Critical care explorations最新文献

{"title":"Multicenter Development and Prospective Validation of eCARTv5: A Gradient-Boosted Machine-Learning Early Warning Score.","authors":"Matthew M Churpek, Kyle A Carey, Ashley Snyder, Christopher J Winslow, Emily Gilbert, Nirav S Shah, Brian W Patterson, Majid Afshar, Alan Weiss, Devendra N Amin, Deborah J Rhodes, Dana P Edelson","doi":"10.1097/CCE.0000000000001232","DOIUrl":"10.1097/CCE.0000000000001232","url":null,"abstract":"<p><strong>Background: </strong>Early detection of clinical deterioration using machine-learning early warning scores may improve outcomes. However, most implemented scores were developed using logistic regression, only underwent retrospective validation, and were not tested in important subgroups.</p><p><strong>Objective: </strong>The objective of our multicenter retrospective and prospective observational study was to develop and prospectively validate a gradient-boosted machine model (eCARTv5) for identifying clinical deterioration on the wards.</p><p><strong>Derivation cohort: </strong>All adult patients admitted to the inpatient medical-surgical wards at seven hospitals in three health systems for model development (2006-2022).</p><p><strong>Validation cohort: </strong>All adult patients admitted to the inpatient medical-surgical wards and at 21 hospitals from three health systems for retrospective (2009-2023) and prospective (2023-2024) external validation.</p><p><strong>Prediction model: </strong>Predictor variables (demographics, vital signs, documentation, and laboratory values) were used in a gradient-boosted trees algorithm to predict ICU transfer or death in the next 24 hours. The developed model (eCARTv5) was compared with the Modified Early Warning Score (MEWS), the National Early Warning Score (NEWS), and eCARTv2 using the area under the receiver operating characteristic curve (AUROC).</p><p><strong>Results: </strong>The development cohort included 901,491 admissions, the retrospective validation cohort included 1,769,461 admissions, and the prospective validation cohort included 205,946 admissions. In retrospective validation, eCARTv5 had the highest AUROC (0.834; 95% CI, 0.834-0.835), followed by eCARTv2 (0.775 [95% CI, 0.775-0.776]), NEWS (0.766 [95% CI, 0.766-0.767]), and MEWS (0.704 [95% CI, 0.703-0.704]). eCARTv5's performance remained high (AUROC ≥0.80) across a range of patient demographics, clinical conditions, and during prospective validation.</p><p><strong>Conclusion: </strong>We developed eCARTv5, which performed better than eCARTv2, NEWS, and MEWS retrospectively, prospectively, and across a range of subgroups. These results served as the foundation for Food and Drug Administration clearance for its use in identifying deterioration in hospitalized ward patients.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1232"},"PeriodicalIF":0.0,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11949291/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143733149","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":"Visual-Guided Transillumination Method for Accurate Percutaneous Tracheal Tube Placement.","authors":"Diane C McLaughlin, Michael P Schaller, Julian Bösel, Mohamad Chmayssani","doi":"10.1097/CCE.0000000000001227","DOIUrl":"10.1097/CCE.0000000000001227","url":null,"abstract":"<p><strong>Background: </strong>Percutaneous tracheostomy (PT) is generally considered a safe procedure, but complications such as malpositioning, bleeding, and tracheal ring rupture remain concerns, particularly during initial needle insertion. This study investigates the feasibility, ease of use, and safety of a novel device and technique for bedside PT, named the Illuminated Tracheal Alignment Guide (iTAG).</p><p><strong>Methods: </strong>An interventional pilot study evaluated the feasibility and safety of the iTAG device and method. The study was approved by our local institutional review board and a Food and Drug Administration waiver was granted for use of our device. Patients in a neurocritical care unit requiring tracheostomy were screened and consented for inclusion. Exclusion criteria included significant vascular overlap and specific ventilator settings. The iTAG method involves a laser light source and a needle guide with a hard stop, used in conjunction with standard PT equipment. Data on demographics, procedure details, and early complications were collected and compared with historical control data from patients who underwent standard tracheostomy (ST).