Critical Care最新文献

{"title":"Atelectrauma can be avoided if expiration is sufficiently brief: evidence from inverse modeling and oscillometry during airway pressure release ventilation","authors":"Jason H. T. Bates, David W. Kaczka, Michaela Kollisch-Singule, Gary F. Nieman, Donald P. Gaver","doi":"10.1186/s13054-024-05112-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05112-w","url":null,"abstract":"Airway pressure release ventilation (APRV) has been shown to be protective against atelectrauma if expirations are brief. We hypothesize that this is protective because epithelial surfaces are not given enough time to come together and adhere during expiration, thereby avoiding their highly damaging forced separation during inspiration. We investigated this hypothesis in a porcine model of ARDS induced by Tween lavage. Animals were ventilated with APRV in 4 groups based on whether inspiratory pressure was 28 or 40 cmH2O, and whether expiration was terminated when end-expiratory flow reached either 75% (a shorter expiration) or 25% (a longer expiration) of its initial peak value. A mathematical model of respiratory system mechanics that included a volume-dependent elastance term characterized by the parameter $${E}_{2}$$ was fit to airway pressure-flow data obtained each hour for 6 h post-Tween injury during both expiration and inspiration. We also measured respiratory system impedance between 5 and 19 Hz continuously through inspiration at the same time points from which we derived a time-course for respiratory system resistance ( $${R}_{rs}$$ ). $${E}_{2}$$ during both expiration and inspiration was significantly different between the two longer expiration versus the two shorter expiration groups (ANOVA, p < 0.001). We found that $${E}_{2}$$ was most depressed during inspiration in the higher-pressure group receiving the longer expiration, suggesting that $${E}_{2}$$ reflects a balance between strain stiffening of the lung parenchyma and ongoing recruitment as lung volume increases. We also found in this group that $${R}_{rs}$$ increased progressively during the first 0.5 s of inspiration and then began to decrease again as inspiration continued, which we interpret as corresponding to the point when continuing derecruitment was reversed by progressive lung inflation. These findings support the hypothesis that sufficiently short expiratory durations protect against atelectrauma because they do not give derecruitment enough time to manifest. This suggests a means for the personalized adjustment of mechanical ventilation.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142385151","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":"Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies","authors":"Michael Beshara, Edward A. Bittner, Alberto Goffi, Lorenzo Berra, Marvin G. Chang","doi":"10.1186/s13054-024-05102-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05102-y","url":null,"abstract":"Point of Care ultrasound (POCUS) of the lungs, also known as lung ultrasound (LUS), has emerged as a technique that allows for the diagnosis of many respiratory pathologies with greater accuracy and speed compared to conventional techniques such as chest x-ray and auscultation. The goal of this narrative review is to provide a simple and practical approach to LUS for critical care, pulmonary, and anesthesia providers, as well as respiratory therapists and other health care providers to be able to implement this technique into their clinical practice. In this review, we will discuss the basic physics of LUS, provide a hands-on scanning technique, describe LUS findings seen in normal and pathological conditions (such as mainstem intubation, pneumothorax, atelectasis, pneumonia, aspiration, COPD exacerbation, cardiogenic pulmonary edema, ARDS, and pleural effusion) and also review the training necessary to achieve competence in LUS.