|
Critical Care Explorations
Number of Followers: 3  Open Access journalISSN (Online) 2639-8028 Published by LWW Wolters Kluwer  [330 journals]
|
- Heparin-Induced Thrombocytopenia in Patients Suffering Cardiogenic Shock
Authors: Lüsebrink; Enzo; Lanz, Hugo; Binzenhöfer, Leonhard; Hoffmann, Sabine; Höpler, Julia; Kraft, Marie; Gade, Nils; Gmeiner, Jonas; Roden, Daniel; Saleh, Inas; Hagl, Christian; Nickenig, Georg; Massberg, Steffen; Zimmer, Sebastian; Jamin, Raúl Nicolás; Scherer, Clemens
Abstract:
OBJECTIVES: Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT.DESIGN: Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022.SETTING: Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn.PATIENTS AND INTERVENTIONS: In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated.MEASUREMENTS AND MAIN RESULTS: In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p> 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p> 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p> 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485).CONCLUSIONS: HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.
PubDate: Mon, 22 Jul 2024 00:00:00 GMT-
- Development and Validation of a Machine Learning COVID-19 Veteran (COVet)
Deterioration Risk Score
Authors: Govindan; Sushant; Spicer, Alexandra; Bearce, Matthew; Schaefer, Richard S.; Uhl, Andrea; Alterovitz, Gil; Kim, Michael J.; Carey, Kyle A.; Shah, Nirav S.; Winslow, Christopher; Gilbert, Emily; Stey, Anne; Weiss, Alan M.; Amin, Devendra; Karway, George; Martin, Jennie; Edelson, Dana P.; Churpek, Matthew M.
Abstract:
BACKGROUND AND OBJECTIVE: To develop the COVid Veteran (COVet) score for clinical deterioration in Veterans hospitalized with COVID-19 and further validate this model in both Veteran and non-Veteran samples. No such score has been derived and validated while incorporating a Veteran sample.DERIVATION COHORT: Adults (age ≥ 18 yr) hospitalized outside the ICU with a diagnosis of COVID-19 for model development to the Veterans Health Administration (VHA) (n = 80 hospitals).VALIDATION COHORT: External validation occurred in a VHA cohort of 34 hospitals, as well as six non-Veteran health systems for further external validation (n = 21 hospitals) between 2020 and 2023.PREDICTION MODEL: eXtreme Gradient Boosting machine learning methods were used, and performance was assessed using the area under the receiver operating characteristic curve and compared with the National Early Warning Score (NEWS). The primary outcome was transfer to the ICU or death within 24 hours of each new variable observation. Model predictor variables included demographics, vital signs, structured flowsheet data, and laboratory values.RESULTS: A total of 96,908 admissions occurred during the study period, of which 59,897 were in the Veteran sample and 37,011 were in the non-Veteran sample. During external validation in the Veteran sample, the model demonstrated excellent discrimination, with an area under the receiver operating characteristic curve of 0.88. This was significantly higher than NEWS (0.79; p < 0.01). In the non-Veteran sample, the model also demonstrated excellent discrimination (0.86 vs. 0.79 for NEWS; p < 0.01). The top three variables of importance were eosinophil percentage, mean oxygen saturation in the prior 24-hour period, and worst mental status in the prior 24-hour period.CONCLUSIONS: We used machine learning methods to develop and validate a highly accurate early warning score in both Veterans and non-Veterans hospitalized with COVID-19. The model could lead to earlier identification and therapy, which may improve outcomes.
PubDate: Fri, 19 Jul 2024 00:00:00 GMT-
- COVID-19 Across Pandemic Variant Periods: The Severe Acute Respiratory
Infection-Preparedness (SARI-PREP) Study
Authors: Mukherjee; Vikramjit; Postelnicu, Radu; Parker, Chelsie; Rivers, Patrick S.; Anesi, George L.; Andrews, Adair; Ables, Erin; Morrell, Eric D.; Brett-Major, David M.; Broadhurst, M. Jana; Cobb, J. Perren; Irwin, Amy; Kratochvil, Christopher J.; Krolikowski, Kelsey; Kumar, Vishakha K.; Landsittel, Douglas P.; Lee, Richard A.; Liebler, Janice M.; Segal, Leopoldo N.; Sevransky, Jonathan E.; Srivastava, Avantika; Uyeki, Timothy M.; Wurfel, Mark M.; Wyles, David; Evans, Laura E.; Lutrick, Karen; Bhatraju, Pavan K.; on behalf of the Severe Acute Respiratory Infection-Preparedness (SARI-PREP Study Group
Abstract:
IMPORTANCE: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has evolved through multiple phases in the United States, with significant differences in patient centered outcomes with improvements in hospital strain, medical countermeasures, and overall understanding of the disease. We describe how patient characteristics changed and care progressed over the various pandemic phases; we also emphasize the need for an ongoing clinical network to improve the understanding of known and novel respiratory viral diseases.OBJECTIVES: To describe how patient characteristics and care evolved across the various COVID-19 pandemic periods in those hospitalized with viral severe acute respiratory infection (SARI).DESIGN: Severe Acute Respiratory Infection-Preparedness (SARI-PREP) is a Centers for Disease Control and Prevention Foundation-funded, Society of Critical Care Medicine Discovery-housed, longitudinal multicenter cohort study of viral pneumonia. We defined SARI patients as those hospitalized with laboratory-confirmed respiratory viral infection and an acute syndrome of fever, cough, and radiographic infiltrates or hypoxemia. We collected patient-level data including demographic characteristics, comorbidities, acute physiologic measures, serum and respiratory specimens, therapeutics, and outcomes. Outcomes were described across four pandemic variant periods based on a SARS-CoV-2 sequenced subsample: pre-Delta, Delta, Omicron BA.1, and Omicron post-BA.1.SETTING: Multicenter cohort of adult patients admitted to an acute care ward or ICU from seven hospitals representing diverse geographic regions across the United States.PARTICIPANTS: Patients with SARI caused by infection with respiratory viruses.MAIN OUTCOMES AND RESULTS: Eight hundred seventy-four adult patients with SARI were enrolled at seven study hospitals between March 2020 and April 2023. Most patients (780, 89%) had SARS-CoV-2 infection. Across the COVID-19 cohort, median age was 60 years (interquartile range, 48.0–71.0 yr) and 66% were male. Almost half (430, 49%) of the study population belonged to underserved communities. Most patients (76.5%) were admitted to the ICU, 52.5% received mechanical ventilation, and observed hospital mortality was 25.5%. As the pandemic progressed, we observed decreases in ICU utilization (94% to 58%), hospital length of stay (median, 26.0 to 8.5 d), and hospital mortality (32% to 12%), while the number of comorbid conditions increased.CONCLUSIONS AND RELEVANCE: We describe increasing comorbidities but improved outcomes across pandemic variant periods, in the setting of multiple factors, including evolving care delivery, countermeasures, and viral variants. An understanding of patient-level factors may inform treatment options for subsequent variants and future novel pathogens.
