Critical Care最新文献

{"title":"Novel cortisol trajectory sub-phenotypes in sepsis","authors":"Fei Leng, Zhunyong Gu, Simeng Pan, Shilong Lin, Xu Wang, Ming Zhong, Jieqiong Song","doi":"10.1186/s13054-024-05071-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05071-2","url":null,"abstract":"Sepsis is a heterogeneous syndrome. This study aimed to identify new sepsis sub-phenotypes using plasma cortisol trajectory. This retrospective study included patients with sepsis admitted to the intensive care unit of Zhongshan Hospital Fudan University between March 2020 and July 2022. A group-based cortisol trajectory model was used to classify septic patients into different sub-phenotypes. The clinical characteristics, biomarkers, and outcomes were compared between sub-phenotypes. A total of 258 patients with sepsis were included, of whom 186 were male. Patients were divided into two trajectory groups: the lower-cortisol group (n = 217) exhibited consistently low and slowly declining cortisol levels, while the higher-cortisol group (n = 41) showed relatively higher levels in comparison. The 28-day mortality (65.9% vs.16.1%, P < 0.001) and 90-day mortality (65.9% vs. 19.8%, P < 0.001) of the higher-cortisol group were significantly higher than the lower-cortisol group. Multivariable Cox regression analysis showed that the trajectory sub-phenotype (HR = 5.292; 95% CI 2.218–12.626; P < 0.001), APACHE II (HR = 1.109; 95% CI 1.030–1.193; P = 0.006), SOFA (HR = 1.161; 95% CI 1.045–1.291; P = 0.006), and IL-1β (HR = 1.001; 95% CI 1.000–1.002; P = 0.007) were independent risk factors for 28-day mortality. Besides, the trajectory sub-phenotype (HR = 4.571; 95% CI 1.980–10.551; P < 0.001), APACHE II (HR = 1.108; 95% CI 1.043–1.177; P = 0.001), SOFA (HR = 1.270; 95% CI 1.130–1.428; P < 0.001), and IL-1β (HR = 1.001; 95% CI 1.000–1.001; P = 0.015) were also independent risk factors for 90-day mortality. This study identified two novel cortisol trajectory sub-phenotypes in patients with sepsis. The trajectories were associated with mortality, providing new insights into sepsis classification.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123527","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 between arterial oxygen partial pressure and mortality in sepsis","authors":"Xinyuan Ding, Shangzhong Chen","doi":"10.1186/s13054-024-05038-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05038-3","url":null,"abstract":"&lt;p&gt;To the editor,&lt;/p&gt;&lt;p&gt;The appropriate arterial oxygen partial pressure (PaO&lt;sub&gt;2&lt;/sub&gt;) in sepsis patients has been investigated in dozens of studies. However, no consensus has been reached. In a recent study [1], Dr. Hyun et al. investigated the association between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality in critically ill sepsis patients. Data on PaO&lt;sub&gt;2&lt;/sub&gt; of 4147 sepsis patients from the Korea Sepsis Alliance Registry (KSA) during the first three days was extracted, and patients were divided into conservative PaO&lt;sub&gt;2&lt;/sub&gt; group (&lt; 80mmHg) and liberal PaO&lt;sub&gt;2&lt;/sub&gt; group (≥ 80mmHg). Statistical methods, including propensity score matching, mixed linear model, and competitive risk models, were used to explore potential causal relationships. The results showed higher PaO&lt;sub&gt;2&lt;/sub&gt; (≥ 80 mm Hg) during the first three ICU days was associated with a lower 28-day mortality than conservative PaO&lt;sub&gt;2&lt;/sub&gt;. Several issues should be noted when interpreting these findings.&lt;/p&gt;&lt;p&gt;First, dividing the entire cohort into groups based on the cut-off value of one continuous variable is a common strategy in observational studies. In the current research, a cut-off value of 80 mmHg of PaO&lt;sub&gt;2&lt;/sub&gt; was used. However, the results may be biased when the correlation between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality is non-linear. For instance, previous studies [2, 3] have pointed out that there may be a U-shaped correlation between PaO&lt;sub&gt;2&lt;/sub&gt; and death, which means either extremely high or low PaO&lt;sub&gt;2&lt;/sub&gt; may be associated with increased mortality compared to normal PaO&lt;sub&gt;2&lt;/sub&gt;. In this case, whether