Journal of Intensive Care最新文献

{"title":"Hospital and regional variations in intensive care unit admission for patients with invasive mechanical ventilation","authors":"Hiroyuki Ohbe, Nobuaki Shime, Hayato Yamana, Tadahiro Goto, Yusuke Sasabuchi, Daisuke Kudo, Hiroki Matsui, Hideo Yasunaga, Shigeki Kushimoto","doi":"10.1186/s40560-024-00736-0","DOIUrl":"https://doi.org/10.1186/s40560-024-00736-0","url":null,"abstract":"Patients who receive invasive mechanical ventilation (IMV) in the intensive care unit (ICU) have exhibited lower in-hospital mortality rates than those who are treated outside. However, the patient-, hospital-, and regional factors influencing the ICU admission of patients with IMV have not been quantitatively examined. This retrospective cohort study used data from the nationwide Japanese inpatient administrative database and medical facility statistics. We included patients aged ≥ 15 years who underwent IMV between April 2018 and March 2019. The primary outcome was ICU admission on the day of IMV initiation. Multilevel logistic regression analyses incorporating patient-, hospital-, or regional-level variables were used to assess cluster effects by calculating the intraclass correlation coefficient (ICC), median odds ratio (MOR), and proportional change in variance (PCV). Among 83,346 eligible patients from 546 hospitals across 140 areas, 40.4% were treated in ICUs on their IMV start day. ICU admission rates varied widely between hospitals (median 0.7%, interquartile range 0–44.5%) and regions (median 28.7%, interquartile range 0.9–46.2%). Multilevel analyses revealed significant effects of hospital cluster (ICC 82.2% and MOR 41.4) and regional cluster (ICC 67.3% and MOR 12.0). Including patient-level variables did not change these ICCs and MORs, with a PCV of 2.3% and − 1.0%, respectively. Further adjustment for hospital- and regional-level variables decreased the ICC and MOR, with a PCV of 95.2% and 85.6%, respectively. Among the hospital- and regional-level variables, hospitals with ICU beds and regions with ICU beds had a statistically significant and strong association with ICU admission. Our results revealed that primarily hospital and regional factors, rather than patient-related ones, opposed ICU admissions for patients with IMV. This has important implications for healthcare policymakers planning interventions for optimal ICU resource allocation.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"145 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2024-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141257101","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Case volume and specialization in critically ill emergency patients: a nationwide cohort study in Japanese ICUs.","authors":"Jun Fujinaga, Takanao Otake, Takehide Umeda, Toshio Fukuoka","doi":"10.1186/s40560-024-00733-3","DOIUrl":"10.1186/s40560-024-00733-3","url":null,"abstract":"<p><strong>Background: </strong>Previous studies have explored the association between the number of cases and patient outcomes for critical illnesses such as sepsis and trauma, as well as various surgeries, with the expectation that a higher number of cases would have a more favorable effect on patient outcomes. The aim of this study was to elucidate the association among intensive care unit (ICU) case volume, specialization, and patient outcomes in critically ill emergency patients and to determine how ICU case volumes and specializations impact the outcomes of these patients in Japanese ICUs.</p><p><strong>Methods: </strong>Utilizing data from the Japanese Intensive Care PAtient Database (JIPAD) from April 2015 to March 2021, this retrospective cohort study was conducted in 80 ICUs across Japan and included 72,214 emergency patients aged ≥ 16 years. The primary outcome measure was in-hospital mortality, and the secondary outcomes encompassed ICU mortality, 28-day mortality, ventilator-free days, and the lengths of ICU and hospital stays. Bayesian hierarchical generalized linear mixed models were used to adjust for patient- and ICU-level variables.</p><p><strong>Results: </strong>This study revealed a significant association between a higher ICU case volume and decreased in-hospital mortality. In particular, ICUs with a higher percentage (> 75%) of emergency patients showed more pronounced effects, with the odds ratios for in-hospital mortality in the higher case volume quartiles (Q2, Q3, and Q4) being 0.92 (95% credible interval [CI]: 0.88-0.96), 0.70 (95% CI: 0.67-0.73), and 0.78 (95% CI: 0.73-0.83), respectively, compared with the lowest quartile (Q1). Similar trends were observed for various secondary outcomes.