Critical care explorations最新文献

{"title":"Evaluating Potential Missed Opportunities to Prevent, Treat, or Diagnose Sepsis: A Population-Based Retrospective Study of Insurance Claims.","authors":"Roger D Struble, Alan T Arakkal, Joseph E Cavanaugh, Philip M Polgreen, Aaron C Miller","doi":"10.1097/CCE.0000000000001240","DOIUrl":"10.1097/CCE.0000000000001240","url":null,"abstract":"<p><strong>Importance: </strong>Delays in diagnosing sepsis may increase morbidity and mortality, but the frequency of delays is poorly understood.</p><p><strong>Objectives: </strong>The aim of this study was to estimate the frequency and duration of diagnostic delays for sepsis and potential risk factors for delay.</p><p><strong>Design, setting, and participants: </strong>We conducted a retrospective case-crossover analysis of sepsis cases from 2016 to 2019 using claims from Merative MarketScan. We ascertained the index diagnosis of sepsis and corresponding hospitalization. We analyzed healthcare visits in the 180 days before diagnosis and then compared the observed and expected trends in signs or symptoms of infection, immune or organ dysfunction (e.g., fever, dyspnea) during the 14 days before diagnosis. A bootstrapping approach was used to estimate the frequency and duration of potential diagnostic delays along with possible risk-factors for experiencing a delay.</p><p><strong>Main outcomes and measures: </strong>The number of patients who experienced a potential diagnostic delay, duration of delay, and number of potential missed opportunities.</p><p><strong>Results: </strong>We identified a total of 649,756 cases of sepsis from 2016 to 2019 meeting inclusion criteria. There was an increase in visits with signs or symptoms of infection, immune or organ dysfunction just before the index diagnosis of sepsis. We estimated that around 16.57% (95% CI, 16.38-16.78) of patients experienced a potential diagnostic delay, with a mean delay duration of 3.21 days (95% CI, 3.13-3.27) and a median of 2 days. Most delays occurred in outpatient settings. Potential diagnostic delays were more frequent among younger age groups and patients who received antibiotics (odds ratio [OR] 2.58 [95% CI, 2.54-2.62]), or treatments for particular symptoms, including opioids (OR 1.43 [95% CI, 1.40-1.46]) and inhalers (OR 1.37 [95% CI, 1.33-1.40]).</p><p><strong>Conclusions and relevance: </strong>There may be a substantial number of potential missed opportunities to diagnose sepsis, especially in outpatient settings. Multiple factors might contribute to delays in diagnosing sepsis including commonly prescribed medications for symptoms.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1240"},"PeriodicalIF":0.0,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11968023/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143765846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Variation in Arterial CO2 is a Stronger Determinant of Brain Tissue Oxygenation Than its Synchronous Value in Critically Ill Patients With Acute Brain Injury.","authors":"Joanie Martineau, Francis Bernard, Alexandrine Gagnon, Virginie Williams, Sabrina Araujo de Franca, David Williamson, Yiorgos Alexandros Cavayas","doi":"10.1097/CCE.0000000000001241","DOIUrl":"10.1097/CCE.0000000000001241","url":null,"abstract":"<p><strong>Objectives: </strong>In critically ill patients with acute brain injury (ABI), maintaining intracranial pressure (ICP) and brain tissue oxygenation (PbtO2) within targets could prevent secondary neurologic injury. Tight control of CO2 (Paco2), a potent regulator of cerebrovascular tone, is generally advocated, but its vasomotor effect may be short-lived. Our aim was to compare the effect of the synchronous Paco2 vs. its variation from a previous baseline on PbtO2 and ICP.</p><p><strong>Design: </strong>We performed a post hoc analysis of a prospective cohort study collecting arterial blood gas (ABG) values alongside synchronous neuromonitoring variables. Linear mixed-effects models were fitted to evaluate the association between Paco2 and/or Paco2 variation from its average of the last 8-24 hr vs. PbtO2 and ICP, while controlling for cerebral perfusion pressure and Pao2.</p><p><strong>Setting: </strong>Mixed medical-surgical ICU of Sacré-Coeur Hospital, an academic trauma center in Montreal, Canada.</p><p><strong>Patients: </strong>All consecutive adult patients admitted for ABI with ICP and PbtO2 monitoring between May 2017 and November 2021.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We included 78 patients with 3047 ABG-neuromonitoring couplets. The model using the variation of Paco2 from its average of the last 24 hr displayed the best performance for the prediction of PbtO2 (coefficient 0.37; 95% CI 0.21-0.53). The strongest predictor of ICP was the variation of Paco2 from its average of the last 8 hr (coefficient 0.17; 95% CI 0.10-0.23).