</p><p><strong>Results: </strong>From January 2023 to July 2024, 30 patients underwent PT using the iTAG device. The mean time from intubation to tracheostomy was 15.53 days, with a mean ICU length of stay of 31.14 days. The iTAG group experienced significantly fewer early complications compared with the historical ST control group, including reduced hemorrhage, and there were no instances of tracheal ring fracture, posterior wall injury, or pneumothorax. The iTAG method allowed for safe PT in all patients.</p><p><strong>Conclusions: </strong>The iTAG device enhances the safety and efficacy of PT by providing precise visualization and limiting needle penetration, reducing early complications. Its use expands patient candidacy for PT and offers a valuable tool for training less-experienced practitioners. Further research with larger cohorts and randomized controlled trials is needed to confirm these findings and establish the iTAG method as a standard of care for PT.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1227"},"PeriodicalIF":0.0,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11949292/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143722765","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":"Airway Safety During Mechanical Ventilation: Survey of ICU Clinicians Practices and Perceptions.","authors":"Maged A Tanios, Jaqueline C Stocking, Jean G Charchaflieh, Andrew G Miller, Jay V Patel, Antonia L Vilella, Huan Mark Nguyen, Scott K Epstein, Antonio Beltran, John W Devlin","doi":"10.1097/CCE.0000000000001234","DOIUrl":"10.1097/CCE.0000000000001234","url":null,"abstract":"<p><p>We report results from a survey of members of the Society of Critical Care Medicine to assess ICU clinicians' perceptions of artificial airway safety practices and unplanned extubation (UE) prevention. The survey was distributed between January and February 2024 and received 518 responses (68.5% response rate), with 87.5% from adult ICUs and 12.5% from Pediatric ICUs. Only 48% of adult ICU respondents tracked UE, compared with 73% tracking pressure injuries. Most respondents did not consider UE a \"never event,\" with over half viewing it as unavoidable. In adult ICUs, delirium was ranked as the highest UE risk factor, and commercial securement devices were the primary endotracheal tube securement method (75.2%). Significant variations were observed in artificial airway management practices and responsibility assignments across ICU settings. The results highlight substantial disparities in airway safety management beliefs and practices, underscoring the need for standardized, evidence-based guidelines.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1234"},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11936560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143701525","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":"Practice Pattern Variation in Management of Severe Acute Asthma Among Mechanically Ventilated Patients in Pediatric Versus Adult ICUs.","authors":"Aaron Dobie, Burton Shen, Collin Homer-Bouthiette, Divya Shankar, Brandon Pang, Anica Law, Nicholas A Bosch","doi":"10.1097/CCE.0000000000001233","DOIUrl":"10.1097/CCE.0000000000001233","url":null,"abstract":"<p><p>A large multicenter retrospective study was conducted to examine practice patterns in the care of severe acute asthma in PICUs compared with adult ICUs. Eligible patients were 12-26 y old, admitted to a PICU or an adult ICU with severe acute asthma, and received noninvasive ventilation or mechanical ventilation. Multiple medication prescribing practice patterns were examined. 3,361 total patients were included: 583 (17.3%) were admitted to PICUs and 2,778 (82.7%) were admitted to adult ICUs. Significantly more patients admitted to PICUs received parenteral terbutaline (25.7% vs. 10.2%, standard mean differences = 0.412) than those admitted to adult ICUs. Admission to PICUs for asthma was associated with a trend toward increased mortality, cardiac arrhythmias and duration of mechanical ventilation compared with adult ICUs. Further studies are needed to assess the safety and efficacy of parenteral terbutaline in adolescents and young adults; guidelines for the management of severe acute asthma in the ICU are needed.