Critical Care最新文献

{"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}

{"title":"How are Long-Covid, Post-Sepsis-Syndrome and Post-Intensive-Care-Syndrome related? A conceptional approach based on the current research literature","authors":"Carolin Fleischmann-Struzek, Franka E. A. Joost, Mathias W. Pletz, Björn Weiß, Nicolas Paul, E. Wesley Ely, Konrad Reinhart, Norman Rose","doi":"10.1186/s13054-024-05076-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05076-x","url":null,"abstract":"Long-Covid (LC), Post-Sepsis-Syndrome (PSS) and Post-Intensive-Care-Syndrome (PICS) show remarkable overlaps in their clinical presentation. Nevertheless, it is unclear if they are distinct syndromes, which may co-occur in the same patient, or if they are three different labels to describe similar symptoms, assigned on the basis on patient history and professional perspective of the treating physician. Therefore, we reviewed the current literature on the relation between LC, PSS and PICS. To date, the three syndromes cannot reliably be distinguished due similarities in clinical presentation as they share the cognitive, psychological and physical impairments with only different probabilities of occurrence and a heterogeneity in individual expression. The diagnosis is furthermore hindered by a lack of specific diagnostic tools. It can be concluded that survivors after COVID-19 sepsis likely have more frequent and more severe consequences than patients with milder COVID-19 courses, and that are some COVID-19-specific sequelae, e.g. an increased risk for venous thromboembolism in the 30 days after the acute disease, which occur less often after sepsis of other causes. Patients may profit from leveraging synergies from PICS, PSS and LC treatment as well as from experiences gained from infection-associated chronic conditions in general. Disentangling molecular pathomechanisms may enable future targeted therapies that go beyond symptomatic treatment.","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":"142100857","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":"Post-discharge functional outcomes in older patients with sepsis","authors":"Sanyu Ge, Ling Zha, Aiko Tanaka, Nobuhiro Narii, Yoshimitsu Shimomura, Masayo Komatsu, Sho Komukai, Fumiko Murata, Megumi Maeda, Kosuke Kiyohara, Tetsuhisa Kitamura, Haruhisa Fukuda","doi":"10.1186/s13054-024-05080-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05080-1","url":null,"abstract":"The post-discharge prognosis of patients with sepsis remains a crucial issue; however, few studies have investigated the relationship between pre-sepsis health status and subsequent prognosis in a large population. This study aimed to examine the effect of the pre-sepsis care needs level on changes in care needs and mortality in patients with sepsis 1 year post-discharge. This was a population-based retrospective cohort study including twelve municipalities in Japan that participated in the Longevity Improvement & Fair Evidence study between April 2014 and March 2022, with a total of 1,491,608 persons. The pre-hospitalization levels of care needs (baseline) were classified from low to high, as no care needs, support level and care needs level 1, care needs levels 2–3, and care needs levels 4–5 (fully dependent). The outcomes were changes in care needs level and mortality 1 year post-discharge, assessed by baseline care needs level using Cox proportional hazard models. The care needs levels of 17,648 patients analyzed at baseline were as follows: no care needs, 7982 (45.2%); support level and care needs level 1, 3736 (21.2%); care needs levels 2–3, 3089 (17.5%); and care needs levels 4–5, 2841 (16.1%). At 1 year post-discharge, the distribution of care needs were as follows: no care needs, 4791 (27.1%); support level and care needs level 1, 2390 (13.5%); care needs levels 2–3, 2629 (14.9%); care needs levels 4–5, 3373 (19.1%); and death, 4465 (25.3%). Patients with higher levels of care needs exhibited an increased association of all-cause mortality 1 year post-discharge after adjusting for confounders [hazard ratios and 95% confidence intervals: support level and care needs level 1, 1.05 (0.96, 1.15); care needs levels 2–3, 1.46 (1.33, 1.60); and care needs levels 4–5, 1.92 (1.75, 2.10); P for trend < 0.001]. Elevated care needs and mortality were observed in patients with sepsis within 1 year post-discharge. Older patients with sepsis and higher baseline levels of care needs had a high association of all-cause mortality 1 year