PubDate: Thu, 18 Jul 2024 00:00:00 GMT-
- Opioid Administration Practice Patterns in Patients With Acute Respiratory
Failure Who Undergo Invasive Mechanical Ventilation
Authors: Myers; Laura C.; Bosch, Nicholas A.; Soltesz, Lauren; Daly, Kathleen A.; Campbell, Cynthia I.; Schwager, Emma; Salvati, Emmanuele; Stevens, Jennifer P.; Wunsch, Hannah; Rucci, Justin M.; Jafarzadeh, S. Reza; Liu, Vincent X.; Walkey, Allan J.
Abstract:
IMPORTANCE: The opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths.OBJECTIVES: To evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation.DESIGN: Retrospective cohort study.SETTING AND PARTICIPANTS: Patients from 21 hospitals in Kaiser Permanente Northern California and 96 hospitals in Philips electronic ICU Research Institute.MAIN OUTCOMES AND MEASURES: We assessed whether patients received opioid infusion and the dose of said opioid infusion.RESULTS: We identified patients with a diagnosis of acute respiratory failure who were initiated on invasive mechanical ventilation. From each patient, we determined if opioid infusions were administered and, among those who received an opioid infusion, the median daily dose of fentanyl infusion. We used hierarchical regression models to quantify variation in opioid infusion use and the median daily dose of fentanyl equivalents across hospitals. We included 13,140 patients in the KPNC cohort and 52,033 patients in the eRI cohort. A total of 7,023 (53.4%) and 16,311 (31.1%) patients received an opioid infusion in the first 21 days of mechanical ventilation in the KPNC and eRI cohorts, respectively. After accounting for patient- and hospital-level fixed effects, the hospital that a patient was admitted to explained 7% (95% CI, 3–11%) and 39% (95% CI, 28–49%) of the variation in opioid infusion use in the KPNC and eRI cohorts, respectively. Among patients who received an opioid infusion, the median daily fentanyl equivalent dose was 692 µg (interquartile range [IQR], 129–1341 µg) in the KPNC cohort and 200 µg (IQR, 0–1050 µg) in the eRI cohort. Hospital explained 4% (95% CI, 1–7%) and 20% (95% CI, 15–26%) of the variation in median daily fentanyl equivalent dose in the KPNC and eRI cohorts, respectively.CONCLUSIONS AND RELEVANCE: In the context of efforts to limit healthcare-associated opioid exposure, our findings highlight the considerable opioid exposure that accompanies mechanical ventilation and suggest potential under and over-treatment with analgesia. Our results facilitate benchmarking of hospitals’ analgesia practices against risk-adjusted averages and can be used to inform usual care control arms of analgesia and sedation clinical trials.
PubDate: Wed, 17 Jul 2024 00:00:00 GMT-
- Lung Protective Ventilation Adherence and Outcomes for Patients With
COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate
Care Unit Repurposed to ICU Level of Care
Authors: Hochberg; Chad H.; Case, Aaron S.; Psoter, Kevin J.; Brodie, Daniel; Dezube, Rebecca H.; Sahetya, Sarina K.; Outten, Carrie; Street, Lara; Eakin, Michelle N.; Hager, David N.
Abstract:
OBJECTIVE: During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs).DESIGN: Retrospective observational study using electronic medical record data.SETTING: Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system.PATIENTS: Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315).INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50–100] vs. 100% [86–100], p = 0.05). Period 2 adherence was similar between groups (100% [75–100] vs. 95% CI [65–100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55–0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85–1.39]).CONCLUSIONS: In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.
PubDate: Wed, 17 Jul 2024 00:00:00 GMT-
- Deriving Automated Device Metadata From Intracranial Pressure Waveforms: A
Transforming Research and Clinical Knowledge in Traumatic Brain Injury ICU
Physiology Cohort Analysis
Authors: Ack; Sophie E.; Dolmans, Rianne G.F.; Foreman, Brandon; Manley, Geoffrey T.; Rosenthal, Eric S.; Zabihi, Morteza
Abstract:
IMPORTANCE: Treatment for intracranial pressure (ICP) has been increasingly informed by machine learning (ML)-derived ICP waveform characteristics. There are gaps, however, in understanding how ICP monitor type may bias waveform characteristics used for these predictive tools since differences between external ventricular drain (EVD) and intraparenchymal monitor (IPM)-derived waveforms have not been well accounted for.OBJECTIVES: We sought to develop a proof-of-concept ML model differentiating ICP waveforms originating from an EVD or IPM.DESIGN, SETTING, AND PARTICIPANTS: We examined raw ICP waveform data from the ICU physiology cohort within the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury multicenter study.MAIN OUTCOMES AND MEASURES: Nested patient-wise five-fold cross-validation and group analysis with bagged decision trees (BDT) and linear discriminant analysis were used for feature selection and fair evaluation. Nine patients were kept as unseen hold-outs for further evaluation.RESULTS: ICP waveform data totaling 14,110 hours were included from 82 patients (EVD, 47; IPM, 26; both, 9). Mean age, Glasgow Coma Scale (GCS) total, and GCS motor score upon admission, as well as the presence and amount of midline shift, were similar between groups. The model mean area under the receiver operating characteristic curve (AU-ROC) exceeded 0.874 across all folds. In additional rigorous cluster-based subgroup analysis, targeted at testing the resilience of models to cross-validation with smaller subsets constructed to develop models in one confounder set and test them in another subset, AU-ROC exceeded 0.811. In a similar analysis using propensity score-based rather than cluster-based subgroup analysis, the mean AU-ROC exceeded 0.827. Of 842 extracted ICP features, 62 were invariant within every analysis, representing the most accurate and robust differences between ICP monitor types. For the nine patient hold-outs, an AU-ROC of 0.826 was obtained using BDT.CONCLUSIONS AND RELEVANCE: The developed proof-of-concept ML model identified differences in EVD- and IPM-derived ICP signals, which can provide missing contextual data for large-scale retrospective datasets, prevent bias in computational models that ingest ICP data indiscriminately, and control for confounding using our model’s output as a propensity score by to adjust for the monitoring method that was clinically indicated. Furthermore, the invariant features may be leveraged as ICP features for anomaly detection.