</p><p><strong>Conclusions: </strong>Variation in Paco2 from baseline is a more significant determinant of PbtO2 and ICP than the absolute Paco2 value at a given time. There may be a baseline vasomotor reset when patients are exposed to a given level of CO2 for 8 to 24 hr. Therefore, sustained intentional manipulation of Paco2 is unlikely to have lasting effects and slower correction rates of high or low Paco2 could help prevent brain tissue hypoxia or intracranial hypertension, respectively.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1241"},"PeriodicalIF":0.0,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11968020/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143765847","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Electrocardiometry for the Management of Pediatric Septic Shock: A Pilot Randomized Controlled Trial.","authors":"Suman Sudha Moharana, Lalitha Av, Santu Ghosh","doi":"10.1097/CCE.0000000000001242","DOIUrl":"10.1097/CCE.0000000000001242","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the difference in the resuscitation fluid volume in the initial 6 hours in pediatric septic shock between those undergoing noninvasive continuous hemodynamic monitoring with electrocardiometry in addition to clinical monitoring vs. clinical monitoring alone.</p><p><strong>Design: </strong>Randomized control trial.</p><p><strong>Setting: </strong>PICU in a tertiary care hospital.</p><p><strong>Patients: </strong>Children from 2 months to 18 years with sepsis and unresolved shock after the initial fluid bolus (FB).</p><p><strong>Interventions: </strong>Children were randomized to one of the two groups, that is, electrocardiometry with clinical monitoring group (group B) and clinical monitoring alone group (group A). In group B, electrocardiometry variables (cardiac index and systemic vascular resistance index) along with clinical monitoring were used to guide FB, as well as selection and titration of vasoactive agents. Clinical parameters were used to initiate and titrate fluid resuscitation and vasoactive therapy in group A as per standard guidelines.</p><p><strong>Measurements and main results: </strong>One hundred nineteen children were enrolled in the study: 60 in group A and 59 in group B. There was a significantly higher requirement for resuscitation fluid volume (mean ± sd) within the initial 6 hours in the group A (30 ± 8.2 mL/kg) as compared with group B (22 ± 9.2 mL/kg). Similarly, maintenance along with resuscitation fluid volume (mean ± sd) administration (56 ±13 vs. 46 ±10.7, p < 0.001) was higher in group A in the first 24 hours of enrollment. Vasoactive therapy initiation was earlier in group B as compared with group A (37 ± 10.14 vs. 47.33 ± 12.41 min) with lower fluid overload percentage (2.98% vs. 1.7%) in this group. However, there was no difference in time to shock resolution, 28-day ICU-free days, hospital-free days, and mortality.</p><p><strong>Conclusions: </strong>Advanced hemodynamic monitoring with electrocardiometry along with clinical assessment led to a restrictive fluid strategy in addition to minimizing the risk of fluid overload.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1242"},"PeriodicalIF":0.0,"publicationDate":"2025-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11960802/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143756442","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prothrombotic Microvesicle Generation in Pediatric Cardiopulmonary Bypass: A Pilot Observational Study.","authors":"Andrew D Meyer, Anjana Rishmawi, Alia Elkhalili, David Rupert, Joshua Walker, John Calhoon, Andrew P Cap, Lauren Kane","doi":"10.1097/CCE.0000000000001236","DOIUrl":"10.1097/CCE.0000000000001236","url":null,"abstract":"<p><strong>Importance: </strong>Over 10% of children develop thrombosis after cardiac surgery for congenital heart disease. Children with a single ventricle physiology have the highest risk of thrombosis associated with increased length of the postoperative stay, neurologic complications, and mortality. To decrease these complications, research is needed to understand the mechanisms that promote cardiopulmonary bypass (CPB) surgery-induced thrombin generation and clot formation.</p><p><strong>Objectives: </strong>The objective of this pilot observational study was to measure the generation of prothrombotic microvesicles (MVs) and thrombin generation in 21 children collected 5 minutes after initiation of CPB, at the end of CPB, upon arrival in the pediatric congenital cardiac unit (PCCU), and 20 to 24 hours after arrival in the PCCU.