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49 emner vises.
Liang Feng Yunyan Qiu Qing-Hui Guo Zhijie Chen James S. W. Seale Kun He Huang Wu Yuanning Feng Omar K. Farha R. Dean Astumian J. Fraser Stoddart
Science, 21.10.2021
Tilføjet 30.11.2021
Xiao Mi, Pedram Roushan, Chris Quintana, Salvatore Mandrà,, Jeffrey Marshall,, Charles Neill, Frank Arute, Kunal Arya, Juan Atalaya, Ryan Babbush, Joseph C. Bardin,, Rami Barends, Joao Basso, Andreas Bengtsson, Sergio Boixo, Alexandre Bourassa,, Michael Broughton, Bob B. Buckley, David A. Buell, Brian Burkett, Nicholas Bushnell, Zijun Chen, Benjamin Chiaro, Roberto Collins, William Courtney, Sean Demura, Alan R. Derk, Andrew Dunsworth, Daniel Eppens, Catherine Erickson, Edward Farhi, Austin G. Fowler, Brooks Foxen, Craig Gidney, Marissa Giustina, Jonathan A. Gross, Matthew P. Harrigan, Sean D. Harrington, Jeremy Hilton, Alan Ho, Sabrina Hong, Trent Huang, William J. Huggins, L. B. Ioffe, Sergei V. Isakov, Evan Jeffrey, Zhang Jiang, Cody Jones, Dvir Kafri, Julian Kelly, Seon Kim, Alexei Kitaev,, Paul V. Klimov, Alexander N. Korotkov,, Fedor Kostritsa, David Landhuis, Pavel Laptev, Erik Lucero, Orion Martin, Jarrod R. McClean, Trevor McCourt, Matt McEwen,, Anthony Megrant, Kevin C. Miao, Masoud Mohseni, Shirin Montazeri, Wojciech Mruczkiewicz, Josh Mutus, Ofer Naaman, Matthew Neeley, Michael Newman, Murphy Yuezhen Niu, Thomas E. O'Brien, Alex Opremcak, Eric Ostby, Balint Pato, Andre Petukhov, Nicholas Redd, Nicholas C. Rubin, Daniel Sank, Kevin J. Satzinger, Vladimir Shvarts, Doug Strain, Marco Szalay, Matthew D. Trevithick, Benjamin Villalonga, Theodore White, Z. Jamie Yao, Ping Yeh, Adam Zalcman, Hartmut Neven, Igor Aleiner, Kostyantyn Kechedzhi, Vadim Smelyanskiy, Yu Chen
Science, 28.10.2021
Tilføjet 30.11.2021
Zhen Zhu, Michał Papaj, Xiao-Ang Nie, Hao-Ke Xu, Yi-Sheng Gu, Xu Yang, Dandan Guan, Shiyong Wang, Yaoyi Li, Canhua Liu, Jianlin Luo, Zhu-An Xu, Hao Zheng, Liang Fu, Jin-Feng Jia
Science, 28.10.2021
Tilføjet 30.11.2021
Chotalia, Minesh; Ali, Muzzammil; Alderman, Joseph; Kalla, Manish; Parekh, Dhruv; Bangash, Mansoor; Patel, Jaimin
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Chotalia, Minesh; Ali, Muzzammil; Alderman, Joseph E.; Kalla, Manish; Parekh, Dhruv; Bangash, Mansoor; Patel, Jaimin
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Dionne, Joanna C.; Oczkowski, Simon J. W.; Hunt, Beverley J.; Antonelli, Massimo; Wijnberge, Marije; Raasveld, Senta Jorinde; Vlaar, Alexander P. J.; for ESICM Transfusion Taskforce and the GUIDE Group
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Tranexamic acid is proposed as a treatment for gastrointestinal bleeding. The Haemorrhage Alleviation with Tranexamic Acid-Intestinal System trial evaluated extended-use (24 hr) high-dose tranexamic acid, prompting a reappraisal for tranexamic acid in gastrointestinal bleeding.
Data Sources:
We conducted a systematic review and meta-analysis of randomized controlled trials comparing tranexamic acid with usual care or placebo in adults with gastrointestinal bleeding. We searched MEDLINE, EMBASE, and CENTRAL (inception to September 2019).
Data Selection:
Two reviewers independently screened citations, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool in duplicate. The main outcomes were mortality, bleeding, and adverse events.