PubDate: Tue, 16 Jul 2024 00:00:00 GMT-
- Time-Dependent Changes in Pulmonary Turnover of Thrombocytes During
Critical COVID-19
Authors: Aarskog; Nikolai Ravn; Hallem, Ronja; Godhavn, Jakob Strand; Rostrup, Morten
Abstract:
OBJECTIVES (BACKGROUND): Under normal conditions, pulmonary megakaryocytes are an important source of circulating thrombocytes, causing thrombocyte counts to be higher in arterial than venous blood. In critical COVID-19, thrombocytes may be removed from the circulation by the lungs because of immunothrombosis, possibly causing venous thrombocyte counts to be higher than arterial thrombocyte counts. In the present study, we investigated time-dependent changes in pulmonary turnover of thrombocytes during critical COVID-19 by measuring arteriovenous thrombocyte differences. We hypothesized that the early stages of the disease would be characterized by a net pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages would be characterized by a net pulmonary release of thrombocytes as normal pulmonary function is restored.DESIGN: Cohort study with repeated measurements of arterial and central venous thrombocyte counts.SETTING: ICU in a large university hospital.PATIENTS: Thirty-one patients with critical COVID-19 that were admitted to the ICU and received invasive or noninvasive mechanical ventilation.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: We found a significant positive association between the arteriovenous thrombocyte difference and time since symptom debut. This finding indicates a negative arteriovenous thrombocyte difference and hence pulmonary removal of thrombocytes in the early stages of the disease and a positive arteriovenous thrombocyte difference and hence pulmonary release of thrombocytes in later stages. Most individual arteriovenous thrombocyte differences were smaller than the variance coefficient of the analysis.CONCLUSIONS: The results of this study support our hypothesis that early stages of critical COVID-19 are characterized by pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages are characterized by the return of normal pulmonary release of thrombocytes. However, in most cases, the arteriovenous thrombocyte difference was too small to say anything about pulmonary thrombocyte removal and release on an individual level.
PubDate: Tue, 16 Jul 2024 00:00:00 GMT-
- Organ Involvement Related to Death in Critically Ill Patients With
Leptospirosis: Unsupervised Analysis in a French West Indies ICU
Authors: Camous; Laurent; Pommier, Jean-David; Tressières, Benoît; Martino, Frederic; Picardeau, Mathieu; Loraux, Cecile; Valette, Marc; Chaumont, Hugo; Carles, Michel; Demoule, Alexandre; Breurec, Sebastien
Abstract:
OBJECTIVES: To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome.DESIGN: Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components).SETTING: All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period.PATIENTS: One hundred thirty critically ill patients with confirmed leptospirosis were included.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters—“Weil’s Disease” (48%), “neurological leptospirosis” (20%), and “multiple organ failure” (32%)—with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy.CONCLUSIONS AND RELEVANCE: Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.
PubDate: Mon, 08 Jul 2024 00:00:00 GMT-
- Onset of Prolonged High-Potency Benzodiazepine Use Among ICU Survivors: A
Nationwide Cohort Study
Authors: Lindström; Ann-Charlotte; von Oelreich, Erik; Eriksson, Jesper; Eriksson, Mikael; Mårtensson, Johan; Larsson, Emma; Oldner, Anders
Abstract:
OBJECTIVES: Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality.DESIGN: Retrospective cohort study.SETTING: Sweden, including all registered ICU admissions between 2010 and 2017.PATIENTS: ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion.INTERVENTIONS: Admission to intensive care.MEASUREMENTS AND MAIN RESULTS: A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7–2.0; p < 0.001). No differences were noted in causes of death between users and nonusers.Conclusions: Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.
PubDate: Mon, 08 Jul 2024 00:00:00 GMT-
- Interhospital Transfer of Patients With Acute Respiratory Failure in the
United States: A Scoping Review
Authors: Ludwig; Amy; Slota, Jennifer; Nunes, Denise A.; Vranas, Kelly C.; Kruser, Jacqueline M.; Scott, Kelli S.; Huang, Reiping; Johnson, Julie K.; Lagu, Tara C.; Nadig, Nandita R.
Abstract:
OBJECTIVES: Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF.DATA SOURCES: Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association.STUDY SELECTION: We included studies that evaluated or described hospital transfers of adult (age> 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria.DATA EXTRACTION: The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors.DATA SYNTHESIS: Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes.CONCLUSIONS: Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes.
PubDate: Fri, 05 Jul 2024 00:00:00 GMT-
- Time to Positive Blood Cultures Among Critically Ill Children Admitted to
the PICU
Authors: Yasechko; Stephanie M.; Hillyer, Margot M.; Smith, Alison G. C.; Rodenbough, Anna L.; Fernandez, Alfred J.; Gonzalez, Mark D.; Jaggi, Preeti
Abstract:
OBJECTIVES: Our study aimed to assess the time to positivity (TTP) of clinically significant blood cultures in critically ill children admitted to the PICU.DESIGN: Retrospective review of positive blood cultures in patients admitted or transferred to the PICU.SETTING: Large tertiary-care medical center with over 90 PICU beds.PATIENTS: Patients 0–20 years old with bacteremia admitted or transferred to the PICU.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the TTP, defined as time from blood culture draw to initial Gram stain result. Secondary endpoints included percentage of cultures reported by elapsed time, as well as the impact of pathogen and host immune status on TTP. Host immune status was classified as previously healthy, standard risk, or immunocompromised. Linear regression for TTP was performed to account for age, blood volume, and Gram stain. Among 164 episodes of clinically significant bacteremia, the median TTP was 13.3 hours (interquartile range, 10.7–16.8 hr). Enterobacterales, Staphylococcus aureus, Streptococcus agalactiae, and Streptococcus pneumoniae were most commonly identified. By 12, 24, 36, and 48 hours, 37%, 89%, 95%, and 97% of positive cultures had resulted positive, respectively. Median TTP stratified by host immune status was 13.2 hours for previously healthy patients, 14.0 hours for those considered standard risk, and 10.6 hours for immunocompromised patients (p = 0.001). Median TTP was found to be independent of blood volume. No difference was seen in TTP for Gram-negative vs. Gram-positive organisms (12.2 vs. 13.9 hr; p = 0.2).CONCLUSIONS: Among critically ill children, 95% of clinically significant blood cultures had an initial positive result within 36 hours, regardless of host immune status. Need for antimicrobial therapy should be frequently reassessed and implementation of a shorter duration of empiric antibiotics should be considered in patients with low suspicion for infection.