there is a difference between the conservative and liberal PaO&lt;sub&gt;2&lt;/sub&gt; groups can be significantly affected by the cut-off value. For instance, in the current study, the restrictive cubic spline between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality showed that the PaO&lt;sub&gt;2&lt;/sub&gt; with the lowest mortality possibility was around 100mmHg. Thus, when using 80mmHg as the cut-off value, the comparison between conservative (PaO&lt;sub&gt;2min&lt;/sub&gt; &lt; 80mmHg) and liberal (PaO&lt;sub&gt;2min&lt;/sub&gt; ≥ 80mmHg) PaO&lt;sub&gt;2&lt;/sub&gt; groups was actually comparing the low PaO&lt;sub&gt;2&lt;/sub&gt; group with the normal PaO&lt;sub&gt;2&lt;/sub&gt; group combined with the high PaO&lt;sub&gt;2&lt;/sub&gt; group (&lt; 80mmHg vs. (80 – 110mmHg + &gt; 110mmHg)), which thus lead to a potentially biased result that liberal PaO&lt;sub&gt;2&lt;/sub&gt; was associated with low mortality rate. Similarly, the difference in mortality rate between the two groups may also be affected by the proportion of patients with high PaO&lt;sub&gt;2&lt;/sub&gt;. In the current study, we noted that the PaO&lt;sub&gt;2&lt;/sub&gt; was relatively low even in the liberal PaO&lt;sub&gt;2&lt;/sub&gt; group (median values were 107, 110, and 106 during three days). In the case of a low proportion of patients with high PaO&lt;sub&gt;2&lt;/sub&gt;, using 80mmHg as the cut-off value may actually be the comparison between the low PaO&lt;sub&gt;2&lt;/sub&gt; group and the normal PaO&lt;sub&gt;2&lt;/sub&gt; group, which may also be one factor for the i","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123563","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":"Mitochondrial dysfunction in sepsis: mechanisms and therapeutic perspectives","authors":"Dongxue Hu, Harshini Sheeja Prabhakaran, Yuan-Yuan Zhang, Gaoxing Luo, Weifeng He, Yih-Cherng Liou","doi":"10.1186/s13054-024-05069-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05069-w","url":null,"abstract":"Sepsis is a severe medical condition characterized by a systemic inflammatory response, often culminating in multiple organ dysfunction and high mortality rates. In recent years, there has been a growing recognition of the pivotal role played by mitochondrial damage in driving the progression of sepsis. Various factors contribute to mitochondrial impairment during sepsis, encompassing mechanisms such as reactive nitrogen/oxygen species generation, mitophagy inhibition, mitochondrial dynamics change, and mitochondrial membrane permeabilization. Damaged mitochondria actively participate in shaping the inflammatory milieu by triggering key signaling pathways, including those mediated by Toll-like receptors, NOD-like receptors, and cyclic GMP-AMP synthase. Consequently, there has been a surge of interest in developing therapeutic strategies targeting mitochondria to mitigate septic pathogenesis. This review aims to delve into the intricate mechanisms underpinning mitochondrial dysfunction during sepsis and its significant impact on immune dysregulation. Moreover, we spotlight promising mitochondria-targeted interventions that have demonstrated therapeutic efficacy in preclinical sepsis models.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123526","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":"Volatile anesthetics for lung- and diaphragm-protective sedation","authors":"Lukas M. Müller-Wirtz, Brian O’Gara, Marcelo Gama de Abreu, Marcus J. Schultz, Jeremy R. Beitler, Angela Jerath, Andreas Meiser","doi":"10.1186/s13054-024-05049-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05049-0","url":null,"abstract":"This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100850","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":"Variability in forgoing life-sustaining treatment practices in critically Ill patients with hospital-acquired bloodstream infections: a secondary analysis of the EUROBACT-2 international cohort","authors":"Hannah Wozniak, Alexis Tabah, Jan J. De Waele, Jean-François Timsit, Niccolò Buetti","doi":"10.1186/s13054-024-05072-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05072-1","url":null,"abstract":"The decision to forgo life-sustaining treatment in intensive care units (ICUs) is