Data Extraction:
Studies were analyzed as high-dose IV tranexamic acid versus all other dosing strategies for tranexamic acid using fixed-effects models. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.
Data Synthesis:
Five randomized controlled trials evaluated extended-use high-dose IV tranexamic acid, seven evaluating low-dose IV or enteral tranexamic acid. Extended-use high-dose IV tranexamic acid did not reduce mortality (relative risk, 0.98%; 95% CI, 0.88–1.09; I2 = 63%; high certainty) or bleeding (relative risk, 0.92; 95% CI, 0.82–1.04; p = 0.17 and absolute risk differences, –0.7%; 95% CI, –1.5 to 0.3; high certainty) but resulted in a small increase in deep venous thrombosis (relative risk, 2.01; 95% CI, 1.08–3.72; I2 = 0%), pulmonary embolism (relative risk, 1.78; 95% CI, 1.06–3.0; I2 = 0%), and seizure (relative risk, 1.73; 95% CI, 1.03–2.93) with high certainty. Low-dose IV/enteral tranexamic acid did not reduce mortality (relative risk, 0.62; 95% CI, 0.36–1.09; I2 = 0%) but did reduce risk of rebleeding (relative risk, 0.5; 95% CI, 0.33–0.75; I2 = 9%) and need for surgery (relative risk, 0.58; 95% CI, 0.38–0.88; I2 = 11%), with moderate certainty.
Conclusions:
Extended-use high-dose IV tranexamic acid does not improve mortality or bleeding outcomes and increases adverse events. Low-dose/enteral tranexamic acid may be effective in reducing hemorrhage; more evidence is required to demonstrate its safety.
Members of the ESICM Transfusion Taskforce are: Alexander Vlaar, Joanna C. Dionne, Sanne de Bruin, Marije Wijnberge, S. Jorinde Raasveld, Frank E.H.P.van Baarle, Massimo Antonelli, Cecile Aubron, Jacques Duranteau, Nicole P. Juffermans, Jens Meier, Gavin J. Murphy, Riccardo Abbasciano, Marcella Müller, Marcus Lance, Nathan D. Nielsen, Herbert Schöchl, Beverly J. Hunt, Maurizio Cecconi, and Simon Oczkowski.
Members of the GUIDE Group are: Joanna Dionne, SImon Oczkowski, Waleed Alhazzani, Emilie Belley-Cote, Erick Duan, Bram Rochwerg, John Centofanti, Mats Junek, Lawrence Mbuagbaw, Mohammed Alsharani, Fayez Alshamsi, Wojciech Szczeklik, Roman Jaeschke, Karin Dearness, Morten Hylander, Ekkehard Kasper, Mark Soth, Dan Peri, Lehana Thabane, and Gordon Guyatt.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Dionne and Oczkowski are cofirst authors.
Dr. Oczkowski received payment as a methodology consultant for the American Thoracic Society. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: dionnejc@mcmaster.ca
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedSaade, Anastasia; Bourmaud, Aurelie; Schnell, David; Darmon, Michael; for the R2D2 Study Group
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The Doppler-based resistive index and semiquantitative evaluation of renal perfusion using color Doppler failed to discriminate renal recovery patterns in a recent study. The influence of operator experience on resistive index and semiquantitative evaluation of renal perfusion performances is however unknown. This study aimed at evaluating the performance of resistive index and semiquantitative evaluation of renal perfusion according to the operator experience to predict short-term renal prognosis in critically ill patients.
Design:
Preplanned ancillary analysis of a prospective multicenter cohort study.
Setting:
Seven ICUs.
Patients:
Unselected ICU patients.
Intervention:
Renal Doppler was performed at admission to the ICU. The diagnostic performance of resistive index and semiquantitative evaluation of renal perfusion to predict persistent acute kidney injury at day 3 was evaluated.
Main results:
Overall, 371 patients were included, of whom 351 could be assessed for short-term renal recovery. Two thirds of the included patients had acute kidney injury (n = 233; 66.3%), of whom 136 had persistent acute kidney injury (58.4%). Overall performance in discriminating persistent acute kidney injury was however null with an area under the receiver operating characteristic curve less than 0.6 for both resistive index and semiquantitative evaluation of renal perfusion, and no difference across operator experience. A multivariate analysis using logistic regression with the center as a random effect adjusted on the operator experience showed no association between resistive index (odds ratio, 0.02 per international units (95% CI, 0.00–18.60 international units]) or semiquantitative evaluation of renal perfusion (odds ratio, 0.96 per international units [95% CI, 0.43–2.11 international units]) and persistent acute kidney injury. Similar results were obtained within subgroups of expert and nonexpert operators.
