Critical Care Medicine最新文献

{"title":"Beneficial Effect of Calcium Treatment for Hyperkalemia Is Not Due to \"Membrane Stabilization\".","authors":"Joseph S Piktel, Xiaoping Wan, Shalen Kouk, Kenneth R Laurita, Lance D Wilson","doi":"10.1097/CCM.0000000000006376","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006376","url":null,"abstract":"<p><strong>Objectives: </strong>Hyperkalemia is a common life-threatening condition causing severe electrophysiologic derangements and arrhythmias. The beneficial effects of calcium (Ca 2+ ) treatment for hyperkalemia have been attributed to \"membrane stabilization,\" by restoration of resting membrane potential (RMP). However, the underlying mechanisms remain poorly understood. Our objective was to investigate the mechanisms underlying adverse electrophysiologic effects of hyperkalemia and the therapeutic effects of Ca 2+ treatment.</p><p><strong>Design: </strong>Controlled experimental trial.</p><p><strong>Setting: </strong>Laboratory investigation.</p><p><strong>Subjects: </strong>Canine myocytes and tissue preparations.</p><p><strong>Interventions and measurements: </strong>Optical action potentials and volume averaged electrocardiograms were recorded from the transmural wall of ventricular wedge preparations ( n = 7) at baseline (4 mM potassium), hyperkalemia (8-12 mM), and hyperkalemia + Ca 2+ (3.6 mM). Isolated myocytes were studied during hyperkalemia (8 mM) and after Ca 2+ treatment (6 mM) to determine cellular RMP.</p><p><strong>Main results: </strong>Hyperkalemia markedly slowed conduction velocity (CV, by 67% ± 7%; p < 0.001) and homogeneously shortened action potential duration (APD, by 20% ± 10%; p < 0.002). In all preparations, this resulted in QRS widening and the \"sine wave\" pattern observed in severe hyperkalemia. Ca 2+ treatment restored CV (increase by 44% ± 18%; p < 0.02), resulting in narrowing of the QRS and normalization of the electrocardiogram, but did not restore APD. RMP was significantly elevated by hyperkalemia; however, it was not restored with Ca 2+ treatment suggesting a mechanism unrelated to \"membrane stabilization.\" In addition, the effect of Ca 2+ was attenuated during L-type Ca 2+ channel blockade, suggesting a mechanism related to Ca 2+ -dependent (rather than normally sodium-dependent) conduction.</p><p><strong>Conclusions: </strong>These data suggest that Ca 2+ treatment for hyperkalemia restores conduction through Ca 2+ -dependent propagation, rather than restoration of membrane potential or \"membrane stabilization.\" Our findings provide a mechanistic rationale for Ca 2+ treatment when hyperkalemia produces abnormalities of conduction (i.e., QRS prolongation).</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 10","pages":"1499-1508"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142307323","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":"Validation of Math Model Using Porous Media for Determining Alveolar CO 2 in Ventilated Patients.","authors":"L D Jiménez-Posada, A F Palacio-Sánchez, Y J Montagut-Ferizzola, M Ardila-Villegas, Juan C Maya","doi":"10.1097/CCM.0000000000006350","DOIUrl":"10.1097/CCM.0000000000006350","url":null,"abstract":"<p><strong>Objectives: </strong>To validate a mathematical model using porous media theory for alveolar CO2 determination in ventilated patients.</p><p><strong>Design: </strong>Mathematical modeling study with prospective clinical validation to simulate CO2 exchange from bloodstream to airway entrance.</p><p><strong>Setting: </strong>ICU.</p><p><strong>Patients: </strong>Thirteen critically ill patients without chronic or acute lung disease.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Model outcomes compared with patient data showed correlations for end-tidal CO2 (EtCO 2 ), area under the CO2 curve, and Pa CO2 of 0.918, 0.954, and 0.995. Determination coefficients ( R2 ) were 0.843, 0.910, and 0.990, indicating precision and predictive power.</p><p><strong>Conclusions: </strong>The mathematical model shows potential in pulmonary critical care. Although promising, practical application demands further validation, clinician training, and patient-specific adjustments. The path to clinical use will be iterative, involving validation and education.