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142384156","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":"Correction to: Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines","authors":"Sung‑Min Cho, Jaeho Hwang, Giovanni Chiarini, Marwa Amer, Marta V. Antonini, Nicholas Barrett, Jan Belohlavek, Daniel Brodie, Heidi J. Dalton, Rodrigo Diaz, Alyaa Elhazmi, Pouya Tahsili‑Fahadan, Jonathon Fanning, John Fraser, Aparna Hoskote, Jae‑Seung Jung, Christopher Lotz, Graeme MacLaren, Giles Peek, Angelo Polito, Jan Pudil, Lakshmi Raman, Kollengode Ramanathan, Dinis Dos Reis Miranda, Daniel Rob, Leonardo Salazar Rojas, Fabio Silvio Taccone, Glenn Whitman, Akram M. Zaaqoq, Roberto Lorusso","doi":"10.1186/s13054-024-05107-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05107-7","url":null,"abstract":"&lt;p&gt;&lt;b&gt;Correction to&lt;/b&gt;&lt;b&gt;: &lt;/b&gt;&lt;b&gt;Critical Care (2024) 28:296 &lt;/b&gt;&lt;b&gt;https://doi.org/10.1186/s13054-024-05082-z&lt;/b&gt;&lt;/p&gt;&lt;p&gt;Following publication of the original article [1], the authors identified an error that it lacked the statement: This article has been co-published with permission in &lt;i&gt;Critical Care&lt;/i&gt; and the &lt;i&gt;ASAIO Journal&lt;/i&gt;.&lt;/p&gt;&lt;p&gt;The statement has been indicated in this correction article.&lt;/p&gt;&lt;ol data-track-component=\"outbound reference\" data-track-context=\"references section\"&gt;&lt;li data-counter=\"1.\"&gt;&lt;p&gt;Cho SM, Hwang J, Chiarini G, et al. Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines. Crit Care. 2024;28:296. https://doi.org/10.1186/s13054-024-05082-z.&lt;/p&gt;&lt;p&gt;Article PubMed PubMed Central Google Scholar &lt;/p&gt;&lt;/li&gt;&lt;/ol&gt;&lt;p&gt;Download references&lt;svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"&gt;&lt;use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"&gt;&lt;/use&gt;&lt;/svg&gt;&lt;/p&gt;&lt;span&gt;Author notes&lt;/span&gt;&lt;ol&gt;&lt;li&gt;&lt;p&gt;Akram M. Zaaqoq and Roberto Lorusso have contributed equally as senior authors.&lt;/p&gt;&lt;/li&gt;&lt;/ol&gt;&lt;h3&gt;Authors and Affiliations&lt;/h3&gt;&lt;ol&gt;&lt;li&gt;&lt;p&gt;Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA&lt;/p&gt;&lt;p&gt;Sung‑Min Cho, Jaeho Hwang &amp; Pouya Tahsili‑Fahadan&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA&lt;/p&gt;&lt;p&gt;Sung‑Min Cho &amp; Glenn Whitman&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands&lt;/p&gt;&lt;p&gt;Giovanni Chiarini &amp; Roberto Lorusso&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Division of Anaesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy&lt;/p&gt;&lt;p&gt;Giovanni Chiarini&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, 11564 Al Mathar Ash Shamali, Riyadh, Saudi Arabia&lt;/p&gt;&lt;p&gt;Marwa Amer &amp; Alyaa Elhazmi&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Alfaisal University College of Medicine, Riyadh, Saudi Arabia&lt;/p&gt;&lt;p&gt;Marwa Amer &amp; Alyaa Elhazmi&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Bufalini Hospital, AUSL Della Romagna, Cesena, Italy&lt;/p&gt;&lt;p&gt;Marta V. Antonini&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Department of Critical Care Medicine, Guy’s and St Thomas’ National Health Service Foundation Trust, London, UK&lt;/p&gt;&lt;p&gt;Nicholas Barrett&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;2nd Department of Medicine, Cardiology and Angiologiy, General University Hospital and 1St School of Medicine, Charles University, Prague, Czech Republic&lt;/p&gt;&lt;p&gt;Jan Belohlavek &amp; Daniel Rob&lt;/p&gt;&lt;/li&gt;&lt;li&gt;&lt;p&gt;Division of Pulmonary, and Critical Care Medicine, Department of Medicine, The Johns Hopkins Univers","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142383839","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":"Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ∆P_ES in ventilated children.","authors":"Meryl Vedrenne-Cloquet, Y Ito, J Hotz, M J Klein, M Herrera, D Chang, A K Bhalla, C J L Newth, R G Khemani","doi":"10.1186/s13054-024-05103-x","DOIUrl":"10.1186/s13054-024-05103-x","url":null,"abstract":"<p><strong>Background: </strong>Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆P_ES) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆P_ES in children. We sought to identify risk factors for P0.1 over or underestimating ∆P_ES in ventilated children.</p><p><strong>Methods: </strong>Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆P_ES (∆P_ES-REAL), P0.1 and predicted ∆P_ES (∆P_ES-PRED = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆P_ES-REAL and ∆P_ES-PRED were aligned (low, normal, and high effort and drive), two where ∆P_ES-REAL and ∆P_ES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes.</p><p><strong>Results: </strong>We analyzed 953 patient days (222 patients). ∆P_ES-REAL and ∆P_ES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017).</p><p><strong>Conclusions: </strong>In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome.</p><p><strong>Trial registration: </strong>NCT03266016; August 23, 2017.