Critical Care最新文献

{"title":"Rezafungin versus caspofungin for patients with candidaemia or invasive candidiasis in the intensive care unit: pooled analyses of the ReSTORE and STRIVE randomised trials.","authors":"Patrick M Honoré, Massimo Girardis, Marin Kollef, Oliver A Cornely, George R Thompson, Matteo Bassetti, Alex Soriano, Haihui Huang, Jose Vazquez, Bart Jan Kullberg, Peter G Pappas, Nick Manamley, Taylor Sandison, John Pullman, Saad Nseir","doi":"10.1186/s13054-024-05117-5","DOIUrl":"10.1186/s13054-024-05117-5","url":null,"abstract":"<p><strong>Background: </strong>Rezafungin is an echinocandin approved in the US and EU to treat candidaemia and/or invasive candidiasis. This post-hoc, pooled analysis of the Phase 2 STRIVE and Phase 3 ReSTORE trials assessed rezafungin versus caspofungin in patients with candidaemia and/or invasive candidiasis (IC) in the intensive care unit (ICU) at randomisation.</p><p><strong>Methods: </strong>STRIVE and ReSTORE were randomised double-blind trials in adults with systemic signs and mycological confirmation of candidaemia and/or IC in blood or a normally sterile site ≤ 96 h before randomisation. Data were pooled for patients in the ICU at randomisation who received intravenous rezafungin (400 mg loading dose then 200 mg once weekly) or caspofungin (70 mg loading dose then 50 mg once daily) for ≤ 4 weeks. Outcomes were Day 30 all-cause mortality (primary outcome), Day 5 and 14 mycological eradication, time to negative blood culture, mortality attributable to candidaemia/invasive candidiasis, safety, and pharmacokinetics.</p><p><strong>Results: </strong>Of 294 patients in STRIVE/ReSTORE, 113 were in the ICU at randomisation (rezafungin n = 46; caspofungin n = 67). At baseline, ~ 30% of patients in each group had impaired renal function and/or an Acute Physiologic Assessment and Chronic Health Evaluation II score ≥ 20. One patient (in the caspofungin group) was neutropenic at baseline. Day 30 all-cause mortality was 34.8% for rezafungin versus 25.4% for caspofungin. Day 5 and 14 mycological eradication was 78.3% and 71.7% for rezafungin versus 59.7% and 65.7% for caspofungin, respectively. Median time to negative blood culture was 18 (interquartile range, 12.6-43.0) versus 38 (interquartile range, 15.9-211.3) h for rezafungin versus caspofungin (stratified log-rank P = 0.001; nominal, not adjusted for multiplicity). Candidaemia/IC-attributable deaths occurred in two rezafungin patients versus one caspofungin patient. Safety profiles were similar between groups. Overall, 17.4% (rezafungin) versus 29.9% (caspofungin) of patients discontinued due to treatment-emergent adverse events. Rezafungin exposure following the initial 400-mg dose was comparable between patients in the ICU at randomisation (n = 50) and non-ICU patients (n = 117).</p><p><strong>Conclusions: </strong>Rezafungin was well tolerated and efficacious in critically ill, mainly non-neutropenic patients with candidaemia and/or IC. This analysis provides additional insights into the efficacy and safety of rezafungin in the ICU population.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11520665/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142521263","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":"Clinical impact of the implementation of monocyte distribution width (MDW) measurement on time to anti-infective administration in sepsis patients in the emergency department: a before/after cohort study.","authors":"Marta Cancella de Abreu, Timothé Sala, Enfel Houas, Ilaria Cherubini, Martin Larsen, Pierre Hausfater","doi":"10.1186/s13054-024-05141-5","DOIUrl":"10.1186/s13054-024-05141-5","url":null,"abstract":"<p><strong>Background: </strong>Timely recognition of sepsis in emergency department (ED) is challenging. We evaluated the impact of implementing the biomarker monocyte distribution width (MDW) at bedside, on the time to anti-infective administration.</p><p><strong>Methods: </strong>We conducted a before-and-after cohort study in the ED of an academic hospital in Paris, to compare sepsis patients care and outcomes, before and after the implementation of point of care (POC) MDW measurement in the ED. During post-implementation period (period-2), MDW was measured with complete blood count by ED nurses with results given in 2 min: if above 21.5 units, ED physicians were asked to consider sepsis and to start an anti-infectious as soon as possible. Primary endpoint was time to anti-infectious administration (TTA) from ED arrival, and secondary endpoints were TTA from sepsis onset (TTAS), length of stay, mortality, and hospitalization rates.