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"e503-e511"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392135/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141295723","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 Dubious Ethics of Patient-Level Cost Containment in the ICU.","authors":"John A Kellum","doi":"10.1097/CCM.0000000000006373","DOIUrl":"10.1097/CCM.0000000000006373","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"1638-1640"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141491224","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":"Don't-Stop Believing!","authors":"Steven M Hollenberg","doi":"10.1097/CCM.0000000000006377","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006377","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 10","pages":"1641-1643"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142281562","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":"Combination of Hydrogen Inhalation and Hypothermic Temperature Control After Out-of-Hospital Cardiac Arrest: A Post hoc Analysis of the Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During PostCardiac Arrest Care II Trial.","authors":"Tomoyoshi Tamura, Hiromichi Narumiya, Koichiro Homma, Masaru Suzuki","doi":"10.1097/CCM.0000000000006395","DOIUrl":"10.1097/CCM.0000000000006395","url":null,"abstract":"<p><strong>Objective: </strong>The Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During Post-Cardiac Arrest Care (HYBRID) II trial (jRCTs031180352) suggested that hydrogen inhalation may reduce post-cardiac arrest brain injury (PCABI). However, the combination of hypothermic target temperature management (TTM) and hydrogen inhalation on outcomes is unclear. The aim of this study was to investigate the combined effect of hydrogen inhalation and hypothermic TTM on outcomes after out-of-hospital cardiac arrest (OHCA).</p><p><strong>Design: </strong>Post hoc analysis of a multicenter, randomized, controlled trial.</p><p><strong>Setting: </strong>Fifteen Japanese ICUs.</p><p><strong>Patients: </strong>Cardiogenic OHCA enrolled in the HYBRID II trial.</p><p><strong>Interventions: </strong>Hydrogen mixed oxygen (hydrogen group) versus oxygen alone (control group).</p><p><strong>Measurements and main results: </strong>TTM was performed at a target temperature of 32-34°C (TTM32-TTM34) or 35-36°C (TTM35-TTM36) per the institutional protocol. The association between hydrogen + TTM32-TTM34 and 90-day good neurologic outcomes was analyzed using generalized estimating equations. The 90-day survival was compared between the hydrogen and control groups under TTM32-TTM34 and TTM35-TTM36, respectively. The analysis included 72 patients (hydrogen [ n = 39] and control [ n = 33] groups) with outcome data. TTM32-TTM34 was implemented in 25 (64%) and 24 (73%) patients in the hydrogen and control groups, respectively ( p = 0.46). Under TTM32-TTM34, 17 (68%) and 9 (38%) patients achieved good neurologic outcomes in the hydrogen and control groups, respectively (relative risk: 1.81 [95% CI, 1.05-3.66], p < 0.05). Hydrogen + TTM32-TTM34 was independently associated with good neurologic outcomes (adjusted odds ratio 16.10 [95% CI, 1.88-138.17], p = 0.01). However, hydrogen + TTM32-TTM34 did not improve survival compared with TTM32-TTM34 alone (adjusted hazard ratio: 0.22 [95% CI, 0.05-1.06], p = 0.06).</p><p><strong>Conclusions: </strong>Hydrogen + TTM32-TTM34 was associated with improved neurologic outcomes after cardiogenic OHCA compared with TTM32-TTM34 monotherapy. Hydrogen inhalation is a promising treatment option for reducing PCABI when combined with TTM32-TTM34.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"1567-1576"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392137/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141916254","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":"Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations.","authors":"Ioannis T Farmakis, Ingo Sagoschen, Stefano Barco, Karsten Keller, Luca Valerio, Johannes Wild, George Giannakoulas, Gregory Piazza, Stavros V Konstantinides, Lukas Hobohm","doi":"10.1097/CCM.0000000000006361","DOIUrl":"10.1097/CCM.0000000000006361","url":null,"abstract":"<p><strong>Objectives: </strong>To investigate the contemporary use of extracorporeal membrane oxygenation (ECMO) in conjunction with reperfusion strategies in high-risk pulmonary embolism (PE).