Conclusions:
Doppler-based measurements performed by an expert or a nonexpert operator did not discriminate renal recovery patterns and neither modified the risk stratification of acute kidney injury persistence.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
ClinicalTrials.gov: NCT02355314.
A list of R2D2 Study Group investigators is reported in the Supplementary Appendix (http://links.lww.com/CCM/G913).
Dr. Darmon disclosed that this study was supported by Saint-Etienne University Hospital. The remaining authors have disclosed that they do not have any potential conflicts of interest.
ClinicalTrials.
For information regarding this article, E-mail: michael.darmon@aphp.fr
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedLim, Michelle J.; Zinter, Matt S.; Chen, Lucia; Wong, Kayley Man Yee; Bhalla, Anoopindar; Gala, Kinisha; Guglielmo, Mona; Alkhouli, Mustafa; Huard, Leanna L.; Hanudel, Mark R.; Vangala, Sitaram; Schwingshackl, Andreas; Matthay, Michael; Sapru, Anil
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Soluble receptor for advanced glycation end products is a known plasma marker of alveolar epithelial injury. However, RAGE is also expressed on cell types beyond the lung, and its activation leads to up-regulation of pro-inflammatory mediators. We sought to examine the relationship between plasma soluble receptor for advanced glycation end products and primary pulmonary dysfunction, extrapulmonary organ dysfunction, and mortality in pediatric acute respiratory distress syndrome patients at two early time points following acute respiratory distress syndrome diagnosis and compare these results to plasma surfactant protein-D, a marker of pure alveolar epithelial injury.
Design:
Prospective observational study.
Setting:
Five academic PICUs.
Patients:
Two hundred fifty-eight pediatric patients 30 days to 18 years old meeting Berlin Criteria for acute respiratory distress syndrome.
Interventions:
None.
Measurements and Main Results:
Plasma was collected for soluble receptor for advanced glycation end products and surfactant protein-D measurements within 24 hours (day 1) and 48 to 72 hours (day 3) after acute respiratory distress syndrome diagnosis. Similar to surfactant protein-D, plasma soluble receptor for advanced glycation end products was associated with a higher oxygenation index (p < 0.01) and worse lung injury score (p < 0.001) at the time of acute respiratory distress syndrome diagnosis. However, unlike surfactant protein-D, plasma soluble receptor for advanced glycation end products was associated with worse extrapulmonary Pediatric Logistic Organ Dysfunction score during ICU stay (day 3; p < 0.01) and positively correlated with plasma levels of interleukin-6 (p < 0.01), tumor necrosis factor-α (p < 0.01), and angiopoietin-2 (p < 0.01). Among children with indirect lung injury, plasma soluble receptor for advanced glycation end products was associated with mortality independent of age, sex, race, cancer/bone marrow transplant, and Pediatric Risk of Mortality score (day 3; odds ratio, 3.14; 95% CI, 1.46–6.75; p < 0.01).
Conclusions:
Unlike surfactant protein-D, which is primarily localized to the alveolar epithelium plasma soluble receptor for advanced glycation end products is systemically expressed and correlates with markers of inflammation, extrapulmonary multiple organ dysfunction, and death in pediatric acute respiratory distress syndrome with indirect lung injury. This suggests that unlike surfactant protein-D, soluble receptor for advanced glycation end products is a multifaceted marker of alveolar injury and increased inflammation and that receptor for advanced glycation end products activation may contribute to the pathogenesis of multiple organ failure among children with indirect acute respiratory distress syndrome.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Lim, Dr. Sapru, and Ms. Chen had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Drs. Lim and Sapru were involved in study concept and design and drafting of the article. Drs. Zinter, Alkhouli, and Sapru were involved in acquisition of data. Dr. Lim, Dr. Zinter, Ms. Chen, Mr. Vangala, and Dr. Sapru were involved in analysis and interpretation of data. Ms. Chen and Mr. Vangala were involved in statistical analysis. Drs. Lim, Zinter, and Alkhouli were involved in administrative, technical, or material support. Dr. Sapru was involved in study supervision. All authors were involved in critical revision of the article for important intellectual content and approval of final article.