</p><p><strong>Results: </strong>In total, 255 patients (period-1) and 180 patients (period-2) with sepsis were included. The TTA was 5.4 h (3.5-7.7) period-1 and 4.9 h (IQR 2.5-7.1) in period-2 (p = 0.06). MDW implementation significantly reduced the median TTAS from to 3.7 h (IQR 1.5-5.8) in period-1, to 2.2 h (IQR 0.5-4.5) in period-2 (p < 0.001). Mortality rates remained similar between the two periods (18% vs. 16% respectively, p = 0.4), as did hospitalization rates (93% vs. 91%, p = 0.4) and ED length of stay (7.2 h (5.3-9.8) vs 7.0 (5.4-9.4), p = 0.7).</p><p><strong>Conclusion: </strong>Implementing POC MDW measurement in the ED protocols enhances the timeliness of anti-infective administration from sepsis onset, meeting current sepsis management guidelines.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11514793/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496577","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":"Self-confidence as a mediator in the relationship between executive functioning and depression among ICU survivors: a latent variable analysis","authors":"Elias Johannesson, Johan Malmgren","doi":"10.1186/s13054-024-05136-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05136-2","url":null,"abstract":"Executive dysfunction and depression are common among ICU survivors, yet the mechanisms linking these two factors remain poorly understood. Self-confidence has been implicated as a key mediator in the relationship between cognitive impairments and mental health outcomes. This study aimed to explore the mediating role of self-confidence in the association between executive functioning and depression in ICU survivors. A provisional questionnaire was used in a cross-sectional study to assess quality of life in 395 adult ICU survivors, each with a minimum 72-h stay at one of three ICUs at a Swedish university hospital, six months to three years post-discharge. Responses to questions on executive function, self-confidence, and depression were analysed. Structural equation modelling and confirmatory factor analysis were employed to examine the mediating effect of self-confidence on the relationship between executive function and depression. Model fit was evaluated using established indicators. Reliability of the measures was assessed using McDonald’s Omega and Cronbach’s Alpha. A significant positive correlation was found between depressive symptoms and both diminished self-confidence (r = 0.80, p < 0.001) and poorer executive function (r = 0.55, p < 0.001). Additionally, a correlation was observed between reduced self-confidence and compromised executive function (r = 0.62, p < 0.001). Age was negatively associated with depression, self-confidence, and executive function, while male gender was positively correlated with higher self-confidence. Mediation analysis revealed that the effect of impaired executive function on depressive symptoms was fully mediated by diminished self-confidence (B = 0.45; 95% CI 0.34–0.59). The direct effect of executive function on depression became non-significant when self-confidence was included in the model (B = 0.07, p = 0.18), suggesting complete mediation. The overall model fit was satisfactory (CFI = 0.962; RMSEA = 0.075), highlighting the robustness of the mediation pathway. Self-confidence mediates the relationship between executive function and depression among ICU survivors. Interventions aimed at enhancing self-confidence could mitigate depressive symptoms in the ICU survivor population. Longitudinal studies are needed to confirm these findings and further explore the causal pathways involved. Trial registration ClinicalTrials.gov Ref# NCT02767180; Registered 28 April 2016.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142490498","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":"Impact of low dose inhaled nitric oxide treatment in spontaneously breathing and intubated COVID-19 patients: a retrospective propensity-matched study","authors":"Shahin Isha, Prasanth Balasubramanian, Abby J. Hanson, Sadhana Jonna, Lekhya Raavi, Subekshya Khadka, Ananya Vasudhar, Jorge Sinclair De Frias, Anna Jenkins, Arvind Balavenkataraman, Aysun Tekin, Vikas Bansal, Swetha Reddy, Sean M. Caples, Syed Anjum Khan, Nitesh K. Jain, Abigail T. LaNou, Rahul Kashyap, Rodrigo Cartin-Ceba, Ricardo Diaz Milian, Carla P. Venegas, Anna B. Shapiro, Anirban Bhattacharyya, Sanjay Chaudhary, Sean P. Kiley, Quintin J. Quinones, Neal M. Patel, Pramod K. Guru, Pablo Moreno Franco, Devang K. Sanghavi","doi":"10.1186/s13054-024-05093-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05093-w","url":null,"abstract":"The