PubDate: Fri, 05 Jul 2024 00:00:00 GMT-
- Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative
Delirium in the Pediatric Cardiac ICU
Authors: Weatherly; Allison J.; Johnson, Cassandra A.; Liu, Dandan; Kannankeril, Prince J.; Smith, Heidi A.B.; Betters, Kristina A.
Abstract:
OBJECTIVE: ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium.DESIGN: Secondary analysis of data obtained from a prospective cohort study.SETTING: Twenty-two-bed pediatric cardiac ICU in a tertiary children’s hospital.PATIENTS: All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605–2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668–2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752–2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859–1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918–1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. –0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05).CONCLUSIONS: Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.
PubDate: Fri, 05 Jul 2024 00:00:00 GMT-
- Early Fluid Is Less Fluid: Comparing Early Versus Late ICU Resuscitation
in Severely Injured Trauma Patients
Authors: Beni; Catherine E.; Arbabi, Saman; Robinson, Bryce R. H.; O’Keefe, Grant E.
Abstract:
OBJECTIVES: The temporal trends of crystalloid resuscitation in severely injured trauma patients after ICU admission are not well characterized. We hypothesized early crystalloid resuscitation was associated with less volume and better outcomes than delaying crystalloid.DESIGN: Retrospective, observational.SETTING: High-volume level 1 academic trauma center.PATIENTS: Adult trauma patients admitted to the ICU with emergency department serum lactate greater than or equal to 4 mmol/dL, elevated lactate (≥ 2 mmol/L) at ICU admission, and normal lactate by 48 hours.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: For the 333 subjects, we analyzed patient and injury characteristics and the first 48 hours of ICU course. Receipt of greater than or equal to 500 mL/hr of crystalloid in the first 6 hours of ICU admission was used to distinguish early vs. late resuscitation. Outcomes included ICU length of stay (LOS), ventilator days, and acute kidney injury (AKI). Unadjusted and multivariable regression methods were used to compare early resuscitation vs. late resuscitation. Compared with the early resuscitation group, the late resuscitation group received more volume by 48 hours (5.5 vs. 4.1 L; p ≤ 0.001), had longer ICU LOS (9 vs. 5 d; p ≤ 0.001), more ventilator days (5 vs. 2 d; p ≤ 0.001), and higher occurrence rate of AKI (38% vs. 11%; p ≤ 0.001). On multivariable regression, late resuscitation remained associated with longer ICU LOS and ventilator days and higher odds of AKI.CONCLUSIONS: Delaying resuscitation is associated with both higher volumes of crystalloid by 48 hours and worse outcomes compared with early resuscitation. Judicious crystalloid given early in ICU admission could improve outcomes in the severely injured.
PubDate: Wed, 03 Jul 2024 00:00:00 GMT-
- Actual Cost of Extracorporeal Cardiopulmonary Resuscitation: A Time-Driven
Activity-Based Costing Study
Authors: Nanjayya; Vinodh B.; Higgins, Alisa M.; Morphett, Laura; Thiara, Sonny; Jones, Annalie; Pellegrino, Vincent A.; Sheldrake, Jayne; Bernard, Stephen; Kaye, David; Nichol, Alistair; Cooper, D. James
Abstract:
OBJECTIVES: To determine the actual cost and drivers of the cost of an extracorporeal cardiopulmonary resuscitation (E-CPR) care cycle.PERSPECTIVE: A time-driven activity-based costing study conducted from a healthcare provider perspective.SETTING: A quaternary care ICU providing around-the-clock E-CPR service for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in Australia.METHODS: The E-CPR care cycle was defined as the time from initiating E-CPR to hospital discharge or death of the patient. Detailed process maps with discrete steps and probabilistic decision nodes accounting for the complex trajectories of E-CPR patients were developed. Data about clinical and nonclinical resources and timing of activities was collected multiple times for each process . Total direct costs were calculated using the time estimates and unit costs per resource for all clinical and nonclinical resources. The total direct costs were combined with indirect costs to obtain the total cost of E-CPR.RESULTS: From 10 E-CPR care cycles observed during the study period, a minimum of 3 observations were obtained per process. The E-CPR care cycle’s mean (95% CI) cost was $75,014 ($66,209–83,222). Initiation of extracorporeal membrane oxygenation (ECMO) and ECMO management constituted 18% of costs. The ICU management (35%) and surgical costs (20%) were the primary cost determinants. IHCA had a higher mean (95% CI) cost than OHCA ($87,940 [75,372–100,570] vs. 62,595 [53,994–71,890], p < 0.01), mainly because of the increased survival and ICU length of stay of patients with IHCA. The mean cost for each E-CPR survivor was $129,503 ($112,422–147,224).CONCLUSIONS: Significant costs are associated with E-CPR for refractory cardiac arrest. The cost of E-CPR for IHCA was higher compared with the cost of E-CPR for OHCA. The major determinants of the E-CPR costs were ICU and surgical costs. These data can inform the cost-effectiveness analysis of E-CPR in the future.
