPAP, when compared to HFNO, was an effective therapeutic ventilatory support strategy to reduce the risk of intubation in patients with mild to moderate hypoxemia caused by coronavirus type 2 in inpatient units other than intensive care. The limitations associated with the difference in size, age and severity between the arms could generate bias.

目的确定在 2021 年期间，在智利的一家中型综合医院中，头盔-CPAP（H_CPAP）与高流量鼻插管供氧疗法（HFNO）在避免更多插管需求或死亡率方面的相对有效性：设计：队列分析研究，单中心：环境：重症监护室以外的病房：干预措施：无：干预措施：无：需要插管或死亡率：研究共纳入 159 名患者，支持比例为 2:10（H_CPAP:HFNO）。46.5%的患者为女性，不同支持方式的性别差异不大（费雪检验，P = 0.99）。HFNO 的 APACHE II 评分中位数为 10.5，比 H_CPAP 高 3.5 个单位（p 0.2，二项回归）；但是，APACHE II 评分确实混淆了支持率与死亡率的关系（p = 0.82，RR 同质性检验）。尽管 H_CPAP 降低了 79.1% 的死亡风险，但这一降低并不具有统计学意义（p = 0.11，二项回归）：结论：与高频硝化氧治疗相比，使用头盔式 CPAP 是一种有效的治疗性通气支持策略，可降低重症监护室以外的住院病房中由冠状病毒 2 型引起的轻度至中度低氧血症患者的插管风险。由于两组患者的大小、年龄和严重程度不同，可能会产生偏差。

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引用次数: 0

“INTUPROS”: an opportunity to reflect upon and improve "INTUPROS"：反思和改进的机会。

Medicina intensiva

Pub Date : 2024-08-01 DOI: 10.1016/j.medine.2024.04.014

引用次数: 0

Towards better mortality prediction in cancer patients in the ICU: a comparative analysis of prognostic scales: systematic literature review 为更好地预测重症监护室癌症患者的死亡率：预后量表的比较分析：系统性文献综述。

Medicina intensiva

Pub Date : 2024-08-01 DOI: 10.1016/j.medine.2024.07.009

Andrea Cabrera Losada , Maria Alejandra Correa Oviedo , Vanessa Carolina Herrera Villazón , Sebastián Gil-Tamayo , Carlos Federico Molina , Carola Gimenez-Esparza Vich , Víctor Hugo Nieto Estrada

Objective

To evaluate the predictive ability of mortality prediction scales in cancer patients admitted to intensive care units (ICUs).

Design

A systematic review of the literature was conducted using a search algorithm in October 2022. The following databases were searched: PubMed, Scopus, Virtual Health Library (BVS), and Medrxiv. The risk of bias was assessed using the QUADAS-2 scale.

Setting

ICUs admitting cancer patients.

Participants

Studies that included adult patients with an active cancer diagnosis who were admitted to the ICU.

Interventions

Integrative study without interventions.

Main variables of interest

Mortality prediction, standardized mortality, discrimination, and calibration.

Results

Seven mortality risk prediction models were analyzed in cancer patients in the ICU. Most models (APACHE II, APACHE IV, SOFA, SAPS-II, SAPS-III, and MPM II) underestimated mortality, while the ICMM overestimated it. The APACHE II had the SMR (Standardized Mortality Ratio) value closest to 1, suggesting a better prognostic ability compared to the other models.

Conclusions

Predicting mortality in ICU cancer patients remains an intricate challenge due to the lack of a definitive superior model and the inherent limitations of available prediction tools. For evidence-based informed clinical decision-making, it is crucial to consider the healthcare team's familiarity with each tool and its inherent limitations. Developing novel instruments or conducting large-scale validation studies is essential to enhance prediction accuracy and optimize patient care in this population.

目的：评估重症监护病房癌症患者死亡率预测量表的预测能力：评估重症监护病房（ICU）癌症患者死亡率预测量表的预测能力：设计：2022 年 10 月，使用搜索算法对文献进行了系统性回顾。检索了以下数据库：PubMed、Scopus、虚拟健康图书馆（BVS）和Medrxiv。采用QUADAS-2量表评估偏倚风险：环境：收治癌症患者的重症监护病房：干预措施：无干预措施的综合研究：干预：无干预的综合研究：死亡率预测、标准化死亡率、区分度和校准：对重症监护室癌症患者的七种死亡率风险预测模型进行了分析。大多数模型（APACHE II、APACHE IV、SOFA、SAPS-II、SAPS-III 和 MPM II）低估了死亡率，而 ICMM 高估了死亡率。APACHE II的SMR（标准化死亡率）值最接近于1，表明其预后能力优于其他模型：结论：由于缺乏明确的优越模型以及现有预测工具的固有局限性，预测 ICU 癌症患者的死亡率仍然是一项复杂的挑战。要做出基于证据的知情临床决策，关键是要考虑医疗团队对每种工具的熟悉程度及其固有的局限性。开发新型工具或进行大规模验证研究对于提高预测准确性和优化该人群的患者护理至关重要。