</p><p><strong>Design: </strong>Observational epidemiological analysis.</p><p><strong>Setting: </strong>The U.S. Nationwide Inpatient Sample (NIS) (years 2016-2020).</p><p><strong>Patients: </strong>High-risk PE hospitalizations.</p><p><strong>Measurements and main results: </strong>Use of ECMO in conjunction with thrombolysis-based reperfusion (systemic thrombolysis or catheter-directed thrombolysis) or mechanical reperfusion (surgical embolectomy or catheter-based thrombectomy) with regards to in-hospital mortality and major bleeding. We identified high-risk PE hospitalizations in the NIS (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Among 122,735 hospitalizations for high-risk PE, ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, thrombolysis-based reperfusion in 0.4%, and mechanical reperfusion in 0.5%. Compared with neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted odds ratio [aOR] 0.61; 95% CI, 0.38-0.98), whereas no difference was found with ECMO plus mechanical reperfusion (aOR 1.03; 95% CI, 0.67-1.60), and ECMO stand-alone was associated with increased in-hospital mortality (aOR 1.60; 95% CI, 1.22-2.10). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (aOR 0.71; 95% CI, 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (aOR 0.55; 95% CI, 0.33-0.91), and mechanical reperfusion showed a trend (aOR 0.75; 95% CI, 0.47-1.19) toward reduced in-hospital mortality compared with no reperfusion, without increases in major bleeding.</p><p><strong>Conclusions: </strong>In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as a stand-alone treatment especially for patients suffering from cardiac arrest.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"e512-e521"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141431634","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":"Characteristics of Patients Hospitalized in Rural and Urban ICUs From 2010 to 2019.","authors":"Emily A Harlan, Muhammad Ghous, Ira S Moscovice, Thomas S Valley","doi":"10.1097/CCM.0000000000006369","DOIUrl":"10.1097/CCM.0000000000006369","url":null,"abstract":"<p><strong>Objectives: </strong>Rural hospitals are threatened by workforce shortages and financial strain. To optimize regional critical care delivery, it is essential to understand what types of patients receive intensive care in rural and urban hospitals.</p><p><strong>Design: </strong>A retrospective cohort study.</p><p><strong>Setting and patients: </strong>All fee-for-service Medicare beneficiaries in the United States who were 65 years old or older hospitalized in an ICU between 2010 and 2019 were included. Rural and urban hospitals were classified according to the 2013 National Center For Health Statistics Urban-Rural Classification Scheme for Counties. Patient comorbidities, primary diagnoses, organ dysfunction, and procedures were measured using the International Classification of Diseases , 9th and 10th revisions diagnosis and procedure codes. Standardized differences were used to compare rural and urban patient admission characteristics.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>There were 12,224,097 ICU admissions between 2010 and 2019, and 1,488,347 admissions (12.2%) were to rural hospitals. The most common diagnoses in rural hospitals were cardiac (30.3%), infectious (24.6%), and respiratory (10.9%). Patients in rural ICUs had similar organ dysfunction compared with urban hospitals (mean organ failures in rural ICUs 0.5, sd 0.8; mean organ failures in urban ICUs 0.6, sd 0.9, absolute standardized mean difference 0.096). Organ dysfunction among rural ICU admissions increased over time (0.4 mean organ failures in 2010 to 0.7 in 2019, p < 0.001).</p><p><strong>Conclusions: </strong>Rural hospitals care for an increasingly complex critically ill patient population with similar organ dysfunction as urban hospitals. There is a pressing need to develop policies at federal and regional healthcare system levels to support the continued provision of high-quality ICU care within rural hospitals.