post-discharge.","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":"142090174","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":"Baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study","authors":"Seung-Hun You, Moon Seong Baek, Tae Wan Kim, Sun-Young Jung, Won-Young Kim","doi":"10.1186/s13054-024-05063-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05063-2","url":null,"abstract":"&lt;p&gt;&lt;b&gt;Dear Editor,&lt;/b&gt;&lt;/p&gt;&lt;p&gt;No large-scale study has compared baricitinib with tocilizumab specifically for critical coronavirus disease 2019 (COVID-19). An exploratory trial that included patients with COVID-19 on mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO) demonstrated a marked reduction in 28-day mortality in the baricitinib group, although baricitinib was compared to placebo [1]. Most of the studies that have conducted head-to-head comparisons between baricitinib and tocilizumab in patients with severe COVID-19 had lower rates of disease severity (&lt; 5% on MV) [2]. Thus, which of the two drugs is more beneficial for patients with rapidly progressing inflammatory response is unclear. Additionally, most patients in previous studies were unvaccinated, thus limiting the stratified analysis according to vaccination status.&lt;/p&gt;&lt;p&gt;To address the current knowledge gaps, this study was performed as a large-scale analysis of Korean health insurance claims data to compare the efficacies of baricitinib versus tocilizumab in patients with COVID-19 receiving MV.&lt;/p&gt;&lt;p&gt;Adult patients (age ≥ 18 years) with confirmed COVID-19 admitted from October 8, 2020 to October 31, 2022, who required MV, were analyzed. Patients who received at least one dose of baricitinib or tocilizumab during the index hospitalization were assessed. The exclusion criteria were age &lt; 18 years, death or discharge within the first 2 days of hospitalization, cardiac arrest, palliative care, pregnancy or related conditions, and co-administration of baricitinib and tocilizumab. Propensity score (PS) matching was conducted to control for differences in the baseline variables of patients receiving either baricitinib or tocilizumab. For the PS model, baricitinib use was employed as the dependent variable, and the independent variables were all the baseline covariates listed in Table S1. Covariate balance before and after matching was evaluated by standardized mean differences, and a difference of &lt; 0.10 was considered well-balanced. Logistic regression analyses were performed to compute the odds ratios (ORs) and 95% confidence intervals (CIs) of the outcomes associated with baricitinib use. Subgroup analyses for the outcomes were performed according to age, sex, Charlson Comorbidity Index, neuromuscular blocking agents, renal replacement therapy, and ECMO. To determine the possible confounding by the COVID-19 vaccination, baseline and outcome analyses were stratified according to the vaccination status prior to admission. All statistical analyses were performed using SAS software (version 9.4; SAS Institute, Cary, NC, USA).&lt;/p&gt;&lt;p&gt;Among 1630 included patients (mean [standard deviation] age, 71.4 [12.8] years; men, 58.6%), PS matching resulted in 557 patients in each group (Fig. S1). No significant differences were observed in the baseline characteristics between the PS-matched groups (Table S1). For the unmatched and PS-matched groups, the median (interquar","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":"142100858","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":"Effect of therapeutic plasma exchange on antimicrobials in critically ill patients","authors":"Ugur Balaban, Emre Kara, Esat Kivanc Kaya, Osman Ilhami Ozcebe, Murat Akova, Arzu Topeli, Kaya Yorganci, Kutay Demirkan","doi":"10.1186/s13054-024-05077-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05077-w","url":null,"abstract":"<p>Dear Editor,</p><p>Therapeutic plasma exchange (TPE) is a procedure in which plasma is separated from the cellular components of whole blood by various methods. The removed plasma is replaced with albumin or fresh frozen plasma (FFP). TPE aims to eliminate disease-related pathogens [1]. Removal of significant amounts of plasma during TPE can alter the pharmacokinetic profiles of antimicrobials, resulting in inadequate therapeutic efficacy. In addition, critically ill patients may have altered pharmacokinetic profiles for many drugs. Data on antimicrobial elimination via TPE in intensive care unit (ICU) patients are scarce. Few studies have examined the effect of TPE on antimicrobials [2].