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 4","pages":"e1233"},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11936554/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143702211","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":"Right Atrial Dysfunction Is Prevalent in Pediatric Acute Respiratory Distress Syndrome and Reflects Pulmonary Hypertension and Right Ventricular Dysfunction.","authors":"Nathan D Markiewitz, Yan Wang, Robert A Berg, Nadir Yehya, Celeste Dixon, Laura Mercer-Rosa, Adam S Himebauch","doi":"10.1097/CCE.0000000000001230","DOIUrl":"10.1097/CCE.0000000000001230","url":null,"abstract":"<p><strong>Importance: </strong>Right atrial (RA) dysfunction is associated with worse outcomes in some populations with pulmonary hypertension or respiratory failure but the prevalence and correlates of RA dysfunction in pediatric acute respiratory distress syndrome (PARDS) are unknown.</p><p><strong>Objectives: </strong>The aim of this study was to evaluate RA function by characterizing the prevalence and pattern of RA dysfunction within the first 24 hours of PARDS onset. We hypothesized that RA dysfunction would be common and correlate with the presence of pulmonary hypertension and right ventricular (RV) systolic dysfunction.</p><p><strong>Design, setting, and participants: </strong>Retrospective, single-center cohort study at a tertiary care PICU of children (< 18 yr) with a clinically obtained echocardiogram within 24 hours following PARDS diagnosis and healthy controls without cardiopulmonary disease.</p><p><strong>Main outcomes and measures: </strong>Echocardiograms were evaluated for conventional and speckle-tracking (or strain) echocardiographic measures of RA and RV systolic function. Nonparametric summary statistics, comparisons, and correlational analyses were completed.</p><p><strong>Results: </strong>Ninety-two PARDS patients and 55 controls were included. Using a priori thresholds (> 2 sds of control values), 49% (n = 45) of PARDS patients demonstrated RA dysfunction in at least one RA functional metric. The maximal RA strain during the reservoir phase was reduced in PARDS compared with controls (median 40.2% vs. 53.7%; p < 0.001). Patients with echocardiographic evidence of pulmonary hypertension had lower maximal RA strain during the reservoir phase (31.7%) compared with patients without (40.5%; p < 0.05). Patients with higher brain-type natriuretic peptide plasma concentrations had worse RA function. RA function significantly correlated with conventional and strain measures of RV systolic function.</p><p><strong>Conclusions and relevance: </strong>RA dysfunction is common within the first 24 hours of PARDS onset. RA dysfunction during the reservoir phase is associated with pulmonary hypertension and RV systolic dysfunction. Future studies investigating trajectories of RA function and their association with outcomes in PARDS patients are needed.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1230"},"PeriodicalIF":0.0,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11922415/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143660107","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":"A Pilot Study Assessing the Utility of Quantitative Myeloid-Derived Suppressor Cell Measurements in Detecting Posttraumatic Infection.","authors":"Grant E O'Keefe, Yiyang Wu, Nina Mirabadi, Minjun Apodaca, Qian Qui, Chihiro Morishima","doi":"10.1097/CCE.0000000000001228","DOIUrl":"10.1097/CCE.0000000000001228","url":null,"abstract":"<p><strong>Objectives: </strong>Biomarkers that facilitate earlier diagnosis of posttraumatic infection could improve outcomes by expediting treatment and mitigating complications, including sepsis. We hypothesized that circulating myeloid-derived suppressor cell (MDSC) counts could identify patients with posttraumatic infection.</p><p><strong>Design, setting, and patients: </strong>We conducted a single-center, prospective observational pilot study of trauma victims who required greater than or equal to 48 hours of mechanical ventilation. Whole blood was collected and tested by flow cytometry.