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11453010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142375276","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":"A narrative review on antimicrobial dosing in adult critically ill patients on extracorporeal membrane oxygenation.","authors":"Myeongji Kim, Maryam Mahmood, Lynn L Estes, John W Wilson, Nathaniel J Martin, Joseph E Marcus, Ankit Mittal, Casey R O'Connell, Aditya Shah","doi":"10.1186/s13054-024-05101-z","DOIUrl":"10.1186/s13054-024-05101-z","url":null,"abstract":"<p><p>The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11453026/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142375275","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":"Polymyxin-containing regimens for treating of pneumonia caused by multidrug-resistant gram-negative bacteria: Mind the breakpoints and the standardization of nebulization therapy","authors":"Lihui Wang, Chunhui Xu, Lining Si, Guifen Gan, Bin Lin, Yuetian Yu","doi":"10.1186/s13054-024-05111-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05111-x","url":null,"abstract":"&lt;p&gt;With great interest we read the recent network meta-analysis by Zhou et al. which found that the intravenous plus inhaled polymyxin-containing regimen could reduce the all-cause mortality of patients with pneumonia caused by multidrug-resistant gram-negative bacterial (MDRGNB) [1]. This is undoubtedly an encouraging result and provides evidence for the subsequent clinical implementation of such regimens. However, there are still some issues that need further attention.&lt;/p&gt;&lt;p&gt;Pneumonia caused by MDRGNB remains a huge challenge in the intensive care unit (ICU). Currently, the available effective antibiotics are limited, and polymyxins are still the cornerstones for treatment. However, with the introduction of new antibiotics into clinical practice (especially new beta-lactam and beta-lactamase inhibitor combination) and the potential renal toxicity of polymyxins, since 2020, the performance standards for antimicrobial susceptibility testing of the Clinical and Laboratory Standards Institute (CLSI) have canceled the susceptibility breakpoints of polymyxins for &lt;i&gt;Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii&lt;/i&gt;. It defines a minimal inhibitory concentration (MIC) of ≤ 2 ug/mL as intermediate (https://clsi.org). At present, the newly available antibiotics for the treatment of MDRGNB pneumonia in China is limited. Therefore, Chinese Medical Association (CMA) still define MIC ≤ 2 ug/mL as susceptible according to the previous versions of CLSI before 2020 or the 10th version of European Committee on Antimicrobial Susceptibility Testing (EUCAST), to guide clinical treatment. The international approved and recognized method for susceptibility testing of polymyxins is broth microdilution (BMD), but its manual operation is complex and time-consuming, making it difficult for laboratories to routinely carry out. Thus, most laboratories still use automated or semi-automated instruments nowadays to detect the susceptibility, and the accuracy of the results still needs further evaluation.&lt;/p&gt;&lt;p&gt;In addition, the clinical pharmacokinetic/pharmacodynamic (PK/PD) target of polymyxins for efficacy is unclear [2]. Some guidelines recommended that for polymyxin B the AUC&lt;sub&gt;ss,24h&lt;/sub&gt; should be about 50 mg h/L and possibly 50–100 mg h/L, with the latter corresponding to an average steady-state concentration across 24 h (C&lt;sub&gt;ss,avg&lt;/sub&gt;) of 2–4 ug/mL for pathogens with MIC of ≤ 2 ug/mL [3]. Therefore, careful interpretation is needed for the susceptible judgment of polymyxins, the optimal PK/PD index, and the effectiveness of antibiotic therapy.&lt;/p&gt;&lt;p&gt;The presence of the blood-alveolar barrier prevents satisfactory concentrations of antibiotics in the epithelial lining fluid (ELF) when antibiotics are administered intravenously, and increasing the dosage of intravenous administration may lead to high rate of side effects such as acute kidney injury. Nebulization therapy can convert liquid antibiotic preparations into particles of 3–5 ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374095","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":"What criteria for neuropronostication: consciousness or ability? The neuro-intensivist’s dilemma","authors":"Nicolas Engrand, Armelle Nicolas-Robin, Pierre Trouiller, Stéphane Welschbillig","doi":"10.1186/s13054-024-05098-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05098-5","url":null,"abstract":"&lt;p&gt;Rohaut et al. published the results of a remarkable 12-year evolutionary project, showing a positive association between substantial improvement in consciousness 1 month after brain injury and a favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] score ≥ 4) 1 year later, with an odds ratio of 14.6 [1]. This is a major new finding on neuropronostication, a fundamental issue in neurocritical care.