Critical Care Medicine最新文献

{"title":"Digital Twins of Acute Hypoxemic Respiratory Failure Patients Suggest a Mechanistic Basis for Success and Failure of Noninvasive Ventilation.","authors":"Liam Weaver, Hossein Shamohammadi, Sina Saffaran, Roberto Tonelli, Marianna Laviola, John G Laffey, Luigi Camporota, Timothy E Scott, Jonathan G Hardman, Enrico Clini, Declan G Bates","doi":"10.1097/CCM.0000000000006337","DOIUrl":"10.1097/CCM.0000000000006337","url":null,"abstract":"<p><strong>Objectives: </strong>To clarify the mechanistic basis for the success or failure of noninvasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF).</p><p><strong>Design: </strong>We created digital twins based on mechanistic computational models of individual patients with AHRF.</p><p><strong>Setting: </strong>Interdisciplinary Collaboration in Systems Medicine Research Network.</p><p><strong>Subjects: </strong>We used individual patient data from 30 moderate-to-severe AHRF patients who had failed high-flow nasal cannula (HFNC) therapy and subsequently underwent a trial of NIV.</p><p><strong>Interventions: </strong>Using the digital twins, we evaluated lung mechanics, quantified the separate contributions of external support and patient respiratory effort to lung injury indices, and investigated their relative impact on NIV success or failure.</p><p><strong>Measurements and main results: </strong>In digital twins of patients who successfully completed/failed NIV, after 2 hours of the trial the mean (sd) of the change in total lung stress was -10.9 (6.2)/-0.35 (3.38) cm H2O, mechanical power -13.4 (12.2)/-1.0 (5.4) J/min, and total lung strain 0.02 (0.24)/0.16 (0.30). In the digital twins, positive end-expiratory pressure (PEEP) produced by HFNC was similar to that set during NIV. In digital twins of patients who failed NIV vs. those who succeeded, intrinsic PEEP was 3.5 (0.6) vs. 2.3 (0.8) cm H2O, inspiratory pressure support was 8.3 (5.9) vs. 22.3 (7.2) cm H2O, and tidal volume was 10.9 (1.2) vs. 9.4 (1.8) mL/kg. In digital twins, successful NIV increased respiratory system compliance +25.0 (16.4) mL/cm H2O, lowered inspiratory muscle pressure -9.7 (9.6) cm H2O, and reduced the contribution of patient spontaneous breathing to total driving pressure by 57.0%.</p><p><strong>Conclusions: </strong>In digital twins of AHRF patients, successful NIV improved lung mechanics, lowering respiratory effort and indices associated with lung injury. NIV failed in patients for whom only low levels of positive inspiratory pressure support could be applied without risking patient self-inflicted lung injury due to excessive tidal volumes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"e473-e484"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11321607/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981920","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Should We Explore Transesophageal Echocardiography During Advanced Cardiac Life Support to Improve Cardiopulmonary Resuscitation Quality and Efficacy?","authors":"José L Díaz-Gómez","doi":"10.1097/CCM.0000000000006370","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006370","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"1487-1490"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Toward Precision in Critical Care Research: Methods for Observational and Interventional Studies.","authors":"Emma J Graham Linck, Ewan C Goligher, Matthew W Semler, Matthew M Churpek","doi":"10.1097/CCM.0000000000006371","DOIUrl":"10.1097/CCM.0000000000006371","url":null,"abstract":"<p><p>Critical care trials evaluate the effect of interventions in patients with diverse personal histories and causes of illness, often under the umbrella of heterogeneous clinical syndromes, such as sepsis or acute respiratory distress syndrome. Given this variation, it is reasonable to expect that the effect of treatment on outcomes may differ for individuals with variable characteristics. However, in randomized controlled trials, efficacy is typically assessed by the average treatment effect (ATE), which quantifies the average effect of the intervention on the outcome in the study population. Importantly, the ATE may hide variations of the treatment's effect on a clinical outcome across levels of patient characteristics, which may erroneously lead to the conclusion that an intervention does not work overall when it may in fact benefit certain patients. In this review, we describe methodological approaches for assessing heterogeneity of treatment effect (HTE), including expert-derived subgrouping, data-driven subgrouping, baseline risk modeling, treatment effect modeling, and individual treatment rule estimation. Next, we outline how insights from HTE analyses can be incorporated into the design of clinical trials. Finally, we propose a research agenda for advancing the field and bringing HTE approaches to the bedside.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"1439-1450"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11328956/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Two Consecutive Weeks Are No Better Than One at a Time: Targeting Optimal Intensivist Scheduling.","authors":"Christopher J Yarnell","doi":"10.1097/CCM.0000000000006344","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006344","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"1476-1478"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Postarrest Hypotension Burden With Unfavorable Neurologic Outcome After Pediatric Cardiac Arrest.","authors":"Raymond Liu, Tanmay Majumdar, Monique M Gardner, Ryan Burnett, Kathryn Graham, Forrest Beaulieu, Robert M Sutton, Vinay M Nadkarni, Robert A Berg, Ryan W Morgan, Alexis A Topjian, Matthew P Kirschen","doi":"10.1097/CCM.0000000000006339","DOIUrl":"10.1097/CCM.0000000000006339","url":null,"abstract":"<p><strong>Objective: </strong>Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest.</p><p><strong>Design: </strong>Retrospective observational study.</p><p><strong>Setting: </strong>Academic PICU.</p><p><strong>Patients: </strong>Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner.</p><p><strong>Conclusions: </strong>High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"1402-1413"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11326994/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141237291","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Ideal Mean Arterial Pressure Target Debate: Heterogeneity Obscures Conclusions.","authors":"Daniel De Backer, Ashish K Khanna","doi":"10.1097/CCM.0000000000006331","DOIUrl":"10.1097/CCM.0000000000006331","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"1495-1498"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Fluid Balance and Hemoglobin Decline With Neurological Outcome After Aneurysmal Subarachnoid Hemorrhage.","authors":"Peter Truckenmueller, Stefan Wolf, David Wasilewski, Peter Vajkoczy, Anton Früh","doi":"10.1097/CCM.0000000000006332","DOIUrl":"10.1097/CCM.0000000000006332","url":null,"abstract":"<p><strong>Objectives: </strong>To explore the relationship between fluid balance and hemoglobin decline with secondary infarctions and neurologic outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients.</p><p><strong>Design: </strong>Secondary analysis of the Earlydrain trial, a prospective randomized controlled study investigating prophylactic lumbar drain use in aSAH patients.</p><p><strong>Setting: </strong>Patients with aSAH treated in ICUs at 19 tertiary hospitals in Germany, Switzerland, and Canada.</p><p><strong>Patients: </strong>From January 2011 to January 2016, 287 patients were enrolled in the Earlydrain trial. Only files with complete information on both daily hemoglobin and balance values were used, leaving 237 patients for analysis.</p><p><strong>Interventions: </strong>Investigation of fluid balance management and hemoglobin levels during the initial 8 days post-aSAH to establish thresholds for unfavorable outcomes and assess their impact on secondary infarctions and 6-month neurologic outcome on the modified Rankin Scale (mRS).</p><p><strong>Measurements and main results: </strong>Patients with unfavorable outcome after 6 months (mRS > 2) showed greater hemoglobin decline and increased cumulative fluid balance. A significant inverse relationship existed between fluid balance and hemoglobin decline. Thresholds for unfavorable outcome were 10.4 g/dL hemoglobin and 4894 mL cumulative fluid balance in the first 8 days. In multivariable analysis, fluid balance, but not fluid intake, remained significantly associated with unfavorable outcome, while the influence of hemoglobin lessened. Fluid balance but not hemoglobin related to secondary infarctions, with the effect being significant after inverse probability of treatment weighting. Transfusion was associated with unfavorable outcomes.</p><p><strong>Conclusions: </strong>Increased fluid balance influences hemoglobin decline through hemodilution. Fluid overload, rather than a slight decrease in hemoglobin levels, appears to be the primary factor contributing to poor outcomes in aSAH patients. The results suggest aiming for euvolemia and that a modest hemoglobin decline may be tolerated. It may be advisable to adopt a restrictive approach to transfusions, as they can potentially have a negative effect on outcome.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"1391-1401"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11321606/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141075312","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Covert Consciousness in the ICU.","authors":"Brian L Edlow, David K Menon","doi":"10.1097/CCM.0000000000006372","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006372","url":null,"abstract":"<p><strong>Objectives: </strong>For critically ill patients with acute severe brain injuries, consciousness may reemerge before behavioral responsiveness. The phenomenon of covert consciousness (i.e., cognitive motor dissociation) may be detected by advanced neurotechnologies such as task-based functional MRI (fMRI) and electroencephalography (EEG) in patients who appear unresponsive on the bedside behavioral examination. In this narrative review, we summarize the state-of-the-science in ICU detection of covert consciousness. Further, we consider the prognostic and therapeutic implications of diagnosing covert consciousness in the ICU, as well as its potential to inform discussions about continuation of life-sustaining therapy for patients with severe brain injuries.</p><p><strong>Data sources: </strong>We reviewed salient medical literature regarding covert consciousness.</p><p><strong>Study selection: </strong>We included clinical studies investigating the diagnostic performance characteristics and prognostic utility of advanced neurotechnologies such as task-based fMRI and EEG. We focus on clinical guidelines, professional society scientific statements, and neuroethical analyses pertaining to the implementation of advanced neurotechnologies in the ICU to detect covert consciousness.</p><p><strong>Data extraction and data synthesis: </strong>We extracted study results, guideline recommendations, and society scientific statement recommendations regarding the diagnostic, prognostic, and therapeutic relevance of covert consciousness to the clinical care of ICU patients with severe brain injuries.</p><p><strong>Conclusions: </strong>Emerging evidence indicates that covert consciousness is present in approximately 15-20% of ICU patients who appear unresponsive on behavioral examination. Covert consciousness may be detected in patients with traumatic and nontraumatic brain injuries, including patients whose behavioral examination suggests a comatose state. The presence of covert consciousness in the ICU may predict the pace and extent of long-term functional recovery. Professional society guidelines now recommend assessment of covert consciousness using task-based fMRI and EEG. However, the clinical criteria for patient selection for such investigations are uncertain and global access to advanced neurotechnologies is limited.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"1414-1426"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The authors reply.","authors":"Todd A Miano, Erin F Barreto, Molly McNett, Niels Martin, Ankit Sakhuja, Adair Andrews, Rajit K Basu, Enyo A Ablordeppey","doi":"10.1097/CCM.0000000000006352","DOIUrl":"10.1097/CCM.0000000000006352","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"e486-e487"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Do Not Estimate, When You Can Measure.","authors":"G Jan Zijlstra, Arne J van Tienhoven, Matijs van Meurs","doi":"10.1097/CCM.0000000000006325","DOIUrl":"10.1097/CCM.0000000000006325","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 9","pages":"e485-e486"},"PeriodicalIF":7.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}