</p><p><strong>Conclusions: </strong>Higher ICU case volumes were significantly associated with lower in-hospital mortality rates in Japanese ICUs predominantly treating critically ill emergency patients. These findings emphasize the importance of ICU specialization and highlight the potential benefits of centralized care for critically ill emergency patients. These findings are potential insights for improving health care policy in Japan and may be valuable in emergency care settings in other countries with similar healthcare systems, after careful consideration of contextual differences.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"20"},"PeriodicalIF":7.1,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11100151/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140957384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mechanisms maintaining right ventricular contractility-to-pulmonary arterial elastance ratio in VA ECMO: a retrospective animal data analysis of RV-PA coupling.","authors":"Kaspar F Bachmann, Per Werner Moller, Lukas Hunziker, Marco Maggiorini, David Berger","doi":"10.1186/s40560-024-00730-6","DOIUrl":"10.1186/s40560-024-00730-6","url":null,"abstract":"<p><strong>Background: </strong>To optimize right ventricular-pulmonary coupling during veno-arterial (VA) ECMO weaning, inotropes, vasopressors and/or vasodilators are used to change right ventricular (RV) function (contractility) and pulmonary artery (PA) elastance (afterload). RV-PA coupling is the ratio between right ventricular contractility and pulmonary vascular elastance and as such, is a measure of optimized crosstalk between ventricle and vasculature. Little is known about the physiology of RV-PA coupling during VA ECMO. This study describes adaptive mechanisms for maintaining RV-PA coupling resulting from changing pre- and afterload conditions in VA ECMO.</p><p><strong>Methods: </strong>In 13 pigs, extracorporeal flow was reduced from 4 to 1 L/min at baseline and increased afterload (pulmonary embolism and hypoxic vasoconstriction). Pressure and flow signals estimated right ventricular end-systolic elastance and pulmonary arterial elastance. Linear mixed-effect models estimated the association between conditions and elastance.</p><p><strong>Results: </strong>At no extracorporeal flow, end-systolic elastance increased from 0.83 [0.66 to 1.00] mmHg/mL at baseline by 0.44 [0.29 to 0.59] mmHg/mL with pulmonary embolism and by 1.36 [1.21 to 1.51] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Pulmonary arterial elastance increased from 0.39 [0.30 to 0.49] mmHg/mL at baseline by 0.36 [0.27 to 0.44] mmHg/mL with pulmonary embolism and by 0.75 [0.67 to 0.84] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Coupling remained unchanged (2.1 [1.8 to 2.3] mmHg/mL at baseline; - 0.1 [- 0.3 to 0.1] mmHg/mL increase with pulmonary embolism; - 0.2 [- 0.4 to 0.0] mmHg/mL with hypoxic pulmonary vasoconstriction, p > 0.05). Extracorporeal flow did not change coupling (0.0 [- 0.0 to 0.1] per change of 1 L/min, p > 0.05). End-diastolic volume increased with decreasing extracorporeal flow (7.2 [6.6 to 7.8] ml change per 1 L/min, p < 0.001).</p><p><strong>Conclusions: </strong>The right ventricle dilates with increased preload and increases its contractility in response to afterload changes to maintain ventricular-arterial coupling during VA extracorporeal membrane oxygenation.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"19"},"PeriodicalIF":7.1,"publicationDate":"2024-05-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11088130/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140908929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hemorrhage and thrombosis in COVID-19-patients supported with extracorporeal membrane oxygenation: an international study based on the COVID-19 critical care consortium.","authors":"Maximilian Feth, Natasha Weaver, Robert B Fanning, Sung-Min Cho, Matthew J Griffee, Mauro Panigada, Akram M Zaaqoq, Ahmed Labib, Glenn J R Whitman, Rakesh C Arora, Bo S Kim, Nicole White, Jacky Y Suen, Gianluigi Li Bassi, Giles J Peek, Roberto Lorusso, Heidi Dalton, John F Fraser, Jonathon P Fanning","doi":"10.1186/s40560-024-00726-2","DOIUrl":"10.1186/s40560-024-00726-2","url":null,"abstract":"<p><strong>Background: </strong>Extracorporeal membrane oxygenation (ECMO) is a rescue therapy in patients with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19. While bleeding and thrombosis complicate ECMO, these events may also occur secondary to COVID-19. Data regarding bleeding and thrombotic events in COVID-19 patients on ECMO are sparse.</p><p><strong>Methods: </strong>Using the COVID-19 Critical Care Consortium database, we conducted a retrospective analysis on adult patients with severe COVID-19 requiring ECMO, including centers globally from 01/2020 to 06/2022, to determine the risk of ICU mortality associated with the occurrence of bleeding and clotting disorders.