</p><p><strong>Design, setting, and participants: </strong>An observational pilot study measured platelet and leukocyte MV, platelet aggregation, coagulation, and thrombin generation in 21 children undergoing CPB surgery. The study setting was a tertiary pediatric hospital. Inclusion criteria included age between birth to 5 years and weight on the day of surgery greater than three kilograms.</p><p><strong>Main outcomes and measures: </strong>Bleeding outcomes were measured by chest tube output and thrombotic outcomes were measured by surveillance ultrasound. Laboratory outcomes of prothrombotic MVs and thrombin generation were measured by high-resolution flow cytometry and calibrated automated thrombogram, respectively.</p><p><strong>Results: </strong>Time on CPB correlated with a significant increase in WBCs and phosphatidylserine-expressing MVs. Children with single ventricle physiology had increased levels of prothrombotic MVs (p = 0.017), platelet aggregation, peak thrombin (p = 0.019), and d-dimer (p = 0.029) upon arrival to the ICU compared with children with a dual ventricle. Only single ventricle children had a positive correlation between generation of platelet MV with peak thrombin (p = 0.010).</p><p><strong>Conclusions and relevance: </strong>Larger prospective studies are needed to determine if prothrombotic MVs can predict children with congenital heart disease at risk for thrombotic events.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1236"},"PeriodicalIF":0.0,"publicationDate":"2025-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11960801/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143756509","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sex Differences in Pediatric Sepsis Mortality: A Systematic Review and Meta-Analysis.","authors":"Uchenna K Kennedy, Juliette Moulin, Lea Bührer, Joanne Lim Fang Nian, Leyla Halter, Luzius Böhni, Melisa Güzelgün, Kusum Menon, Jan Hau Lee, Luregn J Schlapbach, Ulrike Held","doi":"10.1097/CCE.0000000000001226","DOIUrl":"10.1097/CCE.0000000000001226","url":null,"abstract":"<p><strong>Objectives: </strong>Pediatric sepsis remains a leading cause of childhood mortality worldwide. Sex differences have been shown to modify risk factors, treatment, and outcome of various diseases, and adult studies revealed sex differences in pathophysiological responses to septic shock. We aimed to perform a systematic review and meta-analysis on the association of sex with outcomes in hospitalized children with sepsis.</p><p><strong>Data sources: </strong>Medline and Embase databases were searched for studies of children < 18 years with sepsis published between January 01, 2005, and March 31, 2022.</p><p><strong>Study selection: </strong>We included cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years which included sepsis, severe sepsis or septic shock, and mortality as an outcome.</p><p><strong>Data extraction: </strong>Study characteristics, patient demographics, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.</p><p><strong>Data synthesis: </strong>We screened 14,791 studies, with 912 full-text reviews and inclusion of 124 studies. The total population involved 426,163 patients, of which 47% (201,438) were girls. Meta-regression showed moderate evidence for a higher mortality in boys compared with girls. The estimated risk difference of mortality between boys and girls with all types of sepsis was -0.005 (95% CI, -0.0099 to -0.00001; p = 0.049), indicating slightly higher mortality for boys. When including the World Bank income level as a moderator, the effect was -0.008 (95% CI, -0.013 to -0.002; p = 0.005).</p><p><strong>Conclusions: </strong>This large systematic review and meta-analysis on sex differences in pediatric sepsis mortality showed moderate evidence for a higher sepsis mortality in boys compared with girls. The effect persisted when adjusting for country's income level.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1226"},"PeriodicalIF":0.0,"publicationDate":"2025-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11960803/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143756510","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Challenges of Ventilator Procurement and Distribution in the ICU During the COVID-19 Pandemic: A Scoping Review.","authors":"David Wang, Marko Nemet, Gabriele A Dos Anjos, Sara N Zec, Claudia C Zambrano, Lucrezia Rovati, Hieu Truong, Yue Dong","doi":"10.1097/CCE.0000000000001248","DOIUrl":"10.1097/CCE.0000000000001248","url":null,"abstract":"<p><strong>Objectives: </strong>The goal of this scoping review was to review some of the challenges hospitals faced in dealing with the shortage of ventilators during the COVID-19 pandemic and the solutions they were able to implement or suggested. By highlighting these problems and solutions, we hope this review can catalyze further discussions about how to better prepare for future pandemics and medical supply shortages.