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"1577-1586"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11408111/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141449894","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":"Characteristics and Outcomes of Prolonged Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery: The Post-Cardiotomy Extracorporeal Life Support (PELS-1) Cohort Study.","authors":"Jeroen J H Bunge, Silvia Mariani, Christiaan Meuwese, Bas C T van Bussel, Michele Di Mauro, Dominik Wiedeman, Diyar Saeed, Matteo Pozzi, Antonio Loforte, Udo Boeken, Robertas Samalavicius, Karl Bounader, Xiaotong Hou, Hergen Buscher, Leonardo Salazar, Bart Meyns, Daniel Herr, Sacha Matteucci, Sandro Sponga, Graeme MacLaren, Claudio Russo, Francesco Formica, Pranya Sakiyalak, Antonio Fiore, Daniele Camboni, Giuseppe Maria Raffa, Rodrigo Diaz, I-Wen Wang, Jae-Seung Jung, Jan Belohlavek, Vin Pellegrino, Giacomo Bianchi, Matteo Pettinari, Alessandro Barbone, José P Garcia, Kiran Shekar, Glenn J R Whitman, Diederik Gommers, Dinis Dos Reis Miranda, Roberto Lorusso","doi":"10.1097/CCM.0000000000006349","DOIUrl":"10.1097/CCM.0000000000006349","url":null,"abstract":"<p><strong>Objectives: </strong>Most post-cardiotomy (PC) extracorporeal membrane oxygenation (ECMO) runs last less than 7 days. Studies on the outcomes of longer runs have provided conflicting results. This study investigates patient characteristics and short- and long-term outcomes in relation to PC ECMO duration, with a focus on prolonged (> 7 d) ECMO.</p><p><strong>Design: </strong>Retrospective observational cohort study.</p><p><strong>Setting: </strong>Thirty-four centers from 16 countries between January 2000 and December 2020.</p><p><strong>Patients: </strong>Adults requiring post PC ECMO between 2000 and 2020.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Characteristics, in-hospital, and post-discharge outcomes were compared among patients categorized by ECMO duration. Survivors and nonsurvivors were compared in the subgroup of patients with ECMO duration greater than 7 days. The primary outcome was in-hospital mortality. Two thousand twenty-one patients were included who required PC ECMO for 0-3 days ( n = 649 [32.1%]), 4-7 days ( n = 776 [38.3%]), 8-10 days ( n = 263 [13.0%]), and greater than 10 days ( n = 333 [16.5%]). There were no major differences in the investigated preoperative and procedural characteristics among ECMO duration groups. However, the longer ECMO duration category was associated with multiple complications including bleeding, acute kidney injury, arrhythmias, and sepsis. Hospital mortality followed a U-shape curve, with lowest mortality in patients with ECMO duration of 4-7 days ( n = 394, 50.8%) and highest in patients with greater than 10 days ECMO support ( n = 242, 72.7%). There was no significant difference in post-discharge survival between ECMO duration groups. In patients with ECMO duration greater than 7 days, age, comorbidities, valvular diseases, and complex procedures were associated with nonsurvival.</p><p><strong>Conclusions: </strong>Nearly 30% of PC ECMO patients were supported for greater than 7 days. In-hospital mortality increased after 7 days of support, especially in patients undergoing valvular and complex surgery, or who had complications, although the long-term post-discharge prognosis was comparable to PC ECMO patients with shorter support duration.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"e490-e502"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392071/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141295722","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 Use of Ultrasound to Measure Optic Nerve Sheath Diameter: Shadows of the Black Box.","authors":"Paul Nyquist, Austen T Lefebvre","doi":"10.1097/CCM.0000000000006355","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006355","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 10","pages":"1651-1653"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142281616","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":"Early Choices, Lasting Impact: The Colloid Versus Crystalloid Decision in Early Sepsis.","authors":"Deborah Huang, Jen-Ting Chen","doi":"10.1097/CCM.0000000000006363","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006363","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"52 10","pages":"1646-1648"},"PeriodicalIF":7.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142281563","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}