</p><p><strong>Results: </strong>Among 1,248 COVID-19 patients receiving ECMO support in the registry, coagulation complications were reported in 469 cases (38%), among whom 252 (54%) experienced hemorrhagic complications, 165 (35%) thrombotic complications, and 52 (11%) both. The hazard ratio (HR) for Intensive Care Unit mortality was higher in those with hemorrhagic-only complications than those with neither complication (adjusted HR = 1.60, 95% CI 1.28-1.99, p < 0.001). Death was reported in 617 of the 1248 (49.4%) with multiorgan failure (n = 257 of 617 [42%]), followed by respiratory failure (n = 130 of 617 [21%]) and septic shock [n = 55 of 617 (8.9%)] the leading causes.</p><p><strong>Conclusions: </strong>Coagulation disorders are frequent in COVID-19 ARDS patients receiving ECMO. Bleeding events contribute substantially to mortality in this cohort. However, this risk may be lower than previously reported in single-nation studies or early case reports. Trial registration ACTRN12620000421932 ( https://covid19.cochrane.org/studies/crs-13513201 ).</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"18"},"PeriodicalIF":3.8,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11071263/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140850957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Recent advances in cardiorespiratory monitoring in acute respiratory distress syndrome patients","authors":"Davide Chiumello, Antonio Fioccola","doi":"10.1186/s40560-024-00727-1","DOIUrl":"https://doi.org/10.1186/s40560-024-00727-1","url":null,"abstract":"Recent advances on cardiorespiratory monitoring applied in ARDS patients undergoing invasive mechanical ventilation and noninvasive ventilatory support are available in the literature and may have potential prognostic implication in ARDS treatment. The measurement of oxygen saturation by pulse oximetry is a valid, low-cost, noninvasive alternative for assessing arterial oxygenation. Caution must be taken in patients with darker skin pigmentation, who may experience a greater incidence of occult hypoxemia. Dead space surrogates, which are easy to calculate, have important prognostic implications. The mechanical power, which can be automatically computed by intensive care ventilators, is an important parameter correlated with ventilator-induced lung injury and outcome. In patients undergoing noninvasive ventilatory support, the use of esophageal pressure can measure inspiratory effort, avoiding possible delays in endotracheal intubation. Fluid responsiveness can also be evaluated using dynamic indices in patients ventilated at low tidal volumes (< 8 mL/kg). In patients ventilated at high levels of positive end expiratory pressure (PEEP), the PEEP test represents a valid alternative to passive leg raising. There is growing evidence on alternative parameters for evaluating fluid responsiveness, such as central venous oxygen saturation variations, inferior vena cava diameter variations and capillary refill time. Careful cardiorespiratory monitoring in patients affected by ARDS is crucial to improve prognosis and to tailor treatment via mechanical ventilatory support. ","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"1 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2024-05-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140827414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prognostic nutritional index as a predictive marker for acute kidney injury in adult critical illness population: a systematic review and diagnostic test accuracy meta-analysis","authors":"Jia-Jin Chen, Tao-Han Lee, Pei-Chun Lai, Chih-Hsiang Chang, Che-Hsiung Wu, Yen-Ta Huang","doi":"10.1186/s40560-024-00729-z","DOIUrl":"https://doi.org/10.1186/s40560-024-00729-z","url":null,"abstract":"The prognostic nutritional index (PNI), integrating nutrition and inflammation markers, has been increasingly recognized as a prognostic predictor in diverse patient cohorts. Recently, its effectiveness as a predictive marker for acute kidney injury (AKI) in various clinical settings has gained attention. This study aims to assess the predictive accuracy of the PNI for AKI in critically ill populations through systematic review and meta-analysis. A systematic review was conducted using the databases MEDLINE, EMBASE, PubMed, and China National Knowledge Infrastructure up to August 2023. The included trials reported the PNI assessment in adult population with critical illness and its predictive capacity for AKI. Data on study characteristics, subgroup covariates, and diagnostic performance of PNI, including sensitivity, specificity, and event rates, were extracted. A diagnostic test accuracy meta-analysis was performed. Subgroup analyses and meta-regression were utilized to