PubDate: Wed, 03 Jul 2024 00:00:00 GMT-
- Can Biomarkers Correctly Predict Ventilator-associated Pneumonia in
Patients Treated With Targeted Temperature Management After Cardiac
Arrest' An Exploratory Study of the Multicenter Randomized Antibiotic
(ANTHARTIC) Study
Authors: Deye; Nicolas; Le Gouge, Amelie; François, Bruno; Chenevier-Gobeaux, Camille; Daix, Thomas; Merdji, Hamid; Cariou, Alain; Dequin, Pierre-François; Guitton, Christophe; Mégarbane, Bruno; Callebert, Jacques; Giraudeau, Bruno; Mebazaa, Alexandre; Vodovar, Nicolas; for the Clinical Research in Intensive Care the ANtibiotherapy during Therapeutic HypothermiA to pRevenT Infectious Complications (ANTHARTIC Study Group
Abstract:
IMPORTANCE: Ventilator-associated pneumonia (VAP) frequently occurs in patients with cardiac arrest. Diagnosis of VAP after cardiac arrest remains challenging, while the use of current biomarkers such as C-reactive protein (CRP) or procalcitonin (PCT) is debated.OBJECTIVES: To evaluate biomarkers’ impact in helping VAP diagnosis after cardiac arrest.DESIGN, SETTING, AND PARTICIPANTS: This is a prospective ancillary study of the randomized, multicenter, double-blind placebo-controlled ANtibiotherapy during Therapeutic HypothermiA to pRevenT Infectious Complications (ANTHARTIC) trial evaluating the impact of antibiotic prophylaxis to prevent VAP in out-of-hospital patients with cardiac arrest secondary to shockable rhythm and treated with therapeutic hypothermia. An adjudication committee blindly evaluated VAP according to predefined clinical, radiologic, and microbiological criteria. All patients with available biomarker(s), sample(s), and consent approval were included.MAIN OUTCOMES AND MEASURES: The main endpoint was to evaluate the ability of biomarkers to correctly diagnose and predict VAP within 48 hours after sampling. The secondary endpoint was to study the combination of two biomarkers in discriminating VAP. Blood samples were collected at baseline on day 3. Routine and exploratory panel of inflammatory biomarkers measurements were blindly performed. Analyses were adjusted on the randomization group.RESULTS: Among 161 patients of the ANTHARTIC trial with available biological sample(s), patients with VAP (n = 33) had higher body mass index and Acute Physiology and Chronic Health Evaluation II score, more unwitnessed cardiac arrest, more catecholamines, and experienced more prolonged therapeutic hypothermia duration than patients without VAP (n = 121). In univariate analyses, biomarkers significantly associated with VAP and showing an area under the curve (AUC) greater than 0.70 were CRP (AUC = 0.76), interleukin (IL) 17A and 17C (IL17C) (0.74), macrophage colony-stimulating factor 1 (0.73), PCT (0.72), and vascular endothelial growth factor A (VEGF-A) (0.71). Multivariate analysis combining novel biomarkers revealed several pairs with p value of less than 0.001 and odds ratio greater than 1: VEGF-A + IL12 subunit beta (IL12B), Fms-related tyrosine kinase 3 ligands (Flt3L) + C–C chemokine 20 (CCL20), Flt3L + IL17A, Flt3L + IL6, STAM-binding protein (STAMBP) + CCL20, STAMBP + IL6, CCL20 + 4EBP1, CCL20 + caspase-8 (CASP8), IL6 + 4EBP1, and IL6 + CASP8. Best AUCs were observed for CRP + IL6 (0.79), CRP + CCL20 (0.78), CRP + IL17A, and CRP + IL17C.CONCLUSIONS AND RELEVANCE: Our exploratory study shows that specific biomarkers, especially CRP combined with IL6, could help to better diagnose or predict early VAP occurrence in cardiac arrest patients.
PubDate: Mon, 01 Jul 2024 00:00:00 GMT-
- High Levels of Triggering Receptor Expressed in Myeloid Cells-Like
Transcript-1 Positive, but Not Glycoprotein 1b+, Microparticles Are
Associated With Poor Outcomes in Acute Respiratory Distress Syndrome
Authors: Gibson; Angelia D.; Bayrón-Marrero, Zaida; Nieves-Lopez, Benjamin; Maldonado-Martínez, Gerónimo; Washington, A. Valance
Abstract:
OBJECTIVES: To identify triggering receptor expressed in myeloid cells-like transcript-1 positive (TLT-1+) microparticles (MPs) and evaluate if their presence is associated with clinical outcomes and/or disease severity in acute respiratory distress syndrome (ARDS).DESIGN: Retrospective cohort study.SETTING: ARDS Network clinical trials.PATIENTS: A total of 564 patients were diagnosed with ARDS.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Using flow cytometry, we demonstrated the presence of TLT-1+ platelet-derived microparticles (PMP) that bind fibrinogen in plasma samples from fresh donors. We retrospectively quantified TLT-1, glycoprotein (Gp) 1b, or αIIbβIIIa immunopositive microparticles in plasma samples from patients with ARDS enrolled in the ARMA, KARMA, and LARMA (Studies 01 and 03 lower versus higher tidal volume, ketoconazole treatment, and lisofylline treatment Clincial Trials) ARDS Network clinical trials and evaluated the relationship between these measures and clinical outcomes. No associations were found between Gp1b+ MPs and clinical outcomes for any of the cohorts. When stratified by quartile, associations were found for survival, ventilation-free breathing, and thrombocytopenia with αIIbβIIIa+ and TLT-1+ MPs (χ2p < 0.001). Notably, 63 of 64 patients in this study who failed to achieve unassisted breathing had TLT+ PMP in the 75th percentile. In all three cohorts, patients whose TLT+ MP counts were higher than the median had higher Acute Physiology and Chronic Health Evaluation III scores, were more likely to present with thrombocytopenia and were 3.7 times (p < 0.001) more likely to die than patients with lower TLT+ PMP after adjusting for other risk factors.CONCLUSIONS: Although both αIIbβIIIa+ and TLT+ microparticles (αIIbβIIIa, TLT-1) were associated with mortality, TLT-1+ MPs demonstrated stronger correlations with Acute Physiology and Chronic Health Evaluation III scores, unassisted breathing, and multiple system organ failure. These findings warrant further exploration of the mechanistic role of TLT-1+ PMP in ARDS or acute lung injury progression.