Supported, in part, by grant from the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute K23HL085526 (to Dr. Sapru), R01HL114484 (to Dr. Sapru), and NIH National Institute of Diabetes and Digestive Kidney Diseases T32DK10468704 (to Dr. Lim).
Preliminary analysis of a portion of this work was presented, in part, at the Pediatric Academic Societies Meeting, San Francisco, CA, May 2017 and at the American Thoracic Society International Conference, Dallas, CA, May 2019.
Drs. Lim’s and Sapru’s institutions received funding from the National Institutes of Health (NIH). Drs. Lim, Zinter, Alkhouli, and Sapru received support for article research from the NIH. Drs. Zinter’s and Alkhouli’s institution received funding from the National Heart, Lung, and Blood Institute (K23HL146936). Dr. Zinter’s institution received funding from the National Institute of Child Health and Human Development (K12HD000850); he disclosed the off-label product use of anti-receptor for advanced glycation end products antibodies. Dr. Matthay’s institution received funding from Roche-Genetec; he received funding from Citius Pharmaceuticals and Novartis Pharmaceuticals. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: anilsapru@ucla.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedGannon, Whitney D.; Stokes, John W.; Pugh, Meredith E.; Bacchetta, Matthew; Benson, Clayne; Casey, Jonathan D.; Craig, Lynne; Semler, Matthew W.; Shah, Ashish S.; Troutt, Ashley; Rice, Todd W.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Extracorporeal membrane oxygenation has become integral to critical care. Data informing optimal extracorporeal membrane oxygenation education modalities are lacking. We aimed to compare the effect of high-fidelity simulation versus interactive mobile learning on extracorporeal membrane oxygenation knowledge acquisition and retention among clinicians.
Design:
Observer-blinded, randomized controlled trial.
Setting:
A single academic medical center.
Subjects:
Forty-four critical care clinicians with limited extracorporeal membrane oxygenation experience.
Interventions:
Participants were randomized to receive: 1) simulation: three high-fidelity training scenarios, 2) QuizTime: 15 total multiple-choice questions delivered over 3 weeks via mobile device, or 3) experiential: no formal training. Participants completed a survey, written knowledge examination, and simulation assessment prior to randomization, immediately following the intervention, and 4 month postintervention.
Measurements and Main Results:
The primary outcome was knowledge about extracorporeal membrane oxygenation assessed by score on the immediate postintervention written examination. Secondary outcomes included performance in extracorporeal membrane oxygenation simulation postintervention and 4 months later assessed by a rater blinded to group assignment. Clinicians randomized to simulation (n = 15), QuizTime (n = 14), and experiential (n = 15) had similar baseline characteristics. Adjusting for baseline knowledge, postintervention examination scores were higher in the simulation group (90.0%; interquartile range, 85.0–90.0%) than the QuizTime group (70.0%; interquartile range, 65.0–80.0%; p = 0.0003) and the experiential group (75.0%; interquartile range, 65.0–80.0%; p = 0.001). Scores did not differ between the groups at 4 months (p > 0.05 in all analyses). In postintervention extracorporeal membrane oxygenation simulations, the simulation group demonstrated shorter time to critical action compared with QuizTime (80.0 s [interquartile range, 54.0–111.0 s] vs 300.0 s [interquartile range 85.0–300.0 s]; p = 0.02) and compared with both QuizTime (45.0 s [interquartile range, 34.0–92.5 s] vs 255.5 s [interquartile range, 102.0–300.0 s]; p = 0.008) and experiential (300.0 s [interquartile range, 58.0–300.0 s]; p = 0.009) at 4 months.