influenced by ethical, cultural, and medical factors. This study focuses on a population of patients with hospital-acquired bloodstream infections (HABSI) to investigate the association between patient, pathogen, center and country-level factors and these decisions. We analyzed data from the EUROBACT-2 study (June 2019–January 2021) from 265 centers worldwide, focusing on non-COVID-19 patients who died in the hospital or within 28 days after HABSI. We assessed whether death was preceded by a decision to forgo life-sustaining treatment, examining country, center, patient, and pathogen variables. To assess the association of each potentially important variable with the decision to forgo life-sustaining treatment, univariable mixed logistic regression models with a random center effect were performed. Among 1589 non-COVID-19 patients, 519 (32.7%) died, with 191 (36.8%) following a decision to forgo life-sustaining treatment. Significant geographical differences were observed, with no reported decisions to forgo life-sustaining treatment in African countries and fewer in the Middle East compared to Western Europe, Australia, and Asia. Once a center effect was considered, only health expenditure (Odds ratio 1.79, 95%CI: 1.45–2.21, p < 0.01) and age (Odds ratio 1.02, 95%CI: 1.002–1.05, p = 0.03) were significantly associated with decisions to forgo life-sustaining treatment, while other patient and pathogen factors were not. Economic and regional disparities significantly impact end-of-life decision-making in ICUs. Global policies should consider these disparities to ensure equitable end-of-life care practices.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100853","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":"Accelerometer-derived movement features as predictive biomarkers for muscle atrophy in neurocritical care: a prospective cohort study","authors":"Moritz L. Schmidbauer, Timon Putz, Leon Gehri, Luka Ratkovic, Andreas Maskos, Julia Zibold, Johanna Bauchmüller, Sophie Imhof, Thomas Weig, Max Wuehr, Konstantinos Dimitriadis","doi":"10.1186/s13054-024-05067-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05067-y","url":null,"abstract":"Physical inactivity and subsequent muscle atrophy are highly prevalent in neurocritical care and are recognized as key mechanisms underlying intensive care unit acquired weakness (ICUAW). The lack of quantifiable biomarkers for inactivity complicates the assessment of its relative importance compared to other conditions under the syndromic diagnosis of ICUAW. We hypothesize that active movement, as opposed to passive movement without active patient participation, can serve as a valid proxy for activity and may help predict muscle atrophy. To test this hypothesis, we utilized non-invasive, body-fixed accelerometers to compute measures of active movement and subsequently developed a machine learning model to predict muscle atrophy. This study was conducted as a single-center, prospective, observational cohort study as part of the MINCE registry (metabolism and nutrition in neurointensive care, DRKS-ID: DRKS00031472). Atrophy of rectus femoris muscle (RFM) relative to baseline (day 0) was evaluated at days 3, 7 and 10 after intensive care unit (ICU) admission and served as the dependent variable in a generalized linear mixed model with Least Absolute Shrinkage and Selection Operator regularization and nested-cross validation. Out of 407 patients screened, 53 patients (age: 59.2 years (SD 15.9), 31 (58.5%) male) with a total of 91 available accelerometer datasets were enrolled. RFM thickness changed − 19.5% (SD 12.0) by day 10. Out of 12 demographic, clinical, nutritional and accelerometer-derived variables, baseline RFM muscle mass (beta − 5.1, 95% CI − 7.9 to − 3.8) and proportion of active movement (% activity) (beta 1.6, 95% CI 0.1 to 4.9) were selected as significant predictors of muscle atrophy. Including movement features into the prediction model substantially improved performance on an unseen test data set (including movement features: R2 = 79%; excluding movement features: R2 = 55%). Active movement, as measured with thigh-fixed accelerometers, is a key risk factor for muscle atrophy in neurocritical care patients. Quantifiable biomarkers reflecting the level of activity can support more precise phenotyping of ICUAW and may direct tailored interventions to support activity in the ICU. Studies addressing the external validity of these findings beyond the neurointensive care unit are warranted. DRKS00031472, retrospectively registered on 13.03.2023.