benefit of Inhaled nitric oxide (iNO) therapy in the setting of COVID-19-related ARDS is obscure. We performed a multicenter retrospective study to evaluate the impact of iNO on patients with COVID-19 who require respiratory support. This retrospective multicenter study included COVID-19 patients enrolled in the SCCM VIRUS COVID-19 registry who were admitted to different Mayo Clinic sites between March 2020 and June 2022 and required high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV). Patients were included in the ‘spontaneously breathing’ group if they remained non-intubated or were initiated on an HFNC (± NIV) before intubation. Patients who got intubated without prior use of an HFNC (± NIV) were included in the ‘intubated group.’ They were further divided into categories based on their iNO usage. Propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) were performed to examine outcomes. Among 2767 patients included in our analysis, 1879 belonged to spontaneously breathing (153 received iNO), and 888 belonged to the intubated group (193 received iNO). There was a consistent improvement in FiO2 requirement, P/F ratio, and respiratory rate within 48 h of iNO use among both spontaneously breathing and intubated groups. However, there was no significant difference in intubation risk with iNO use among spontaneously breathing patients (PSM OR 1.08, CI 0.71–1.65; IPTW OR 1.10, CI 0.90–1.33). In a time-to-event analysis using Cox proportional hazard model, spontaneously breathing patients initiated on iNO had a lower hazard ratio of in-hospital mortality (PSM HR 0.49, CI 0.32–0.75, IPTW HR 0.40, 95% CI 0.26–0.62) but intubated patients did not (PSM HR: 0.90; CI 0.66–1.24, IPTW HR 0.98, 95% CI 0.73–1.31). iNO use was associated with longer in-hospital stays, ICU stays, ventilation duration, and a higher incidence of creatinine rise. This retrospective propensity-score matched study showed that spontaneously breathing COVID-19 patients on HFNC/ NIV support had a decreased in-hospital mortality risk with iNO use in a time-to-event analysis. Both intubated and spontaneously breathing patients had improvement in oxygenation parameters with iNO therapy but were associated with longer in-hospital stays, ICU stays, ventilation duration, and higher incidence of creatinine rise.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142490501","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":"Identification of novel sub-phenotypes of severe ARDS requiring ECMO using latent class analysis","authors":"Mitsuaki Nishikimi, Shinichiro Ohshimo, Giacomo Bellani, Wataru Fukumoto, Tatsuhiko Anzai, Keibun Liu, Junki Ishii, Michihito Kyo, Kazuo Awai, Kunihiko Takahashi, Nobuaki Shime","doi":"10.1186/s13054-024-05143-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05143-3","url":null,"abstract":"Sub-phenotyping of acute respiratory distress syndrome (ARDS) could be useful for evaluating the severity of ARDS or predicting its responsiveness to given therapeutic strategies, but no studies have yet investigated the heterogeneity of patients with severe ARDS requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). We conducted this retrospective multicenter observational study in adult patients with severe ARDS treated by V-V ECMO. We performed latent class analysis (LCA) for identifying sub-phenotypes of severe ARDS based on the radiological and clinical findings at the start of ECMO support. Multivariate Cox regression analysis was conducted to investigate the differences in mortality and association between the PEEP setting of ≥ 10 cmH2O and mortality by the sub-phenotypes. We identified three sub-phenotypes from analysis of the data of a total of 544 patients with severe ARDS treated by V-V ECMO, as follows: Dry type (n = 185; 34%); Wet type (n = 169; 31%); and Fibrotic type (n = 190; 35%). The 90-days in-hospital mortality risk was higher in the patients with the Fibrotic type than in those with the Dry type (adjusted hazard ratio [95% confidence interval] 1.75 [1.10–2.79], p = 0.019) or the Wet type (1.50 [1.02–2.23], p = 0.042). The PEEP setting of ≥ 10 cmH2O during the first 3 days of ECMO decreased the 90-days in-hospital mortality risk only in patients with the Wet type, and not in those with the Dry or Fibrotic type. A significant interaction effect was observed between the Wet type and the PEEP setting of ≥ 10 cmH2O in relation to the 90-day in-hospital mortality (pinteraction = 0.036). The three sub-phenotypes showed different mortality rates and different relationships between higher PEEP settings in the early phase of V-V ECMO and patient outcomes. Our data suggest that we may need to change our management approach to patients with severe ARDS during V-V ECMO according to their clinical sub-phenotype.