Conclusions:
Simulation was superior to QuizTime and experiential learning with regard to extracorporeal membrane oxygenation knowledge acquisition. Further studies are needed to ascertain the effect of these interventions on knowledge retention, clinical performance, and patient outcomes.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Ms. Gannon received support from the Vanderbilt Institute for Clinical and Translational Research, which is funded by the National Center for Advancing Translational Sciences Clinical Translational Science Award Program, Award Number 5UL1TR002243-03. Ms. Gannon’s institution received funding from the National Center for Advancing Translational Sciences Clinical Translational Science Award Program (5UL1TR002243-03). Dr. Pugh received funding from Chest Foundation. Drs. Casey, Semler, and Rice received support for article research from the National Institutes of Health. Dr. Semler’s institution received funding from the National Heart, Lung, and Blood Institute. Dr. Rice received funding from Cumberland Pharmaceuticals and Cytovale. The remaining authors have disclosed that they do not have any potential conflicts of interest. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: whitney.gannon@vumc.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedSpinella, Philip C.; Leonard, Julie C.; Gaines, Barbara A.; Luther, James F.; Wisniewski, Stephen R.; Josephson, Cassandra D.; Leeper, Christine M.; for the MAssive Transfusion epidemiology and outcomes In Children (MATIC) Investigators and BloodNet
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To assess the impact of antifibrinolytics in children with life-threatening hemorrhage.
Design:
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.
Setting:
Twenty-four children’s hospitals in the United States, Canada, and Italy.
Patients:
Children 0–17 years old who received greater than 40 mL/kg of total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
Intervention/Exposure:
Children were compared according to receipt of antifibrinolytic medication (tranexamic acid or aminocaproic acid) during the bleeding event.
Measures and Main Results:
Patient characteristics, medications administered, and clinical outcomes were analyzed using Cox proportional hazard and Kaplan-Meier survival analysis. The primary outcome was 24-hour mortality. Of 449 patients analyzed, median age was 7 years (2–15 yr), and 55% were male. The etiology of bleeding was 46% traumatic, 34% operative, and 20% medical. Twelve percent received antifibrinolytic medication during the bleeding event (n = 54 unique subjects; n = 18 epsilon aminocaproic acid, n = 35 tranexamic acid, and n = 1 both). The antifibrinolytic group was comparable with the nonantifibrinolytic group on baseline demographic and physiologic parameters; the antifibrinolytic group had longer massive transfusion protocol duration, received greater volume blood products, and received factor VII more frequently. In the antifibrinolytic group, there was significantly less 6-hour mortality overall (6% vs 17%; p = 0.04) and less 6-hour mortality due to hemorrhage (4% vs 14%; p = 0.04). After adjusting for age, bleeding etiology, Pediatric Risk of Mortality score, and plasma deficit, the antifibrinolytic group had decreased mortality at 6- and 24-hour postbleed (adjusted odds ratio, 0.29 [95% CI, 0.09–0.93]; p = 0.04 and adjusted odds ratio, 0.45 [95% CI, 0.21–0.98]; p = 0.04, respectively).
Conclusions:
Administration of antifibrinolytic medications during the life-threatening event was independently associated with improved 6- and 24-hour survivals in bleeding children. Consideration should be given to use of antifibrinolytics in pediatric patients with life-threatening hemorrhage.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Spinella is a consultant for Secure Transfusion Services, Hemanext, and Haima; Dr. Leonard receives royalty payments from UpToDate; Dr. Josephson is a consultant for Immucor, Octapharma, and Cellphine, and has an unrestricted grant from Medtronics. Drs. Spinella, Leonard, and Josephson received support for article research from the National Institutes of Health. Dr. Leonard’s institution received funding from National Institutes of Child Health and Development. The remaining authors have disclosed that they do not have any potential conflicts of interest.
The original MAssive Transfusion epidemiology and outcomes In Children study was supported, in part, by grant R21HL128863 from the National Heart, Lung and Blood Institute. No direct funding was received for the present study.
MATIC Investigators are listed in Appendix 1.
For information regarding this article, E-mail: leepercm@upmc.du
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedAndersen, Sarah K.; Stewart, Samuel; Leier, Brendan; Alden, Lynn E.; Townsend, Derek R.; Garros, Daniel
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying.
Design:
Electronic survey.
Setting:
Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation.
Participants:
We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test.
Interventions:
Not applicable.
Measurements and Main Results:
We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies.
Conclusions:
Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
The authors have disclosed that they do not have any potential conflicts of interest.