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引用次数: 0

Duration of the first prone positioning maneuver and its association with 90-day mortality in patients with acute respiratory failure due to COVID-19: A retrospective study of time terciles COVID-19导致的急性呼吸衰竭患者首次俯卧位操作的持续时间及其与90天死亡率的关系：时间分层回顾性研究。

Medicina intensiva

Pub Date : 2024-08-01 DOI: 10.1016/j.medine.2024.04.009

Objective

To investigate the association between the duration of the first prone positioning maneuver (PPM) and 90-day mortality in patients with C-ARDS.

Design

Retrospective, observational, and analytical study.

Setting

COVID-19 ICU of a tertiary hospital.

Patients

Adults over 18 years old, with a confirmed diagnosis of SARS-CoV-2 disease requiring PPM.

Interventions

Multivariable analysis of 90-day survival.

Main variables of interest

Duration of the first PPM, number of PPM sessions, 90-day mortality.

Results

271 patients undergoing PPM were analyzed: first tertile (n = 111), second tertile (n = 95) and third tertile (n = 65). The results indicated that the median duration of PDP was 14 h (95% CI: 10−16 h) in the first tertile, 19 h (95% CI: 18−20 h) in the second tertile and 22 h (95% CI: 21−24 h) in the third tertile. Comparison of survival curves using the Logrank test did not reach statistical significance (p = 0.11). Cox Regression analysis showed an association between the number of pronation sessions (patients receiving between 2 and 5 sessions (HR = 2.19; 95% CI: 1.07–4.49); and those receiving more than 5 sessions (HR = 6.05; 95% CI: 2.78–13.16) and 90-day mortality.

Conclusions

while the duration of PDP does not appear to significantly influence 90-day mortality, the number of pronation sessions is identified as a significant factor associated with an increased risk of mortality.

目的研究C-ARDS患者首次俯卧位操作（PPM）持续时间与90天死亡率之间的关系：设计：回顾性、观察性和分析性研究：地点：一家三甲医院的COVID-19重症监护室：患者：18岁以上确诊患有SARS-CoV-2疾病并需要进行PPM治疗的成年人：90天存活率的多变量分析：结果：对271名接受PPM的患者进行了分析：第一梯队（111人）、第二梯队（95人）和第三梯队（65人）。结果显示，PDP持续时间的中位数在第一梯度为14小时（95% CI：10-16小时），第二梯度为19小时（95% CI：18-20小时），第三梯度为22小时（95% CI：21-24小时）。使用 Logrank 检验比较生存曲线没有统计学意义（P = 0.11）。Cox 回归分析显示，代偿治疗次数（接受 2 到 5 次治疗的患者（HR = 2.19；95% CI：1.07-4.49）；接受 5 次以上治疗的患者（HR = 6.05；95% CI：2.78-13.16））与 90 天死亡率之间存在关联。结论：虽然 PDP 的持续时间似乎不会显著影响 90 天死亡率，但代偿治疗次数被确定为与死亡风险增加相关的重要因素。

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引用次数: 0

Emphysematous cystitis in the postoperative period of aortic valve replacement. 主动脉瓣置换术术后气肿性膀胱炎。

Medicina intensiva

Pub Date : 2024-07-29 DOI: 10.1016/j.medine.2024.07.007

Iratxe Iriondo Irigoras, M Ángeles Rodríguez Esteban

引用次数: 0

Anti-Xa activity below range is related to thrombosis in patients with severe COVID-19. 抗 Xa 活性低于范围与严重 COVID-19 患者的血栓形成有关。

Medicina intensiva

Pub Date : 2024-07-24 DOI: 10.1016/j.medine.2024.07.003

Pilar Marcos-Neira, Cristian Morales-Indiano, Mariana Fernández-Caballero, Teresa Tomasa-Irriguible, Luisa Bordejé-Laguna, Víctor Ruíz-Artola

Objective: We aimed to anlayse the relationship between anti-Xa activity below range and thomboembolic events.

Design: Single center prospective observational longitudinal cohort study (February-November 2021).

Setting: Patients admitted to the ICU of a University Hospital.

Participants: Patients with severe COVID-19 pneumoniae.

Interventions: Enoxaparin was used for prophylactic and therapeutic anticoagulation. Enoxaparin dosing and dose adjustment were based on anti-Xa activity according to the hospital protocol.

Main variables of interest: Target: thomboembolic events.

Predictors: demographics, pharmacotherapy, anti-Xa measurements, clinical data, and laboratory results. Logistic regression was used to identify independent risk factors for thomboembolic events.