</p><p><strong>Data sources: </strong>A comprehensive search strategy using identifying key words was applied to several different databases to procure relevant literature.</p><p><strong>Study selection: </strong>Four thousand two hundred fifty-nine studies were found in the initial search. Inclusion and exclusion criteria were created and applied to screen studies. Included studies focused on the supply and distribution of ventilators during the COVID-19 pandemic. In the case where reviewers disagreed about whether a study should be included, a third reviewer acted as a tie-breaker.</p><p><strong>Data extraction: </strong>Thirty-three studies were included for final data extraction. Two independent reviewers collected various data points from these studies, including the main challenges discussed by the authors, the level of ventilator shortage being addressed, whether ventilator sharing was discussed, and the limitations of the study.</p><p><strong>Data synthesis: </strong>A third reviewer compared the collected data and decided on the results.</p><p><strong>Conclusions: </strong>Some of the common solutions for the ventilator shortage discussed included augmenting overall ventilator supply through increased production, transporting ventilators between hospitals, ventilator sharing, designing new ventilators, and repurposing other resources to help address shortages of supplies.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1248"},"PeriodicalIF":0.0,"publicationDate":"2025-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11957643/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143736306","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Physician Assistants/Associates in Critical Care: A Descriptive Analysis Using the National Commission on Certification of Physician Assistants Dataset.","authors":"Ryan W Hunton, Dalton C Gifford, Kasey K Puckett, Mirela Bruza-Augatis, Andrzej Kozikowski, Virginia L Valentin","doi":"10.1097/CCE.0000000000001250","DOIUrl":"10.1097/CCE.0000000000001250","url":null,"abstract":"<p><strong>Objectives: </strong>Little is known about the size, trajectory, and practice characteristics of the physician assistant/associate (PA) workforce specializing in critical care. The demand for critical care service delivery is growing, and the supply of physician critical care specialists is not fully meeting this demand. The purpose of this research is to describe the characteristics of PAs in critical care medicine.</p><p><strong>Design: </strong>Descriptive cross-sectional analysis.</p><p><strong>Setting: </strong>\"PA Professional Profile\" 2023 survey instrument from the National Commission on Certification for Physician Assistants.</p><p><strong>Subjects: </strong>PAs who have identified their role in critical care medicine.</p><p><strong>Interventions: </strong>Dataset regarding demographics, practice characteristics, income, and retention for the study population. Descriptive and bivariate statistics were used to compare findings of PAs practicing in critical care and PAs in all other disciplines.</p><p><strong>Measurements and main results: </strong>By the end of 2023, 2561 PAs reported working in critical care (2.0% of PAs). Of these PAs, 1738 (67.9%) were under age 40 (mean, 37.5; sd, 9.3), and 1740 (67.9%) had 10 years or less as a board-certified PA (mean, 9.3; sd, 7.8). The average income was $137,793 (sd, $32,882). Geographically, there were more PAs in critical care in the Northeast (38.7%) and South (36.1%) compared with other regions in the United States, and 2493 PAs in critical care (97.7%) resided in urban settings. Additionally, 408 PAs (16.1%) in critical care reported completing a postgraduate training program, more prevalent than PAs in all other specialties (5.4%; p < 0.001). More PAs in critical care report symptoms of burnout (n = 944; 38.5%) than PAs in all other specialties.</p><p><strong>Conclusions: </strong>Team-based and multidisciplinary health care is becoming standard in the ICU setting, and the role of PAs is growing in critical care. This follows a trend over the last 10 years of PAs increasingly working in inpatient acute care settings and completing postgraduate clinical training.