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Samples were analyzed in real-time with an 11-parameter quantitative MDSC assay. Two physician adjudications of infection were performed through a blinded review of medical records. MDSC and other cell counts were compared between subjects with and without posttraumatic infection using non-parametric methods. Data are presented as medians (25th-75th percentile). The area under the receiver operating characteristic (ROC) curves were used to assess the accuracy of cell counts for diagnosing infection. Most subjects (n = 39) were male (79%) with a median age of 48 (interquartile range [IQR] 32-65), Injury Severity Score of 29 (IQR 21-41), and ICU length of stay of 13 days (IQR 8-19). Twenty-one (54%) developed an infection and 11 (28%) of the cohort died. We compared total MDSC (T-MDSC) counts closest to the day of infection diagnosis with the initial T-MDSC counts in subjects without infection. T-MDSC counts were higher in those with infection compared to those without infection (696 [368-974] and 304 [181-404] cells/μL, respectively; p < 0.001). Lymphocyte, neutrophil, and CD45+ leukocyte counts were not statistically different between the groups. The area under the ROC curve distinguishing those with infection from those without for T-MDSC was 0.83 (p < 0.001).</p><p><strong>Conclusions: </strong>MDSC counts determined by quantitative whole blood flow cytometrics can detect posttraumatic infection and may be useful to guide further diagnostic testing in critically ill trauma victims.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1228"},"PeriodicalIF":0.0,"publicationDate":"2025-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11918587/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143660105","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":"A Pilot Study Assessing the Utility of Quantitative Myeloid-Derived Suppressor Cell Measurements in Detecting Posttraumatic Infection.","authors":"Grant E O'Keefe, Yiyang Wu, Nina Mirabadi, Minjun Apodaca, Qian Qui, Chihiro Morishima","doi":"10.1097/CCE.0000000000001228","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001228","url":null,"abstract":"<p><strong>Objectives: </strong>Biomarkers that facilitate earlier diagnosis of posttraumatic infection could improve outcomes by expediting treatment and mitigating complications, including sepsis. We hypothesized that circulating myeloid-derived suppressor cell (MDSC) counts could identify patients with posttraumatic infection.</p><p><strong>Design setting and patients: </strong>We conducted a single-center, prospective observational pilot study of trauma victims who required greater than or equal to 48 hours of mechanical ventilation. Whole blood was collected and tested by flow cytometry.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Samples were analyzed in real-time with an 11-parameter quantitative MDSC assay. Two physician adjudications of infection were performed through a blinded review of medical records. MDSC and other cell counts were compared between subjects with and without posttraumatic infection using non-parametric methods. Data are presented as medians (25th-75th percentile). The area under the receiver operating characteristic (ROC) curves were used to assess the accuracy of cell counts for diagnosing infection. Most subjects (<i>n</i> = 39) were male (79%) with a median age of 48 (interquartile range [IQR] 32-65), Injury Severity Score of 29 (IQR 21-41), and ICU length of stay of 13 days (IQR 8-19). Twenty-one (54%) developed an infection and 11 (28%) of the cohort died. We compared total MDSC (T-MDSC) counts closest to the day of infection diagnosis with the initial T-MDSC counts in subjects without infection. T-MDSC counts were higher in those with infection compared to those without infection (696 [368-974] and 304 [181-404] cells/μL, respectively; <i>p</i> < 0.001). Lymphocyte, neutrophil, and CD45+ leukocyte counts were not statistically different between the groups. The area under the ROC curve distinguishing those with infection from those without for T-MDSC was 0.83 (<i>p</i> < 0.001).</p><p><strong>Conclusions: </strong>MDSC counts determined by quantitative whole blood flow cytometrics can detect posttraumatic infection and may be useful to guide further diagnostic testing in critically ill trauma victims.