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142488813","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":"Incidence, predictability, and outcomes of systemic venous congestion following a fluid challenge in initially fluid-tolerant preload-responders after cardiac surgery: a pilot trial","authors":"Bianca Morosanu, Cosmin Balan, Cristian Boros, Federico Dazzi, Adrian Wong, Francesco Corradi, Serban-Ion Bubenek-Turconi","doi":"10.1186/s13054-024-05124-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05124-6","url":null,"abstract":"Fluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes. This single-center, prospective, observational study (May 2023–July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer’s Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS). 45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001). Post-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications. Trial Registration: NCT06440772. Registered 30 May 2024. Retrospectively registered.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142486861","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":"An update on the mechanical versus manual cardiopulmonary resuscitation in cardiac arrest patients","authors":"Ayman El-Menyar, Mashhood Naduvilekandy","doi":"10.1186/s13054-024-05131-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05131-7","url":null,"abstract":"&lt;p&gt;The cardiopulmonary resuscitation (CPR) technique and its outcome remains a debate. In response to Zhao et al.'s [1] regarding the inclusion of duplicated studies in the meta-analysis [2], we have conducted a thorough review of the two studies published by Ong et al. (2012) and Casner et al. (2005). After that, we removed these two studies, along with an additional data point from Halperin et al. (1993), which exhibited high variance and did not meet the variance thresholds set for our updated analysis, and then we performed a revised meta-analysis to maintain consistency. Despite these changes, the results remained consistent, with an (Odds Ratio (OR) of 1.11; 95% CI 0.99–1.22) (Fig. 1). Thus, our original umbrella review findings [2] and Zhao et al.'s analysis showed that mechanical CPR was not superior to manual CPR in achieving the return of spontaneous circulation (ROSC).&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05131-7/MediaObjects/13054_2024_5131_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"525\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05131-7/MediaObjects/13054_2024_5131_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;Revised Forest plot of pooled odds ratio for ROSC of studies included in the Umbrella review after removing the duplicate and a study with a high variance&lt;/p&gt;&lt;span&gt;Full size image&lt;/span&gt;&lt;svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"&gt;&lt;use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"&gt;&lt;/use&gt;&lt;/svg&gt;&lt;/figure&gt;&lt;p&gt;We respectfully disagree with Zhao et al. second point regarding the inclusion of Axelson et al. (2013) and Jennings et al. (2012) in the meta-analysis. A few relevant data required for our analysis were obtained from the already published systematic review (SR) by Sheraton et al. (2021) [3]. The ROSC-related ORs were extracted from the second graph of the Sheraton et al. meta-analysis [3]. It is also worth noting that Zhao et al. [1] included a study published by Hallstrom et al. (2006) [4], even though this study did not explicitly mention ROSC as an outcome in the original work.&lt;/p&gt;&lt;p&gt;We agree that data derived solely from abstracts can affect the robustness of outcomes; therefore, we intended to gather and synthesize as much data as possible from the published SRs and not from individual studies or abstracts for the umbrella review [2]. However, for the umbrella meta-analysis, data from 3 abstracts (Lairet et al. (2005), Paradis et al. (2009), and Morozov et al. (2012)) were used. The ORs from these abstracts were extracted from a meta-analysis published by Bonnes et al. (2016) and their illustrations [5]. Thus, in this letter, we recalculated the ORs after removing data gathered from abstracts or did","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142486860","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":"Comparison of electrical impedance tomography, blood gas analysis, and respiratory mechanics for positive end-expiratory pressure titration","authors":"Han Chen, Takeshi Yoshida, Jian-Xin Zhou","doi":"10.1186/s13054-024-05137-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05137-1","url":null,"abstract":"&lt;p&gt;&lt;b&gt;To the Editor&lt;/b&gt;&lt;/p&gt;&lt;p&gt;Electrical impedance tomography (EIT) is increasingly utilized for tailoring positive end-expiratory pressure (PEEP). By non-invasively assessing lung collapse and over-distention [1], EIT helps adjust PEEP to minimize both conditions, assuming they are equally harmful. The EIT-guided PEEP selection approach may potentially provide more lung protection by reducing mechanical power [2].