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100851","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":"Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis","authors":"Renato Carneiro de Freitas Chaves, Carmen Silvia Valente Barbas, Veronica Neves Fialho Queiroz, Ary Serpa Neto, Rodrigo Octavio Deliberato, Adriano José Pereira, Karina Tavares Timenetsky, João Manoel Silva Júnior, Flávio Takaoka, Daniel de Backer, Leo Anthony Celi, Thiago Domingos Corrêa","doi":"10.1186/s13054-024-05078-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05078-9","url":null,"abstract":"Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes. To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients. The protocol was registered at PROSPERO: CRD42019146781. PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023. Prospective and intervention studies were selected. Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed. A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5–12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84–0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9–13.3)%, and AUC with 95% CI was 0.87 (0.84–0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3–15.3)%, and AUC was 0.88 (0.82–0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7–10.1) mmHg, and AUC with 95% CI was 0.77 (0.69–0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3–17.6)%, and AUC with 95% CI was 0.83 (0.78–0.89). Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100852","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":"Septic shock in the immunocompromised cancer patient: a narrative review","authors":"Joseph L. Nates, Frédéric Pène, Michael Darmon, Djamel Mokart, Pedro Castro, Sascha David, Pedro Povoa, Lene Russell, Nathan D. Nielsen, Gabriel-Petre Gorecki, Kim O. Gradel, Elie Azoulay, Philippe R. Bauer","doi":"10.1186/s13054-024-05073-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05073-0","url":null,"abstract":"Immunosuppressed patients, particularly those with cancer, represent a momentous and increasing portion of the population, especially as cancer incidence rises with population growth and aging. These patients are at a heightened risk of developing severe infections, including sepsis and septic shock, due to multiple immunologic defects such as neutropenia, lymphopenia, and T and B-cell impairment. The diverse and complex nature of these immunologic profiles, compounded by the concomitant use of immunosuppressive therapies (e.g., corticosteroids, cytotoxic drugs, and immunotherapy), superimposed by the breakage of natural protective barriers (e.g., mucosal damage, chronic indwelling catheters, and alterations of anatomical structures), increases the risk of various infections. These and other conditions that mimic sepsis pose substantial diagnostic and therapeutic challenges. Factors that elevate the risk of progression to septic shock in these patients include advanced age, pre-existing comorbidities, frailty, type of cancer, the severity of immunosuppression, hypoalbuminemia, hypophosphatemia, Gram-negative bacteremia, and type and timing of responses to initial treatment. The management of vulnerable cancer patients with sepsis or septic shock varies due to biased clinical practices that may result in delayed access to intensive care and worse outcomes. While septic shock is typically associated with poor outcomes in patients with malignancies, survival has significantly improved over time. Therefore, understanding and addressing the unique needs of cancer patients through a new paradigm, which includes the integration of innovative technologies into our healthcare system (e.g., wireless technologies, medical informatics, precision medicine), targeted management strategies, and robust clinical practices, including early identification and diagnosis, coupled with prompt admission to high-level care facilities that promote a multidisciplinary approach, is crucial for improving their prognosis and overall survival rates. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100855","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":"Brief report: incidence and outcomes of pediatric tracheal intubation-associated cardiac arrests in the ICU-RESUS clinical trial","authors":"Akira Nishisaki, Ron W. Reeder, Elizabeth Laverriere McGovern, Tageldin Ahmed, Michael J. Bell, Robert Bishop, Matthew Bochkoris, Candice Burns, Joseph A. Carcillo, Todd C. Carpenter, Wesley Diddle, Myke Federman, Ericka L. Fink, Deborah Franzon, Aisha H. Frazier, Stuart H. Friess, Kathryn Graham, Mark Hall, David A. Hehir, Christopher M. Horvat, Leanna L. Huard, Tensing Maa, Arushi Manga, Patrick McQuillen, Kathleen L. Meert, Ryan W. Morgan, Peter M. Mourani, Vinay M. Nadkarni, Maryam Y. Naim, Daniel Notterman, Chella A. Palmer, Anil Sapru, Carleen Schneiter, Matthew P. Sharron, Neeraj Srivastava, Shirley Viteri, David Wessel, Heather A. Wolfe, Andrew R. Yates, Athena F. Zuppa, Robert M. Sutton, Robert A. Berg","doi":"10.1186/s13054-024-05065-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05065-0","url":null,"abstract":"Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA. Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. The primary exposure was TI-CA, defined as cardiac arrest occurred during TI procedure or within 20 min after endotracheal tube placement. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category score 1–3 or unchanged). Among 315 children with cardiac arrests, 48 (15.2%) met criteria for TI-CA. Pre-existing medical conditions were similar between groups. Pre-arrest non-invasive mechanical ventilation was more common among TI-CA patients (18/48, 37.5%) compared to non-TI-CA patients (35/267, 13.1%). In 48% (23/48), the TI-CA occurred within 20 min after intubation (i.e., not during intubation). Duration of CPR was longer in TI-CA patients (median 11.0 min, interquartile range [IQR]: 2.5, 35.5) than non-TI-CA patients (median 5.0 min, IQR 2.0, 21.0), p = 0.03. Return of spontaneous circulation occurred in 32/48 (66.7%) TI-CA versus 186/267 (69.7%) non-TI-CA, p = 0.73. Survival to hospital discharge with favorable neurological outcome occurred in 29/48 (60.4%) TI-CA versus 146/267 (54.7%) non-TI-CA, p = 0.53. Fifteen percent of these pediatric ICU cardiac arrests were associated with TI. Half of TI-CA occurred after endotracheal tube placement. While duration of CPR was longer in TI-CA patients, there were no differences in unadjusted outcomes following TI-CA versus non-TI-CA. The ICU-RESUS (ClinicalTrials.gov Identifier: NCT 02837497).","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100854","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 ventilator of the future: key principles and unmet needs","authors":"John J. Marini, Luciano Gattinoni","doi":"10.1186/s13054-024-05060-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05060-5","url":null,"abstract":"Persistent shortcomings of invasive positive pressure ventilation make it less than an ideal intervention. Over the course of more than seven decades, clinical experience and scientific investigation have helped define its range of hazards and limitations. Apart from compromised airway clearance and lower airway contamination imposed by endotracheal intubation, the primary hazards inherent to positive pressure ventilation may be considered in three broad categories: hemodynamic impairment, potential for ventilation-induced lung injury, and impairment of the respiratory muscle pump. To optimize care delivery, it is crucial for monitoring and machine outputs to integrate information with the potential to impact the underlying requirements of the patient and/or responses of the cardiopulmonary system to ventilatory interventions. Trending analysis, timely interventions, and closer communication with the caregiver would limit adverse clinical trajectories. Judging from the rapid progress of recent years, we are encouraged to think that insights from physiologic research and emerging technological capability may eventually address important aspects of current deficiencies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100856","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}