investigate the sources of heterogeneity. The GRADE framework evaluated the confidence in the meta-analysis’s evidence. The analysis encompassed 16 studies with 17 separate cohorts, totaling 21,239 patients. The pooled sensitivity and specificity of PNI for AKI prediction were 0.67 (95% CI 0.58–0.74) and 0.74 (95% CI 0.67–0.80), respectively. The pooled positive likelihood ratio was 2.49 (95% CI 1.99–3.11; low certainty), and the negative likelihood ratio was 0.46 (95% CI 0.37–0.56; low certainty). The pooled diagnostic odds ratio was 5.54 (95% CI 3.80–8.07), with an area under curve of summary receiver operating characteristics of 0.76. Subgroup analysis showed that PNI’s sensitivity was higher in medical populations than in surgical populations (0.72 vs. 0.55; p < 0.05) and in studies excluding patients with chronic kidney disease (CKD) than in those including them (0.75 vs. 0.56; p < 0.01). Overall, diagnostic performance was superior in the non-chronic kidney disease group. Our study demonstrated that PNI has practical accuracy for predicting the development of AKI in critically ill populations, with superior diagnostic performance observed in medical and non-CKD populations. However, the diagnostic efficacy of the PNI has significant heterogeneity with different cutoff value, indicating the need for further research.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"11 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2024-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140798433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Respiratory drive: a journey from health to disease","authors":"Dimitrios Georgopoulos, Maria Bolaki, Vaia Stamatopoulou, Evangelia Akoumianaki","doi":"10.1186/s40560-024-00731-5","DOIUrl":"https://doi.org/10.1186/s40560-024-00731-5","url":null,"abstract":"Respiratory drive is defined as the intensity of respiratory centers output during the breath and is primarily affected by cortical and chemical feedback mechanisms. During the involuntary act of breathing, chemical feedback, primarily mediated through CO2, is the main determinant of respiratory drive. Respiratory drive travels through neural pathways to respiratory muscles, which execute the breathing process and generate inspiratory flow (inspiratory flow-generation pathway). In a healthy state, inspiratory flow-generation pathway is intact, and thus respiratory drive is satisfied by the rate of volume increase, expressed by mean inspiratory flow, which in turn determines tidal volume. In this review, we will explain the pathophysiology of altered respiratory drive by analyzing the respiratory centers response to arterial partial pressure of CO2 (PaCO2) changes. Both high and low respiratory drive have been associated with several adverse effects in critically ill patients. Hence, it is crucial to understand what alters the respiratory drive. Changes in respiratory drive can be explained by simultaneously considering the (1) ventilatory demands, as dictated by respiratory centers activity to CO2 (brain curve); (2) actual ventilatory response to CO2 (ventilation curve); and (3) metabolic hyperbola. During critical illness, multiple mechanisms affect the brain and ventilation curves, as well as metabolic hyperbola, leading to considerable alterations in respiratory drive. In critically ill patients the inspiratory flow-generation pathway is invariably compromised at various levels. Consequently, mean inspiratory flow and tidal volume do not correspond to respiratory drive, and at a given PaCO2, the actual ventilation is less than ventilatory demands, creating a dissociation between brain and ventilation curves. Since the metabolic hyperbola is one of the two variables that determine PaCO2 (the other being the ventilation curve), its upward or downward movements increase or decrease respiratory drive, respectively. Mechanical ventilation indirectly influences respiratory drive by modifying PaCO2 levels through alterations in various parameters of the ventilation curve and metabolic hyperbola. Understanding the diverse factors that modulate respiratory drive at the bedside could enhance clinical assessment and the management of both the patient and the ventilator.