PubDate: Thu, 27 Jun 2024 00:00:00 GMT-
- Kidney Outcomes and Trajectories of Tubular Injury and Function in
Critically Ill Patients With and Without COVID-19
Authors: Granda; Michael L.; Tian, Frances; Zelnick, Leila R.; Bhatraju, Pavan K.; Hallowell, Julia; Wurfel, Mark M.; Hoofnagle, Andrew; Morrell, Eric; Kestenbaum, Bryan
Abstract:
IMPORTANCE: COVID-19 may injure the kidney tubules via activation of inflammatory host responses and/or direct viral infiltration. Most studies of kidney injury in COVID-19 lacked contemporaneous controls or measured kidney biomarkers at a single time point.OBJECTIVES: To better understand mechanisms of acute kidney injury in COVID-19, we compared kidney outcomes and trajectories of tubular injury, viability, and function in prospectively enrolled critically ill adults with and without COVID-19.DESIGN, SETTING, AND PARTICIPANTS: The COVID-19 Host Response and Outcomes study prospectively enrolled patients admitted to ICUs in Washington State with symptoms of lower respiratory tract infection, determining COVID-19 status by nucleic acid amplification on arrival.MAIN OUTCOMES AND MEASURES: We evaluated major adverse kidney events (MAKE) defined as a doubling of serum creatinine, kidney replacement therapy, or death, in 330 patients after inverse probability weighting. In the 181 patients with available biosamples, we determined trajectories of urine kidney injury molecule-1 (KIM-1) and epithelial growth factor (EGF), and urine:plasma ratios of endogenous markers of tubular secretory clearance.RESULTS: At ICU admission, the mean age was 55 ± 16 years; 45% required mechanical ventilation; and the mean serum creatinine concentration was 1.1 mg/dL. COVID-19 was associated with a 70% greater occurrence of MAKE (relative risk 1.70; 95% CI, 1.05–2.74) and a 741% greater occurrence of KRT (relative risk 7.41; 95% CI, 1.69–32.41). The biomarker cohort had a median of three follow-up measurements. Urine EGF, secretory clearance ratios, and estimated glomerular filtration rate (eGFR) increased over time in the COVID-19 negative group but remained unchanged in the COVID-19 positive group. In contrast, urine KIM-1 concentrations did not significantly change over the course of the study in either group.CONCLUSIONS: Among critically ill adults, COVID-19 is associated with a more protracted course of proximal tubular dysfunction and reduced eGFR despite similar degrees of kidney injury.
PubDate: Wed, 26 Jun 2024 00:00:00 GMT-
- Quantitative Comparison of Ventilation Parameters of Different Approaches
to Ventilator Splitting and Multiplexing
Authors: Kim; Doowon; Roy, Steven; McBeth, Paul; Lee, Jihyun
Abstract:
CONTEXT: Amid the COVID-19 pandemic, this study delves into ventilator shortages, exploring simple split ventilation (SSV), simple differential ventilation (SDV), and differential multiventilation (DMV). The knowledge gap centers on understanding their performance and safety implications.HYPOTHESIS: Our hypothesis posits that SSV, SDV, and DMV offer solutions to the ventilator crisis. Rigorous testing was anticipated to unveil advantages and limitations, aiding the development of effective ventilation approaches.METHODS AND MODELS: Using a specialized test bed, SSV, SDV, and DMV were compared. Simulated lungs in a controlled setting facilitated measurements with sensors. Statistical analysis honed in on parameters like peak inspiratory pressure (PIP) and positive end-expiratory pressure.RESULTS: Setting target PIP at 15 cm H2O for lung 1 and 12.5 cm H2O for lung 2, SSV revealed a PIP of 15.67 ± 0.2 cm H2O for both lungs, with tidal volume (Vt) at 152.9 ± 9 mL. In SDV, lung 1 had a PIP of 25.69 ± 0.2 cm H2O, lung 2 at 24.73 ± 0.2 cm H2O, and Vts of 464.3 ± 0.9 mL and 453.1 ± 10 mL, respectively. DMV trials showed lung 1’s PIP at 13.97 ± 0.06 cm H2O, lung 2 at 12.30 ± 0.04 cm H2O, with Vts of 125.8 ± 0.004 mL and 104.4 ± 0.003 mL, respectively.INTERPRETATION AND CONCLUSIONS: This study enriches understanding of ventilator sharing strategy, emphasizing the need for careful selection. DMV, offering individualization while maintaining circuit continuity, stands out. Findings lay the foundation for robust multiplexing strategies, enhancing ventilator management in crises.
PubDate: Tue, 25 Jun 2024 00:00:00 GMT-
- Predicting Organ Dysfunction in Septic and Critically Ill Patients: A
Prospective Cohort Study Using Rapid Ex Vivo Immune Profiling
Authors: Samuelsen; Abigail M.; Halstead, E. Scott; Lehman, Erik B.; McKeone, Daniel J.; Bonavia, Anthony S.
Abstract:
OBJECTIVES: While cytokine response patterns are pivotal in mediating immune responses, they are also often dysregulated in sepsis and critical illness. We hypothesized that these immunological deficits, quantifiable through ex vivo whole blood stimulation assays, may be indicative of subsequent organ dysfunction.DESIGN: In a prospective observational study, adult septic patients and critically ill but nonseptic controls were identified within 48 hours of critical illness onset. Using a rapid, ex vivo assay based on responses to lipopolysaccharide (LPS), anti-CD3/anti-CD28 antibodies, and phorbol 12-myristate 13-acetate with ionomycin, cytokine responses to immune stimulants were quantified. The primary outcome was the relationship between early cytokine production and subsequent organ dysfunction, as measured by the Sequential Organ Failure Assessment score on day 3 of illness (SOFAd3).SETTING: Patients were recruited in an academic medical center and data processing and analysis were done in an academic laboratory setting.PATIENTS: Ninety-six adult septic and critically ill nonseptic patients were enrolled.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Elevated levels of tumor necrosis factor and interleukin-6 post-endotoxin challenge were inversely correlated with SOFAd3. Interferon-gamma production per lymphocyte was inversely related to organ dysfunction at day 3 and differed between septic and nonseptic patients. Clustering analysis revealed two distinct immune phenotypes, represented by differential responses to 18 hours of LPS stimulation and 4 hours of anti-CD3/anti-CD28 stimulation.CONCLUSIONS: Our rapid immune profiling technique offers a promising tool for early prediction and management of organ dysfunction in critically ill patients. This information could be pivotal for early intervention and for preventing irreversible organ damage during the acute phase of critical illness.