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1228"},"PeriodicalIF":0.0,"publicationDate":"2025-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11918587/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143660104","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":"Interferon Regulatory Factor 3 Exacerbates the Severity of COVID-19 in Mice.","authors":"Wendy E Walker, Luiz F Garcia, Pedro M Palermo, Nawar Hakim, Dinesh G Goswami, Alok K Dwivedi, Douglas M Watts","doi":"10.1097/CCE.0000000000001225","DOIUrl":"10.1097/CCE.0000000000001225","url":null,"abstract":"<p><strong>Context: </strong>Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in 2019, causing the COVID-19 pandemic. While most infected people experienced mild illness, others progressed to severe disease, characterized by hyperinflammation and respiratory distress. There is still much to learn about the innate immune response to this virus. Interferon regulatory factor 3 (IRF3) is a transcription factor that is activated when pattern recognition receptors detect viruses. Upon activation, IRF3 induces the expression of interferon beta (IFN-β) and interferon-stimulated genes, which protect the host from viral infection. However, coronaviruses antagonize this pathway, delaying type 1 IFN production. It is, therefore, unclear how IRF3 influences COVID-19 disease. Our prior reports showed that IRF3 promotes harmful inflammation during bacterial sepsis in mice.</p><p><strong>Hypothesis: </strong>We hypothesized that IRF3 cannot effectively control the SARS-CoV-2 viral load and instead promotes harmful inflammation during severe COVID-19.</p><p><strong>Methods and models: </strong>We used mice transgenic for the human angiotensin converting-enzyme 2 transgene, driven by the keratin 18 promoter (K18-ACE2 mice) that were IRF3 deficient or IRF3 sufficient to test how IRF3 influences COVID-19 disease.</p><p><strong>Results: </strong>Upon infection with SARS-CoV-2, K18-ACE2 mice showed a dose-dependent disease, characterized by mortality, lethargy, weight loss, and lung pathology, reminiscent of clinical COVID-19. However, K18-ACE2 mice lacking IRF3 were protected from severe disease with reduced mortality (84.6% vs. 100%) and disease score. We found that IRF3 promoted IFN-β production in the lungs and reprogrammed the cytokine profile, while viral load in the lungs was similar in the presence or absence of IRF3.</p><p><strong>Interpretations and conclusions: </strong>These data indicated that IRF3 played a detrimental role in murine COVID-19 associated with changes in IFN-β and inflammatory cytokines.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1225"},"PeriodicalIF":0.0,"publicationDate":"2025-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11918655/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143660106","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":"Host Response Protein Biomarkers Indicative of Persistent Acute Kidney Injury in Critically Ill COVID-19 Patients.","authors":"Thei S Steenvoorden, Koen C de Kruijf, Brent Appelman, Bas Moggre, Lieuwe D J Bos, Alexander P J Vlaar, Reneé A Douma, Fabrice Uhel, Jesper Kers, Jetta J Oppelaar, Lonneke A van Vught, Martijn Beudel, Paul W G Elbers, W Joost Wiersinga, Tom van der Poll, Liffert Vogt, Hessel Peters-Sengers","doi":"10.1097/CCE.0000000000001222","DOIUrl":"10.1097/CCE.0000000000001222","url":null,"abstract":"<p><strong>Importance: </strong>Sepsis-related host-response anomalies contribute to acute kidney injury (AKI) duration. Data on the host-response specific to COVID-19-associated AKI (COVID-AKI) in critically ill patients is limited.</p><p><strong>Objectives: </strong>We postulated that persistent COVID-AKI (> 48 hr) differs in host response from transient (< 48 hr) or no COVID-AKI.</p><p><strong>Design, setting, and participants: </strong>This prospective biomarker study observed patients with severe acute respiratory syndrome coronavirus 2 infection, without chronic kidney disease, in three ICUs from March 2020 to July 2020. AKI was assessed by hourly urine output and daily plasma creatinine.</p><p><strong>Main outcomes and measures: </strong>Luminex and enzyme-linked immunosorbent assay were used to analyze 48 plasma protein biomarkers across six pathophysiological domains, which were tested with mixed-effects models.</p><p><strong>Results: </strong>Of 177 included patients, 106 (59.9%) had AKI within the first 48 hours of admission, of whom 76 (71.7%) had persistent AKI and 30 (28.3%) transient AKI. Those with persistent AKI often had obesity, hypertension, and a higher Sequential Organ Failure Assessment score due to the renal component. Longitudinal analyses revealed that seven proteins were elevated in persistent AKI compared with no AKI. These were related to inflammation (triggering receptor expressed on myeloid cells 1, p < 0.001; tumor necrosis factor receptor 1, p < 0.001; procalcitonin, p = 0.001), complement activation (mannan-binding lectin serine protease-2, p = 0.001), kidney dysfunction (cystatin C, p < 0.001; neutrophil gelatinase-associated lipocalin, p < 0.001), and lung dysfunction (Clara cell secretory protein 16, p < 0.001). AKI (duration) was not associated with differences in the cytokine signaling, endothelial cell activation, or coagulation domains.