&lt;/p&gt;&lt;p&gt;Although the balance between over-distension and collapse may help individualize PEEP titration, the requirement for specialized EIT equipment limits its widespread application. Furthermore, EIT focuses on morphology without considering PEEP's impact on hemodynamics and ventilation-perfusion matching. Alternatively, PEEP can be titrated by calculating intrapulmonary shunt (Qs/Qt) and dead space (Vd/Vt) using blood gases [3]. High alveolar pressure can cause both lung over-distension (high stress and strain) and pulmonary capillary collapse and subsequently impaired CO&lt;sub&gt;2&lt;/sub&gt; elimination (namely functional over-distension). However, whether the calculated Vd/Vt and Qs/Qt are consistent with EIT-derived over-distension and collapse is unclear. In this pilot study, we attempted to compare these PEEP selection approaches.&lt;/p&gt;&lt;p&gt;The experiment protocol was approved by the Animal Care Committee of Fujian Provincial Hospital. The animals were treated in compliance with the hospital's guidelines for the care and utilization of laboratory animals.&lt;/p&gt;&lt;h3&gt;Preparation and measurements&lt;/h3&gt;&lt;p&gt;Eight male Bama miniatured pigs (weight 40.1 to 58.0 kg) were anesthetized with 10 mg·kg&lt;sup&gt;–1&lt;/sup&gt;·h&lt;sup&gt;–1&lt;/sup&gt; pentobarbital. Rocuronium bromide boluses of 0.5 mg·kg&lt;sup&gt;–1&lt;/sup&gt; were administered as needed to suppress spontaneous breathing. After tracheotomy, mechanical ventilation was initiated. A catheter in the right carotid artery enabled blood pressure monitoring and gas sampling. A Swan-Ganz catheter, inserted via the internal jugular vein, facilitated mixed venous blood sampling and hemodynamic measurements. Mixed expired CO&lt;sub&gt;2&lt;/sub&gt; (PeCO&lt;sub&gt;2&lt;/sub&gt;) was measured via a mainstream PeCO&lt;sub&gt;2&lt;/sub&gt; module. Vital signs and cardiac output (via thermodilution) were monitored. Collapse and over-distension were determined using EIT (PulmoVista 500, Dräger, Germany) at the 4th–5th intercostal space, with thresholds previously reported [1].&lt;/p&gt;&lt;h3&gt;Experiment protocol&lt;/h3&gt;&lt;p&gt;Lung injury was induced using a 'two-hits' model: surfactant depletion and injurious ventilation [4]. Saline lung lavage (30 ml·kg-1) was repeated until PaO&lt;sub&gt;2&lt;/sub&gt;/FiO&lt;sub&gt;2&lt;/sub&gt; &lt; 100 mmHg for 10 min at PEEP 5 cmH&lt;sub&gt;2&lt;/sub&gt;O, followed by injurious ventilation for 60 min, with driving pressure/PEEP adjusted every 15 min [4].&lt;/p&gt;&lt;p&gt;After lung recruitment, a decremental PEEP trial (20 to 4 cmH&lt;sub&gt;2&lt;/sub&gt;O, 2 cmH&lt;sub&gt;2&lt;/sub&gt;O steps) was conducted. Static compliance, cardiac output, and blood gases were measured at each PEEP level. EIT data were continuously re","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142487215","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":"A plea for enhanced monitoring of depth of sedation in patients who are intubated and ventilated","authors":"Stefano Romagnoli, Basil Matta, Brian E. Driver, Lisbeth Evered","doi":"10.1186/s13054-024-05105-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05105-9","url":null,"abstract":"&lt;p&gt;Awareness with recall during surgery and anesthesia occurs when the hypnotic and amnesic components of a general anesthetic fail to sustain disconnected consciousness and ablate memory. This is a rare yet significant complication that occurs in a small percentage (0.1–0.2%) of patients undergoing surgery under general anaesthesia [1]. This phenomenon involves the vivid recollection of sensory experiences during surgery, which can lead to posttraumatic stress disorders. The risk of being aware under general anaesthesia in highest in those patients who are administered muscle relaxants without sufficient hypnotics as they are unable to communicate due to paralysis. This event is frequently associated with a number of dramatic feelings (e.g., patients thinking “they were going to die,” sensations of fear and terror, feelings of being unsafe and abandoned or betrayed by doctors and nurses, and pain on being mechanically ventilated).