PubDate: Tue, 25 Jun 2024 00:00:00 GMT-
- Use of Speckle-Tracking Echocardiography in Septic Cardiomyopathy in
Critically Ill Children: A Narrative Review
Authors: Chan; J. Charmaine; Menon, Anuradha P.; Rotta, Alexandre T.; Choo, Jonathan T.L.; Hornik, Christoph P.; Lee, Jan Hau
Abstract:
OBJECTIVES: In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and inotropic support, and higher mortality risk. The objective of this review was to evaluate the role of speckle-tracking echocardiography (STE) in the diagnosis and prognosis of pediatric SCM in the PICU setting.DATA SOURCES: We performed detailed searches using PubMed, Scopus, Web of Science, and Google Scholar. Reference lists of all included studies were also examined for further identification of potentially relevant studies.STUDY SELECTION: Studies with the following medical subject headings and keywords were selected: speckle-tracking echocardiography, strain imaging, global longitudinal strain, echocardiography, sepsis, severe sepsis, septic shock, septic cardiomyopathy, and myocardial dysfunction.DATA EXTRACTION: The following data were extracted from all included studies: demographics, diagnoses, echocardiographic parameters, severity of illness, PICU management, and outcomes.DATA SYNTHESIS: STE is a relatively new echocardiographic technique that directly quantifies myocardial contractility. It has high sensitivity in diagnosing SCM, correlates well with illness severity, and has good prognosticating value as compared with conventional echocardiographic parameters. Further studies are required to establish its role in evaluating biventricular systolic and diastolic dysfunction, and to investigate whether it has a role in individualizing treatment and improving treatment outcomes in this group of patients.CONCLUSIONS: STE is a useful adjunct to conventional measures of cardiac function on 2D-echocardiography in the assessment of pediatric SCM in the PICU.
PubDate: Tue, 25 Jun 2024 00:00:00 GMT-
- Recruitment and Retention Strategies for Randomized Clinical Trials
Involving Family Members of ICU Patients
Authors: Samuels; Aaron; Sygal, Valeria; Burns, Karen E. A.; Goldfarb, Michael
Abstract: OBJECTIVES: To review recruitment and retention strategies of randomized family-centered interventional studies in adult ICUs.DATA SOURCES: The MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library database from inception to February 2023.STUDY SELECTION: Randomized controlled trials with family-centered interventions in the ICU setting that reported at least one family-centered outcome that were included in our previously published systematic review.DATA EXTRACTION: For recruitment: Number of family members approached and enrolled, type of approach, location, time of day approached, whether medical team approached first, compensation offered, and type of consent. For retention: Number of family members enrolled and completed initial follow-up visit, mode of follow-up, location of follow-up visit, data collection method, timing of follow-up visits, number of follow-up visits, and compensation offered. Recruitment (participants approached/enrolled) and retention (participants enrolled/completed initial follow-up) percentage were calculated.DATA SYNTHESIS: There were 51 studies in the analysis. The mean recruitment percentage was 49.3% ± 24.3%. There were no differences in recruitment percentage by study country, ICU type, recruitment approach, or whether the medical team approached the family member first (all p> 0.05). The mean retention percentage for the initial follow-up visit was 81.6% ± 18.0%. There were no differences in retention percentage by mode of participant contact, data collection type, or follow-up location (all p> 0.05). Minimal data were available to determine the impact of time of day approached and compensation on recruitment and retention outcomes.CONCLUSIONS: About half of family members of ICU patients approached participated in trials and more than eight in ten completed the initial follow-up visit. We did not identify specific factors that impacted family recruitment or retention. There is a strong need for further studies to characterize optimal strategies to ensure family participation in clinical trials.
PubDate: Mon, 24 Jun 2024 00:00:00 GMT-
- Behavioral Assessment With the Coma Recovery Scale—Revised Is Safe and
Feasible in Critically Ill Patients With Disorders of Consciousness
Authors: Woodward; Matthew R.; Wells, Chris L.; Arnold, Shannon; Dorman, Farra; Ahmed, Zaka; Morris, Nicholas A.; Ciryam, Prajwal; Podell, Jamie E.; Chang, Wan-Tsu W.; Zimmerman, W. Denney; Motta, Melissa; Butt, Bilal; Pergakis, Melissa B.; Labib, Mohamed; Wang, Ting I.; Edlow, Brian L.; Badjatia, Neeraj; Braun, Robynne; Parikh, Gunjan Y.
Abstract:
OBJECTIVES: Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale—Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke.DESIGN: Retrospective cohort study.SETTING: This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center.PATIENTS: We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS).INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7–66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72–0.94; p < 0.0001).CONCLUSIONS: Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.
PubDate: Mon, 24 Jun 2024 00:00:00 GMT-
- Use of Early Ketamine Sedation and Association With Clinical and Cost
Outcomes Among Mechanically Ventilated Patients With COVID-19: A
Retrospective Cohort Study
Authors: Royce-Nagel; Galen; Jarzebowski, Mary; Wongsripuemtet, Pattrapun; Krishnamoorthy, Vijay; Fuller, Matthew; Ohnuma, Tetsu; Treggiari, Miriam; Yaport, Miguel; Cobert, Julien; Garrigan, Ethan; Bartz, Raquel; Raghunathan, Karthik
Abstract:
OBJECTIVES: To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes.DESIGN: Retrospective cohort study.SETTING: Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021.PATIENTS: Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization.INTERVENTION: The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day.MEASUREMENTS: Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders.MAIN RESULTS: Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06–1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08–1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12–1.27]). There were no associations for hospital LOS (17 [10–27] vs. 17 [9–28], MR: 1.05 [0.99–1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95–1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92–1.21]). Total hospital cost was higher (median $72,481 vs. $65,584, MR: 1.11 [1.05–1.19]).CONCLUSIONS: In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients.
PubDate: Fri, 21 Jun 2024 00:00:00 GMT-
- Methylene Blue in Septic Shock: A Systematic Review and Meta-Analysis
Authors: Fernando; Shannon M.; Tran, Alexandre; Soliman, Karim; Flynn, Barbara; Oommen, Thomas; Wenzhe, Li; Adhikari, Neill K.J.; Kanji, Salmaan; Seely, Andrew J.E.; Fox-Robichaud, Alison E.; Wax, Randy S.; Cook, Deborah J.; Lamontagne, François; Rochwerg, Bram
Abstract:
OBJECTIVES: Although clinicians may use methylene blue (MB) in refractory septic shock, the effect of MB on patient-important outcomes remains uncertain. We conducted a systematic review and meta-analysis to investigate the benefits and harms of MB administration in patients with septic shock.DATA SOURCES: We searched six databases (including PubMed, Embase, and Medline) from inception to January 10, 2024.STUDY SELECTION: We included randomized clinical trials (RCTs) of critically ill adults comparing MB with placebo or usual care without MB administration.DATA EXTRACTION: Two reviewers performed screening, full-text review, and data extraction. We pooled data using a random-effects model, assessed the risk of bias using the modified Cochrane tool, and used Grading of Recommendations Assessment, Development, and Evaluation to rate certainty of effect estimates.DATA SYNTHESIS: We included six RCTs (302 patients). Compared with placebo or no MB administration, MB may reduce short-term mortality (RR [risk ratio] 0.66 [95% CI, 0.47–0.94], low certainty) and hospital length of stay (mean difference [MD] –2.1 d [95% CI, –1.4 to –2.8], low certainty). MB may also reduce duration of vasopressors (MD –31.1 hr [95% CI, –16.5 to –45.6], low certainty), and increase mean arterial pressure at 6 hours (MD 10.2 mm Hg [95% CI, 6.1–14.2], low certainty) compared with no MB administration. The effect of MB on serum methemoglobin concentration was uncertain (MD 0.9% [95% CI, –0.2% to 2.0%], very low certainty). We did not find any differences in adverse events.CONCLUSIONS: Among critically ill adults with septic shock, based on low-certainty evidence, MB may reduce short-term mortality, duration of vasopressors, and hospital length of stay, with no evidence of increased adverse events. Rigorous randomized trials evaluating the efficacy of MB in septic shock are needed.REGISTRATION: Center for Open Science (https://osf.io/hpy4j).