Results: Data were available for 896 serum anti-Xa measurements from 228 subjects. Overall, 71.9% were male, with a median age of 62. Most patients needed invasive mechanical ventilation (87.7%) and mortality was 24.1%. A total of 28.9% new thomboembolic events were diagnosed. There were 27.1% anti-Xa measesurements below range. When multivariable logistic regression analysis was performed anti-Xa activity below range (RR, 4.2; p = 0.000), C-reactive protein (25 mg/L increase) (RR, 1.14; p = 0.005) and D-dimer (1000 ng/L increase) (RR, 1.06; p = 0.002) were the independent factors related to new thomboembolic events in patients with severe COVID-19.

Conclusions: Anti-Xa activity below range, C-reactive protein and D-dimer were the independent factors related to thomboembolic events in patients with severe COVID-19. Purposely designed clinical trials should be carried out to confirm the benefit of an anti-Xa monitoring.

目的我们旨在分析抗 Xa 活性低于范围与血栓栓塞事件之间的关系：单中心前瞻性纵向队列研究（2021 年 2 月至 11 月）：地点：某大学附属医院重症监护室收治的患者：重症COVID-19肺炎患者：干预措施：依诺肝素用于预防性和治疗性抗凝。干预措施：使用依诺肝素进行预防性和治疗性抗凝，并根据医院的方案，根据抗 Xa 活性对依诺肝素的剂量和剂量进行调整：目标：血栓栓塞事件。预测因素：人口统计学、药物治疗、抗 Xa 测量、临床数据和实验室结果。采用逻辑回归法确定血栓栓塞事件的独立风险因素：228名受试者的896次血清抗Xa测量数据可用。总体而言，71.9%为男性，中位年龄为62岁。大多数患者需要有创机械通气（87.7%），死亡率为 24.1%。共诊断出 28.9% 的新血栓栓塞事件。27.1%的患者抗Xa测定值低于范围。在进行多变量逻辑回归分析时，抗 Xa 活性低于范围（RR，4.2；P = 0.000）、C 反应蛋白（增加 25 毫克/升）（RR，1.14；P = 0.005）和 D-二聚体（增加 1000 纳克/升）（RR，1.06；P = 0.002）是严重 COVID-19 患者新发血栓栓塞事件的独立相关因素：结论：抗-Xa活性低于范围、C反应蛋白和D-二聚体是严重COVID-19患者发生血栓栓塞事件的独立相关因素。应开展专门设计的临床试验，以确认抗 Xa 监测的益处。

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引用次数: 0

Impact of high-flow oxygen therapy via high velocity nasal insufflation on diaphragmatic thickening fraction in healthy subjects 通过高速鼻腔充气进行高流量氧疗对健康受试者膈肌增厚率的影响。

Medicina intensiva

Pub Date : 2024-07-23 DOI: 10.1016/j.medine.2024.05.017

Gustavo Adrián Plotnikow , Facundo José Federico Bianchini , Roque Moracci , Jaime Andrés Santana Mackinlay , Federico Melgarejo , Malena Paula Loustau , Valeria Silvina Acevedo , Emanuel Di Salvo , Facundo Javier Gutierrez , Matias Madorno , Javier Mariani

Objective

The primary objective of this study was to evaluate the impact of high-flow nasal cannula oxygen therapy [HFNC] on the diaphragm thickening fraction.

Design

Prospective, descriptive, cohort study

Setting

The study was conducted in the Physiology and Respiratory Care Laboratory, Intensive Care Unit, Hospital Británico de Buenos Aires.

Participants

Thirteen healthy subjects >18 years old

Interventions

High-flow nasal cannula oxygen therapy

Main variables of interest

Demographic data (age and gender), anthropometric data (weight, height, and body mass index), and clinical and respiratory variables (Diaphragm thickening fraction [DTf], esophageal pressure swing, respiratory rate [RR], esophageal pressure-time product per minute [PTPes/min]).

Results

Median DTf decreased significantly as flow increased (p < 0.05). The baseline DTf measurement was 21.4 %, 18.3 % with 20 L/m, and 16.4 % with 40 L/m. We also observed a significant decrease in RR as flow increased in HFNC (p < 0.05). In the 8 subjects with recordings, the PTPes/min was 81.3 (±30.8) cmH2O/sec/min and 64.4 (±25.3) cmH₂O/sec/min at baseline and 40 L/m respectively (p = 0.044).

Conclusions

The use of high-flow oxygen therapy through nasal cannula of HFNC in healthy subjects decreases the DTf and RR in association with increased flow. In addition, the use of 40 L/m flow may reduce the muscular work associated with respiration.