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1250"},"PeriodicalIF":0.0,"publicationDate":"2025-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11957654/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143736308","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Women Physicians in Leadership Roles in Critical Care Medicine or Academic Medicine-A Systematic Literature Review.","authors":"Shahla Siddiqui, Bhargavi Gali, Elizabeth Cotter, Margo Short, Megan McNichol, Teresa A Mulaikal, Jessica Cassavaugh, Jarva Chow, Cortessa Russell, Shweta Y Golhar, Talia K Ben-Jacob","doi":"10.1097/CCE.0000000000001249","DOIUrl":"10.1097/CCE.0000000000001249","url":null,"abstract":"<p><strong>Objective: </strong>To systematically review and synthesize the evidence surrounding factors impacting women rising to leadership positions in critical care medicine (CCM).</p><p><strong>Data sources: </strong>PubMed, Embase, Web of Science, and Cochrane Library from 2011 to 2024.</p><p><strong>Study selection: </strong>Articles included were cohort studies, surveys, and interviews addressing women physicians practicing in CCM and related fields of academic medicine.</p><p><strong>Data extraction: </strong>Causes of not rising to leadership among women were extracted and tabulated along with other pertinent study characteristics.</p><p><strong>Data synthesis: </strong>The database searches generated 892 records. Thirty-nine studies met inclusion criteria for data extraction. The included articles represented seven countries, with 30 studies originating in the United States. Only two studies were from CCM, whereas others addressed leadership in other academic and clinical fields of medicine, medical journals, and societies and medical faculty. Twenty-six studies were qualitative, observational studies; five were survey based and eight included interviews. Using thematic analysis, the following five domains emerged: pipeline issues, lack of opportunities, lack of self-efficacy, lack of mentorship, and sustaining women in leadership.</p><p><strong>Conclusions: </strong>While the satisfaction rates of women in CCM were high, challenges remain for women to obtain leadership opportunities. A culture of support could better nurture and sustain women in leadership roles. More CCM-focused gender bias research is needed. Future targets for interventions include gender bias training, awareness, and developing strategies to break through the cycle of gender preferential promotions in CCM.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1249"},"PeriodicalIF":0.0,"publicationDate":"2025-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11957621/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143736309","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Performance of Pediatric Risk of Mortality IV in Brazilian PICUs: A Multicenter Prospective Study.","authors":"Gustavo Rodrigues-Santos, Arnaldo Prata-Barbosa, Fernanda Lima-Setta, Pedro Henrique Nunes Costa Silami, Mariana Barros Genuíno de Oliveira, Jaqueline Rodrigues Robaina, José Colleti Júnior, Felipe Rezende Caino de Oliveira, Luís Fernando Andrade de Carvalho, Mariana Digiovanni, Ana Paula Novaes Bellinat, Thiago Peres da Silva, Taisa Roberta Ramos Nantes de Castilho, Simone Camera Gregory, Ana Carolina Cabral Pinheiro Scarlato, Paula Marins Riveiro, José Oliva Proença Filho, Antonio José Ledo Alves da Cunha, Maria Clara de Magalhães-Barbosa, Claudia de Souza Lopes","doi":"10.1097/CCE.0000000000001243","DOIUrl":"10.1097/CCE.0000000000001243","url":null,"abstract":"<p><strong>Importance: </strong>This is the first Brazilian study evaluating the performance of Pediatric Risk of Mortality (PRISM) IV and the first to use the calibration belt technique.</p><p><strong>Objectives: </strong>This study aimed to evaluate the performance of PRISM IV in a large cohort of patients admitted to Brazilian PICUs.</p><p><strong>Design, setting and participants: </strong>This is a longitudinal, prospective, multicenter study conducted in 36 Brazilian PICUs with children between 29 days and 18 years old admitted from March 2020 to March 2022.</p><p><strong>Main outcomes and measures: </strong>PRISM IV's performance was assessed using the standardized mortality ratio (SMR), the area under the receiver operating characteristic curve (AUROC) with 95% CI, and the calibration belt with 80% and 95% CI.