PubDate: Fri, 21 Jun 2024 00:00:00 GMT-
- Microvascular Autoregulation in Skeletal Muscle Using Near-Infrared
Spectroscopy and Derivation of Optimal Mean Arterial Pressure in the ICU:
Pilot Study and Comparison With Cerebral Near-Infrared Spectroscopy
Authors: Mirsajadi; Amirali; Erickson, Dustin; Alias, Soumya; Froese, Logan; Singh Sainbhi, Amanjyot; Gomez, Alwyn; Majumdar, Raju; Herath, Isuru; Wilson, Maggie; Zarychanski, Ryan; Zeiler, Frederick A.; Mendelson, Asher A.; on behalf of the Microvasclar Monitoring in Circulatory Shock the Canadian Critical Care Translational Biology Group
Abstract:
IMPORTANCE: Microvascular autoregulation (MA) maintains adequate tissue perfusion over a range of arterial blood pressure (ABP) and is frequently impaired in critical illness. MA has been studied in the brain to derive personalized hemodynamic targets after brain injury. The ability to measure MA in other organs is not known, which may inform individualized management during shock.OBJECTIVES: This study determines the feasibility of measuring MA in skeletal muscle using near-infrared spectroscopy (NIRS) as a marker of tissue perfusion, the derivation of optimal mean arterial pressure (MAPopt), and comparison with indices from the brain.DESIGN: Prospective observational study.SETTING: Medical and surgical ICU in a tertiary academic hospital.PARTICIPANTS: Adult critically ill patients requiring vasoactive support on the first day of ICU admission.MAIN OUTCOMES AND MEASURES: Fifteen critically ill patients were enrolled. NIRS was applied simultaneously to skeletal muscle (brachioradialis) and brain (frontal cortex) while ABP was measured continuously via invasive catheter. MA correlation indices were calculated between ABP and NIRS from skeletal muscle total hemoglobin (MVx), muscle tissue saturation index (MOx), brain total hemoglobin (THx), and brain tissue saturation index (COx). Curve fitting algorithms derive the MAP with the lowest correlation index value, which is the MAPopt.RESULTS: MAPopt values were successfully calculated for each correlation index for all patients and were frequently (77%) above 65 mm Hg. For all correlation indices, median time was substantially above impaired MA threshold (24.5–34.9%) and below target MAPopt (9.0–78.6%). Muscle and brain MAPopt show moderate correlation (MVx–THx r = 0.76, p < 0.001; MOx–COx r = 0.69, p = 0.005), with a median difference of –1.27 mm Hg (–9.85 to –0.18 mm Hg) and 0.05 mm Hg (–7.05 to 2.68 mm Hg).CONCLUSIONS AND RELEVANCE: This study demonstrates, for the first time, the feasibility of calculating MA indices and MAPopt in skeletal muscle using NIRS. Future studies should explore the association between impaired skeletal muscle MA, ICU outcomes, and organ-specific differences in MA and MAPopt thresholds.
PubDate: Fri, 21 Jun 2024 00:00:00 GMT-
- Critically Ill Older Adults’ Representation in Intervention Trials:
A Systematic Review
Authors: Forget; Marie-France; Wang, Han Ting; Carignan, Raphaelle; Dessureault, Alexandre; Gravel, Mathieu; Bienvenue, Jeanne; Bouchard, Maude; Durivage, Camille; Coveney, Richard; Munshi, Laveena
Abstract:
OBJECTIVES: Older adults may be under-represented in critical care research, and results may not apply to this specific population. Our primary objective was to evaluate the prevalence of inclusion of older adults across critical care trials focused on common ICU conditions or interventions. Our secondary objective was to evaluate whether older age was used as a stratification variable for randomization or outcome analysis.DESIGN, SETTING AND SUBJECTS: We performed a systematic review of previously published systematic reviews of randomized controlled trials (RCTs) in critical care. We searched PubMed, Ovid, CENTRAL, and Cochrane from 2009 to 2022. Systematic reviews of any interventions across five topics: acute respiratory distress syndrome (ARDS), sepsis/shock, nutrition, sedation, and mobilization were eligible.MAIN RESULTS: We identified 216 systematic reviews and included a total of 253 RCTs and 113,090 patients. We extracted baseline characteristics and the reported proportion of older adults. We assessed whether any upper age limit was an exclusion criterion for trials, whether age was used for stratification during randomization or data analysis, and if age-specific subgroup analysis was present. The most prevalent topic was sepsis (78 trials, 31%), followed by nutrition (62 trials, 25%), ARDS (39 trials, 15%), mobilization (38 trials, 15%), and sedation (36 trials, 14%). Eighteen trials (7%) had exclusion criteria based on older age. Age distribution with information on older adults prevalence was given in six trials (2%). Age was considered in the analysis of ten trials (5%) using analytic methods to evaluate the outcome stratified by age.Conclusions: In this systematic review, the proportion of older critically ill patients is undetermined, and it is unclear how age is or is not an effect modifier or to what extent the results are valid for older adult groups. Reporting age is important to guide clinicians in personalizing care. These results highlight the importance of incorporating older critically ill patients in future trials to ensure the results are generalizable to this growing population.
PubDate: Fri, 21 Jun 2024 00:00:00 GMT-