</p><p>Several factors may influence antimicrobial elimination during TPE. High plasma protein-binding (&gt; 80%) and low volume of distribution (V_d &lt; 0.2 L/kg) are important pharmacokinetic factors indicating a high rate of removal via TPE [3]. Studies have also shown that allowing an adequate interval for drug distribution significantly decreases drug elimination via TPE [4]. It is important to note that distribution half-life values are not typically available to clinicians through drug monographs. However, because the distribution phase generally has a shorter half-life than the elimination phase, elimination half-life data can be used as a surrogate measure of drug distribution half-life [5].</p><p>We report the plasma levels of meropenem, teicoplanin, voriconazole, and amikacin immediately before and after TPE, along with the amounts of antimicrobials in plasmapheresate (removed plasma) from three critically ill ICU patients. All antimicrobials were at steady-state during TPE sessions, with none given immediately before or during TPE. TPE was performed using the Spectra Optia Apheresis System (TERUMOBCT) by continuous-flow-centrifugation. Plasma levels of these drugs are routinely monitored at our hospital using liquid chromatography with tandem mass spectrometry (LC–MS/MS). The amount of drug removed (mg) (Q_TPE) was calculated as follows: drug concentration in plasmapheresate (mg/L) x volume of plasma removed (L). To the best of our knowledge, this study is the first to provide data on the effect of TPE on steady-state plasma levels of meropenem, teicoplanin, and amikacin, as well as the first to report on the effect of TPE on the disposition of amikacin.</p><p>A 40-year-old male patient with hemochromatosis, chronic liver disease, type 2 diabetes, and atrial fibrillation was admitted to the medical ICU for neutropenic fever and community-acquired pneumonia (Case 1). He underwent 7 TPE sessions with FFP to treat worsening hyperbilirubinemia associated with hepatic encephalopathy. The patient's antimicrobial therapy included meropenem for neutropenic fever, teicoplanin for gram-positive pathogens due to epididymitis, and voriconazole for <i>Aspergillus fumigatus</i>. Maintenance doses were meropenem 2 g q8h as a prolonged infusio","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142085726","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":"Role of age as eligibility criterion for ECMO in patients with ARDS: meta-regression analysis.","authors":"Tommaso Tonetti, Rossana Di Staso, Laura Bambini, Martina Bordini, Rosanna D'Albo, Domenico Nocera, Irene Sbaraini Zernini, Ilaria Turriziani, Luciana Mascia, Paola Rucci, V Marco Ranieri","doi":"10.1186/s13054-024-05074-z","DOIUrl":"10.1186/s13054-024-05074-z","url":null,"abstract":"<p><strong>Background: </strong>Age as an eligibility criterion for V-V ECMO is widely debated and varies among healthcare institutions. We examined how age relates to mortality in patients undergoing V-V ECMO for ARDS.</p><p><strong>Methods: </strong>Systematic review and meta-regression of clinical studies published between 2015 and June 2024. Studies involving at least 6 ARDS patients treated with V-V ECMO, with specific data on ICU and/or hospital mortality and patient age were included. The search strategy was executed in PubMed, limited to English-language. COVID-19 and non-COVID-19 populations were analyzed separately. Meta-regressions of mortality outcomes on age were performed using gender, BMI, SAPS II, APACHE II, Charlson comorbidity index or SOFA as covariates.</p><p><strong>Results: </strong>In non-COVID ARDS, the meta-regression of 173 studies with 56,257 participants showed a significant positive association between mean age and ICU/hospital mortality. In COVID-19 ARDS, a significant relationship between mean age and ICU mortality, but not hospital mortality, was found in 103 studies with 21,255 participants. Sensitivity analyses confirmed these findings, highlighting a linear relationship between age and mortality in both groups. For each additional year of mean age, ICU mortality increased by 1.2% in non-COVID ARDS and 1.9% in COVID ARDS.</p><p><strong>Conclusions: </strong>The relationship between age and ICU mortality is linear and shows no inflection point. Consequently, no age cut-off can be recommended for determining patient eligibility for V-V ECMO.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11348734/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142079445","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}