</p><p><strong>Results: </strong>A total of 12,046 patients from 36 PICUs were included. Observed overall in-hospital mortality was higher than predicted: observed = 249 (2.1%) × predicted = 188.1 (1.56%) (SMR = 1.32 [95% CI, 1.16-1.50]); discrimination was good (AUROC = 0.86 [95% CI, 0.83-0.89]), and calibration was poor, underestimating mortality over a wide range of predicted mortality (2-61%). To explore the impact of the COVID-19 pandemic on PRISM IV's performance, we divided the study period into prevaccine and postvaccine. In the prevaccine period, the SMR was 1.38 (95% CI, 1.17-1.62), the AUROC was 0.84 (95% CI, 0.80-0.88), and the range of miscalibration was broader than in the total cohort (underestimation in the 2-98% range). In the postvaccine period, the SMR was 1.26 (95% CI, 1.03-1.51), the AUROC was 0.90 (95% CI, 0.86-0.94), and the calibration belt underestimated mortality in a narrower range of 3-46% of predicted mortality.</p><p><strong>Conclusions and relevance: </strong>PRISM IV showed good discrimination but miscalibration across a wide range of predicted mortality and different COVID-19 pandemic periods in a large cohort. Further research with subgroup analyses are needed to develop strategies to improve the performance of PRISM IV in different and heterogeneous Brazilian healthcare contexts.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1243"},"PeriodicalIF":0.0,"publicationDate":"2025-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11957651/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143736307","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of Plasma Biomarkers to Understand the Biology and Heterogeneity of Treatment Effect in Lower Tidal Volume Ventilation Facilitated by Extracorporeal CO2 Removal in Acute Hypoxemic Respiratory Failure: A Secondary Analysis of the REST Trial.","authors":"Andrew J Boyle, Kiran Reddy, John Conlon, Georg Auzinger, Jonathan Bannard-Smith, Nicholas A Barrett, Luigi Camporota, Michael A Gillies, Colette Jackson, Clíona McDowell, Brijesh Patel, Gavin D Perkins, Tamás Szakmány, William Tunnicliffe, Ingeborg D Welters, James J McNamee, Daniel F McAuley, Cecilia M O'Kane","doi":"10.1097/CCE.0000000000001246","DOIUrl":"10.1097/CCE.0000000000001246","url":null,"abstract":"<p><strong>Objectives: </strong>In patients with acute hypoxemic respiratory failure (AHRF), the use of lower tidal volume ventilation facilitated by veno-venous extracorporeal CO2 removal (vv-ECCO2R) does not improve clinical outcomes. The primary objective of this analysis was to evaluate for differences in indices of systemic inflammation and ventilator-induced lung injury between patients treated with lower tidal volume ventilation facilitated by vv-ECCO2R and standard care. Secondary objectives included an evaluation for heterogeneity of treatment effect.</p><p><strong>Design: </strong>Substudy of a randomized clinical trial.</p><p><strong>Setting: </strong>Nine U.K. ICUs.</p><p><strong>Patients: </strong>Moderate-to-severe AHRF (Pao2: Fio2 < 150mmHg [20ka]).</p><p><strong>Intervention: </strong>Plasma samples obtained at baseline and day 3.</p><p><strong>Measurements and main results: </strong>The primary outcome was day 3 C-reactive protein (CRP). Clinical outcomes included 90-day mortality and ventilator-free days (VFD) until day 28. Exploratory analyses included an evaluation of plasma indices of lung injury, inflammation, and heterogeneity of treatment effect (HTE). Seventy-nine patients were enrolled, and 69 patients had paired plasma samples taken at baseline and day 3. There was no difference in day 3 plasma CRP (intervention 138.6 [70.4, 189.4] vs. standard care 113.0 [62.7, 233.8] mg/L; p = 0.72). Between baseline and day 3, there was a greater increase in plasma interleukin-18 in patients that received intervention compared with those that received standard care (Δ 337.7 [-128.9, 738.9] vs. 6.4 [-457.2, 6.4] pg/mL p = 0.05). In patients with high interleukin-18, allocation to intervention was associated with increased VFDs (p = 0.03). Similarly in patients with a hyperinflammatory phenotype, the intervention was independently associated with increased VFDs (p < 0.01) and decreased 90-day mortality (p = 0.01).</p><p><strong>Conclusions: </strong>In patients with moderate-to-severe AHRF, lower tidal volume ventilation, facilitated by vv-ECCO2R, was not associated with a difference in day 3 plasma CRP, but was associated with an increase in plasma interleukin-18 between baseline and day 3. Baseline plasma interleukin-18 and inflammatory phenotypes may identify subgroups of patients with moderate-to-severe AHRF that benefit from lower tidal volume ventilation facilitated by vv-ECCO2R.</p><p><strong>Trial registration: </strong>NCT02654327.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1246"},"PeriodicalIF":0.0,"publicationDate":"2025-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11952827/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143722849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}