&lt;/p&gt;&lt;p&gt;The multimodal assessment (MMA) based on seven objective criteria, combined with a critical reading by a panel of experts (the “DoC team”) comprising neuro-intensivists, neurologists, neurophysiologists, neuroradiologists and neuroscientists, allowed for predicting GOS-E score 1–3 at 1 year with 100% accuracy in the group with predicted poor prognosis. Assuming that the aim of the MMA is to give a chance for neurological recovery to every patient with a capacity for recovery, these results are highly effective. This also means that at 1 month after brain injury, when the MMA and DoC team predicted a poor 1-year prognosis, they were right. So, the first important lesson for neuro-intensivists is that they can withhold or even withdraw life-sustaining therapies according to this result, without compromising a significant chance of neurological recovery, sparing the patient 1 year of invasive care and rehabilitation.&lt;/p&gt;&lt;p&gt;However, only 39% of the group with predicted good prognosis achieved a GOS-E score ≥ 4 (excluding withdrawal of life-sustaining therapies and unknown decisions). Similarly, only 24% of patients in the group with an uncertain prognosis achieved this good result. Therefore, the MMA’s prediction of an uncertain or favorable outcome exposed the patient to the risk of continuing treatment inappropriately, thus leading to a large number of disabilities and dependencies. In other words, there were very few early “good-prognosis patients,” and even after the MMA, 83% of the 277 patients had a GOS-E score &lt; 4. So, although increasing the number of modalities improved accuracy, the MMA still remained not able to reliably detect long-term ability.&lt;/p&gt;&lt;p&gt;These results raise the question of the goal of neurocritical care.&lt;/p&gt;&lt;p&gt;Although it is known that all patients ultimately recover wakefulness after severe brain injury [2] and many even recover substantial consciousness [3], some will never regain the ability to interact with their environment. These latter conditions, classified as unresponsive wakefulness syndrome or vegetative state without consciousness, are widely considered failure of care. However, what about a conscious but highly dependent patient with modified Rankin Scale (mRS) score 4 or 5 or GOS-E score 4 or 3? In neurovascular studies, an mRS score of 4 (often even 3) is considered failure. For example, this score is considered an outcome to be avoided in decompressive craniectomy studies [4] (with the exception of the recent Switch study [5]) but considered a success in studies of consciousness recovery [6].&lt;/p&gt;&lt;p&gt;A","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142369448","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":"Consensus statements for the establishment of medical intensive care in low-resource settings: international study using modified Delphi methodology.","authors":"Pedja Kovacevic, Jadranka Vidovic, Boris Tomic, Jihad Mallat, Ali Ait Hssain, Muyiwa Rotimi, Owoniya Temitope Akindele, Kent Doi, Rajesh Mishra, F Joachim Meyer, Ivan Palibrk, Ranko Skrbic, Enrique Boloña, Oguz Kilickaya, Ognjen Gajic","doi":"10.1186/s13054-024-05113-9","DOIUrl":"10.1186/s13054-024-05113-9","url":null,"abstract":"<p><strong>Background: </strong>The inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS.</p><p><strong>Methods: </strong>In December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement.</p><p><strong>Results: </strong>Out of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education.</p><p><strong>Conclusion: </strong>Delphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11451122/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142371201","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":"Derivation and validation of generalized sepsis-induced acute respiratory failure phenotypes among critically ill patients: a retrospective study.","authors":"Tilendra Choudhary, Pulakesh Upadhyaya, Carolyn M Davis, Philip Yang, Simon Tallowin, Felipe A Lisboa, Seth A Schobel, Craig M Coopersmith, Eric A Elster, Timothy G Buchman, Christopher J Dente, Rishikesan Kamaleswaran","doi":"10.1186/s13054-024-05061-4","DOIUrl":"10.1186/s13054-024-05061-4","url":null,"abstract":"<p><strong>Background: </strong>Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis, considering multi-organ dynamics. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate the generalizability of the derived phenotypes.</p><p><strong>Methods: </strong>We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥ 24 h. Data from two different high-volume academic hospital centers were used, where all phenotypes were derived in MICU of Hospital-I (N = 3225). The derived phenotypes were validated in MICU of Hospital-II (N = 848), SICU of Hospital-I (N = 1112), and SICU of Hospital-II (N = 465). Clinical data from 24 h preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts.</p><p><strong>Results: </strong>Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F = 123]), C (mild hypoxia [median P/F = 240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing the MICU of Hospital-II and SICUs from Hospital-I and -II. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p < 0.01) and consistent across MICU and SICU of both Hospital-I and -II. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy.</p><p><strong>Conclusion: </strong>The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11445942/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142361276","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":"Comparison of mechanical versus manual cardiopulmonary resuscitation in cardiac arrest","authors":"Yang Zhao, Da Chen, Qian Wang","doi":"10.1186/s13054-024-05088-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05088-7","url":null,"abstract":"&lt;p&gt;To the editor&lt;/p&gt;&lt;p&gt;We read with great interest the article by El-Menyar et al., titled “Mechanical versus manual cardiopulmonary resuscitation (CPR): an umbrella review of contemporary systematic reviews and more”, recently published in &lt;i&gt;Critical Care&lt;/i&gt; [1]. The findings from the umbrella review and the new systematic review in this study suggest that mechanical CPR is not superior to manual CPR in achieving return of spontaneous circulation (ROSC).&lt;/p&gt;&lt;p&gt;Although this article offers valuable insights, several issues warrant further discussion and clarification. In Fig. 2’s Forest plot for ROSC from El-Menyar et al.’s article, we observed some issues with the study selection. The umbrella meta-analysis included duplicated studies [2, 3] and studies with no ROSC-related data upon our detailed review [4, 5]. Additionally, the inclusion of just the abstracts from three studies [6, 7, 8] could potentially limit the robustness of the findings. Moreover, when replicating the authors’ search strategy, we identified a missing randomized controlled trial (RCT) comparing mechanical and manual CPR in in-hospital cardiac arrest (IHCA) settings [9].&lt;/p&gt;&lt;p&gt;We consolidated studies from the umbrella review and the new systematic review, excluding improperly included studies and adding the newly identified RCT. Using Stata Version 16.0 (StataCorp, College Station, TX), we conducted subgroup analyses for out-of-hospital cardiac arrest (OHCA) and IHCA patients across RCTs and non-RCTs. For OHCA patients, mechanical CPR did not improve ROSC rates in either study type. However, the IHCA outcomes varied by study type: RCTs showed a higher probability of ROSC with mechanical CPR, whereas non-RCTs indicated a reduced likelihood of achieving ROSC (Figs. 1 and 2)&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%2Fs13054-024-05088-7/MediaObjects/13054_2024_5088_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"631\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05088-7/MediaObjects/13054_2024_5088_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;Forest plot of ROSC in mechanical CPR versus manual CPR in RCTs. ROSC, return of spontaneous circulation; CPR, cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; IHCA, in-hospital cardiac arrest; RCT, randomized controlled trial; CI, confidence interval&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;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 2&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05088-7/MediaObjects/13054_2024_5088_Fig2_","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142325485","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}