&lt;/p&gt;&lt;p&gt;An unexpected number of patients suffer awareness after emergency tracheal intubation. Recent research, including a meta-analysis of randomized or nonrandomized studies (&lt;i&gt;n&lt;/i&gt; = 941 patients)[2] revealed that an overall estimate of 12.3% of patients who receive a neuromuscular blocking agent for muscle relaxation before tracheal intubation and during mechanical ventilation in the emergency department (ED) might recover consciousness and encode memories of the intubation manoeuvre, mechanical ventilation, a bronchoscopy, or a combination of these and other painful procedures [2,3,4,5]. This occurrence could be underestimated due to factors like patient mortality before extubation, memory loss, or neurological deficits. This concerning incidence of conscious paralysis may result from a combination of factors that include the urgent nature of critical patient conditions, intubation before optimal hypnotic effects, anesthetic under-dosing to avoid hemodynamic collapse, and the lack of sedation-protocolized monitoring during invasive mechanical ventilation. Notably, patients’ pharmacogenomics, pharmacokinetics, and pharmacodynamics vary significantly, complicating the dosage-effect relationship of hypnotics and muscle relaxants [6] and clinical sedation assessments before intubation may not guarantee continued unconsciousness due to the complex interplay between hypnotics and painful stimuli.&lt;/p&gt;&lt;p&gt;While adjusting sedative dosages seems logical, it can be challenging in critically ill, paralyzed patients. Hemodynamic vital signs are often used as proxies for sedation, but they lack precision. Heart rate and blood pressure are unreliable for determining unconsciousness or the degree of sedation or anesthetic depth.&lt;/p&gt;&lt;p&gt;The development and the diffusion of depth-of-anesthesia monitors (DOA) has made intraoperative electroencephalography (EEG) more accessible and practical for detecting excessive light anesthesia, thus reducing the risk of intraoperative awareness. Modern DOA monitors help the physician with the com","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142487234","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":"High-cost users after sepsis: a population-based observational cohort study","authors":"Kali A. Barrett, Fatima Sheikh, Victoria Chechulina, Hannah Chung, Peter Dodek, Laura Rosella, Kednapa Thavorn, Damon C. Scales","doi":"10.1186/s13054-024-05108-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05108-6","url":null,"abstract":"High-cost users (HCU) represent important targets for health policy interventions. Sepsis is a life-threatening syndrome that is associated with high morbidity, mortality, and economic costs to the healthcare system. We sought to estimate the effect of sepsis on being a subsequent HCU. Using linked health-administrative databases, we conducted a population-based, propensity score-weighted cohort study of adults who survived a hospitalization in Ontario, Canada between January 2016 and December 2017. Sepsis was identified using a validated algorithm. The primary outcome was being a persistent HCU after hospital discharge (in the top 5% or 1% of total health care spending for 90 consecutive days), and the proportion of follow-up time since discharge as a HCU. We identified 927,057 hospitalized individuals, of whom 79,065 had sepsis. Individuals who had sepsis were more likely to be a top 5% HCU for 90 consecutive days at any time after discharge compared to those without sepsis (OR 2.24; 95% confidence interval [CI] 2.04–2.46) and spent on average 42.3% of their follow up time as a top 5% HCU compared to 28.9% of time among those without sepsis (RR 1.46; 95% CI 1.45–1.48). Individuals with sepsis were more likely to be a top 1% HCU for 90 consecutive days compared to those without sepsis (10% versus 5.1%, OR 2.05 [95% CI 1.99–2.11]), and spent more time as a top 1% HCU (18.5% of time versus 10.8% of time, RR 1.68 [95% CI 1.65–1.70]). The sequelae of sepsis result in higher healthcare costs with important economic implications. After discharge, individuals who experienced sepsis are more likely to be a HCU and spend more time as a HCU compared to individuals who did not experience sepsis during hospitalization.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142452189","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}