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"33 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140634367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The optimal glycemic target in critically ill patients: an updated network meta-analysis","authors":"Aiko Tanaka, Tomoaki Yatabe, Tomohiro Suhara, Moritoki Egi","doi":"10.1186/s40560-024-00728-0","DOIUrl":"https://doi.org/10.1186/s40560-024-00728-0","url":null,"abstract":"Acute glycemic control significantly affects the clinical outcomes of critically ill patients. This updated network meta-analysis examines the benefits and harms of four target blood glucose levels (< 110, 110–144, 144–180, and > 180 mg/dL). Analyzing data of 27,541 patients from 37 trials, the surface under the cumulative ranking curve for mortality and hypoglycemia was highest at a target blood glucose level of 144–180 mg/dL, while for infection and acute kidney injury at 110–144 mg/dL. Further evidence is needed to determine whether 110–144 or 144–180 mg/dL is superior as an optimal glucose target, considering prioritized outcomes.","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"51 1","pages":""},"PeriodicalIF":7.1,"publicationDate":"2024-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140565262","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study.","authors":"Clare Fong, Wern Lunn Kueh, Sennen Jin Wen Lew, Benjamin Choon Heng Ho, Yu-Lin Wong, Yie Hui Lau, Yew Woon Chia, Hui Ling Tan, Ying Hao Christopher Seet, Wen Ting Siow, Graeme MacLaren, Rohit Agrawal, Tian Jin Lim, Shir Lynn Lim, Toon Wei Lim, Vui Kian Ho, Chai Rick Soh, Duu Wen Sewa, Chian Min Loo, Faheem Ahmed Khan, Chee Keat Tan, Roshni Sadashiv Gokhale, Chuin Siau, Noelle Louise Siew Hua Lim, Chik-Foo Yim, Jonathen Venkatachalam, Kumaresh Venkatesan, Naville Chi Hock Chia, Mei Fong Liew, Guihong Li, Li Li, Su Mon Myat, Zena Zena, Shuling Zhuo, Ling Ling Yueh, Caroline Shu Fang Tan, Jing Ma, Siew Lian Yeo, Yiong Huak Chan, Jason Phua","doi":"10.1186/s40560-024-00725-3","DOIUrl":"10.1186/s40560-024-00725-3","url":null,"abstract":"<p><strong>Background: </strong>Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.</p><p><strong>Methods: </strong>This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.</p><p><strong>Results: </strong>There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.</p><p><strong>Conclusions: </strong>Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"13"},"PeriodicalIF":7.1,"publicationDate":"2024-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10964634/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140288331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk factors for arterial catheter failure and complications during critical care hospitalisation: a secondary analysis of a multisite, randomised trial.","authors":"Jessica A Schults, Emily R Young, Nicole Marsh, Emily Larsen, Amanda Corley, Robert S Ware, Marghie Murgo, Evan Alexandrou, Matthew McGrail, John Gowardman, Karina R Charles, Adrian Regli, Hideto Yasuda, Claire M Rickard","doi":"10.1186/s40560-024-00719-1","DOIUrl":"10.1186/s40560-024-00719-1","url":null,"abstract":"<p><strong>Objectives: </strong>Arterial catheters (ACs) are critical for haemodynamic monitoring and blood sampling but are prone to complications. We investigated the incidence and risk factors of AC failure.</p><p><strong>Methods: </strong>Secondary analysis of a multi-centre randomised controlled trial (ACTRN 12610000505000). Analysis included a subset of adult intensive care unit patients with an AC. The primary outcome was all-cause device failure. Secondary outcomes were catheter associated bloodstream infection (CABSI), suspected CABSI, occlusion, thrombosis, accidental removal, pain, and line fracture. Risk factors associated with AC failure were investigated using Cox proportional hazards and competing-risk models.</p><p><strong>Results: </strong>Of 664 patients, 173 (26%) experienced AC failure (incidence rate [IR] 37/1000 catheter days). Suspected CABSI was the most common failure type (11%; IR 15.3/1000 catheter days), followed by occlusion (8%; IR 11.9/1,000 catheter days), and accidental removal (4%; IR 5.5/1000 catheter days). CABSI occurred in 16 (2%) patients. All-cause failure and occlusion were reduced with ultrasound-assisted insertion (failure: adjusted hazard ratio [HR] 0.43, 95% CI 0.25, 0.76; occlusion: sub-HR 0.11, 95% CI 0.03, 0.43). Increased age was associated with less AC failure (60-74 years HR 0.63, 95% CI 0.44 to 0.89; 75 + years HR 0.36, 95% CI 0.20, 0.64; referent 15-59 years). Females experienced more occlusion (adjusted sub-HR 2.53, 95% CI 1.49, 4.29), while patients with diabetes had less (SHR 0.15, 95% CI 0.04, 0.63). Suspected CABSI was associated with an abnormal insertion site appearance (SHR 2.71, 95% CI 1.48, 4.99).</p><p><strong>Conclusions: </strong>AC failure is common with ultrasound-guided insertion associated with lower failure rates. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000); date registered: 18 June 2010.</p>","PeriodicalId":16123,"journal":{"name":"Journal of Intensive Care","volume":"12 1","pages":"12"},"PeriodicalIF":7.1,"publicationDate":"2024-03-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10924392/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140065257","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}