</p><p><strong>Conclusions and relevance: </strong>In contrast with sepsis-associated AKI, primarily inflammation-related biomarker levels correlated with COVID-AKI persistence. This study offers insights into COVID-AKI and may guide approaches to mitigate its persistence.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1222"},"PeriodicalIF":0.0,"publicationDate":"2025-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11908758/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143627095","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":"The Case for Telemedicine-Enhanced Nighttime Staffing in a Neuro-ICU.","authors":"Belinda L Udeh, Nicolas R Thompson, Ryan D Honomichl, Brittany R Lapin, Irene L Katzan, Lori Griffiths, Joao A Gomes","doi":"10.1097/CCE.0000000000001231","DOIUrl":"10.1097/CCE.0000000000001231","url":null,"abstract":"<p><strong>Importance: </strong>This study compares the health outcomes and healthcare utilization of two staffing models for specialized neuro-ICU (NICU): a 24/7 intensive staffing (IS) model and a daytime 12-hour intensivist model with 12-hour nocturnal telemedicine-enhanced (TE) coverage. The IS model was studied from July 2016 to June 2017. The TE model was studied during the implementation period from July 2017 to June 2018.</p><p><strong>Objectives: </strong>To compare the health outcomes and healthcare utilization of two staffing models for a specialized NICU.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting and participants: </strong>NICU with 24 beds in a 1200-bed urban, quaternary care, academic hospital in Northeast Ohio. Participants were critically ill patients with primary neurologic injuries admitted to the NICU between July 2016 and June 2018.</p><p><strong>Main outcomes and measures: </strong>Multivariable logistic, and negative binomial regression analysis compared the following outcomes: mortality, ICU length of stay (LOS), hospital LOS, and ventilator days. Demographics and patient characteristics, including Acute Physiology and Chronic Health Evaluation scores, were used in model adjustments.</p><p><strong>Results: </strong>Three thousand seventy-three patients were studied: n equals to 1542 IS (average age 61 yr [sd 17], 49% female, 73% White race) and n equals to 1531 TE (average age 62 yr (sd 17), 49% female, 70% White race). The TE model required less staff than IS model (5 vs. 9 staff intensivists), respectively. Compared with IS, the TE cohort had similar demographics and clinical indications, although the groups differed on the distribution of the body systems necessitating ICU admission. TE model was protective of ICU mortality compared with IS model (odds ratio = 0.59; 95% CI, 0.43-0.82; p = 0.002). However, TE was associated with a 10% increase in ICU LOS (incident rate ratio [IRR] = 1.10; 95% CI, 1.03-1.18; p = 0.006) and a 13% increase in total LOS (IRR = 1.13; 95% CI, 1.06-1.20; p < 0.001). There was no difference in ventilator days between groups.</p><p><strong>Conclusions and relevance: </strong>The availability of critical care staff is not keeping pace with demand, especially in specialized ICUs, including NICU. The TE model required fewer staff with similar clinical outcomes. This is a preliminary study highlighting that alternate specialized ICU staffing models could require fewer labor requirements while still maintaining quality of care. Further research is required to assess the true impact of LOS differences and examine the impact of these models on physician burnout and retention. This new understanding would provide additional guidance on ICU staffing options and telemedicine costs to hospitals, ensuring efficient and effective resource allocation as ICU demands continue to increase.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"7 3","pages":"e1231"},"PeriodicalIF":0.0,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11884836/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143558434","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}