研究目的本研究的主要目的是评估高流量鼻插管氧疗[HFNC]对横隔膜增厚分数的影响：前瞻性、描述性、队列研究：研究在布宜诺斯艾利斯不列颠医院重症监护室生理学和呼吸护理实验室进行：干预措施：高流量鼻插管供氧疗法主要关注变量：人口统计学数据（年龄和性别）：人口统计学数据（年龄和性别）、人体测量数据（体重、身高和体重指数）以及临床和呼吸变量（膈肌增厚分数[DTf]、食管压力摆动、呼吸频率[RR]、食管压力-时间乘积/分钟[PTPes/min]）：结果：随着流量的增加，中位 DTf 明显降低（基线和 40 L/m 时分别为 2O/sec/min (p = 0.044)）：结论：健康受试者通过 HFNC 鼻插管进行高流量氧疗时，DTf 和 RR 会随着流量的增加而降低。此外，使用 40 L/m 流量可减少与呼吸有关的肌肉工作。

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引用次数: 0

Stress relaxation, another cause of “Pseudo auto-PEEP”? 压力松弛，"假性自动心电图 "的另一个原因？

Medicina intensiva

Pub Date : 2024-07-18 DOI: 10.1016/j.medine.2024.07.002

Manuel Valdivia Marchal , María Carmen Bermúdez Ruiz , José Ricardo Naranjo Izurieta , Ashlen Rodríguez Carmona , Juan Francisco Martínez Carmona , José Manuel Serrano Simón

引用次数: 0

Risk factors and outcome of acute kidney injury in critically ill patients with SARS-CoV-2 pneumonia: a multicenter study. SARS-CoV-2 肺炎重症患者急性肾损伤的风险因素和预后：一项多中心研究。

Medicina intensiva

Pub Date : 2024-07-12 DOI: 10.1016/j.medine.2024.06.022

Iban Oliva, Cristina Ferré, Xavier Daniel, Marc Cartanyà, Christian Villavicencio, Melina Salgado, Loreto Vidaur, Elisabeth Papiol, Fj González de Molina, María Bodí, Manuel Herrera, Alejandro Rodríguez

Objective: To assess incidence, risk factors and impact of acute kidney injury(AKI) within 48 h of intensive care unit(ICU) admission on ICU mortality in patients with SARS-CoV-2 pneumonia. To assess ICU mortality and risk factors for continuous renal replacement therapy (CRRT) in AKI I and II patients.

Design: Retrospective observational study.

Setting: Sixty-seven ICU from Spain, Andorra, Ireland.

Patients: 5399 patients March 2020 to April 2022.

Main variables of interest: Demographic variables, comorbidities, laboratory data (worst values) during the first two days of ICU admission to generate a logistic regression model describing independent risk factors for AKI and ICU mortality. AKI was defined according to current international guidelines (kidney disease improving global outcomes, KDIGO).

Results: Of 5399 patients included 1879 (34.8%) developed AKI. These patients had higher ICU mortality and AKI was independently associated with a higher ICU mortality (HR 1.32 CI 1.17-1.48; p < 0.001). Male gender, hypertension, diabetes, obesity, chronic heart failure, myocardial dysfunction, higher severity scores, and procalcitonine were independently associated with the development of AKI. In AKI I and II patients the need for CRRT was 12.6% (217/1710). In these patients, APACHE II, need for mechanical ventilation in the first 24 h after ICU admission and myocardial dysfunction were associated with risk of needing CRRT. AKI I and II patients had a high ICU mortality (38.5%), especially if CRRT were required (64.1% vs. 34,8%; p < 0.001).

Conclusions: Critically ill patients with SARS-CoV-2 pneumonia and AKI have a high ICU mortality. Even AKI I and II stages are associated with high risk of needing CRRT and ICU mortality.

目的评估SARS-CoV-2肺炎患者入重症监护病房（ICU）48小时内急性肾损伤（AKI）的发生率、风险因素及其对ICU死亡率的影响。评估急性肾损伤I型和II型患者的ICU死亡率和持续肾脏替代治疗（CRRT）的风险因素：设计：回顾性观察研究：西班牙、安道尔、爱尔兰的 67 家重症监护病房：2020年3月至2022年4月，5399名患者：人口统计学变量、合并症、重症监护室入院头两天的实验室数据（最差值），以生成描述AKI和重症监护室死亡率独立风险因素的逻辑回归模型。AKI是根据现行国际指南（肾脏疾病改善全球结果，KDIGO）定义的：在纳入的 5399 例患者中，有 1879 例（34.8%）发生了 AKI。这些患者的重症监护病房死亡率较高，而且 AKI 与较高的重症监护病房死亡率密切相关（HR 1.32 CI 1.17-1.48；P 结论：SARS 感染者的重症监护病房死亡率较高，而 AKI 与较高的重症监护病房死亡率密切相关：患有 SARS-CoV-2 肺炎和 AKI 的重症患者的重症监护病房死亡率较高。即使是 AKI I 和 II 阶段也与需要 CRRT 的高风险和 ICU 死亡率相关。

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引用次数: 0

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