Address requests for reprints to: Sarah K. Andersen, Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada. E-mail: sanderse@ualberta.ca
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedFranchineau, Guillaume; Chommeloux, Juliette; Pineton de Chambrun, Marc; Lebreton, Guillaume; Bréchot, Nicolas; Hékimian, Guillaume; Bourcier, Simon; Le Guennec, Loïc; Luyt, Charles-Edouard; Combes, Alain; Schmidt, Matthieu
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The impact of bronchoalveolar lavage on regional ventilation in mechanically ventilated patients with acute respiratory distress syndrome has rarely been described. Our objectives were use electrical impedance tomography to describe lung impedance variation post bronchoalveolar lavage and identify morphologic patterns according to respiratory failure severity.
Design:
Monocenter physiologic study on mechanically ventilated patients.
Setting:
University medical ICU.
Interventions:
After a recruitment maneuver, tidal impedance variation distributions (a surrogate for impact of bronchoalveolar lavage on tidal volume distribution), end-expiratory lung impedance (correlated with end-expiratory lung volume and used to quantify postbronchoalveolar lavage derecruitment), respiratory mechanics, and blood gases were recorded before and over 6 hours post bronchoalveolar lavage with PaO2 to the FIO2 ratio. Patients were grouped according to their prebronchoalveolar lavage, that is, PaO2 to the FIO2 ratio less than 200 or greater than or equal to 200.
Results:
Twenty-one patients (median [interquartile range] age 55 yr [50–58 yr]; 13 males), 13 with PaO2 to the FIO2 ratio less than 200, were included. Unlike that latter group, bronchoalveolar lavage significantly impacted tidal impedance variation distribution in patients with PaO2 to the FIO2 ratio greater than or equal to 200, with a ventilation shift to the contralateral lung (from 54% to 42% in the bronchoalveolar lavage side), which persisted up to 6 hours post bronchoalveolar lavage. Similarly, end-expiratory lung impedance was less distributed in the bronchoalveolar lavage side post procedure of patients with PaO2 to the FIO2 ratio greater than or equal to 200, but the difference did not reach statistical significance (p = 0.09). As reported for tidal impedance variation, end-expiratory lung impedance distribution in patients with severe or moderate acute respiratory distress syndrome did not change significantly during the 6 hours post bronchoalveolar lavage. Although bronchoalveolar lavage effects on gas exchanges were minor in all patients, static compliance in patients with PaO2 to the FIO2 ratio greater than or equal to 200 was significantly lower post bronchoalveolar lavage (p = 0.04).
Conclusions:
The negative impact of bronchoalveolar lavage on regional ventilation, which persisted at least 6 hours, appeared to be more profound in patients with normal lung function or mild acute respiratory distress syndrome. In contrast, regional ventilation, lung recruitment, respiratory mechanics, and gas exchanges were modestly impacted by the bronchoalveolar lavage in patients with severe or moderate acute respiratory distress syndrome. That finding is reassuring and supports not summarily proscribing bronchoalveolar lavage for the most severely ill with acute respiratory distress syndrome.
Drs. Franchineau and Schmidt contributed to conception and design. Drs. Franchineau, Chommeloux, Combes, and Schmidt contributed to analysis and interpretation. Drs. Franchineau, Chommeloux, Combes, and Schmidt contributed to drafting the first draft of the article. All authors contributed to reviewing and drafting for important intellectual content.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Written informed consent was obtained from all patients’ surrogates before inclusion. The study was approved by the appropriate legal and ethics authorities (Comité de Protection des Personnes Sud-Est VI, Clermont-Ferrand, France, AU1431).
This work was done in the Service de Médecine Intensive Reanimation, Assistance Publique–Hôpitaux de Paris, Groupe Hospitalier Pitié–Salpetrière, Paris, France. The Pulmovista electrical impedance tomography was provided by Dräger (Lübeck, Germany) during the study period.
Dr. Luyt received funding from Bayer Healthcare, Merck, and ThermoFisher Brahms, Biomerieux, Carmat, and Correvio. Dr. Combes received lecture fees from Getinge and Baxter. Dr. Schmidt received lecture fees from Getinge, Dräger, and Xenios. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: matthieu.schmidt@aphp.fr
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedvan Sleuwen, Meike; Sun, Haoqi; Eckhardt, Christine; Neelagiri, Anudeepthi; Tesh, Ryan A.; Westmeijer, Mike; Paixao, Luis; Rajan, Subapriya; Velpula Krishnamurthy, Parimala; Sikka, Pooja; Leone, Michael J.; Panneerselvam, Ezhil; Quadri, Syed A.; Akeju, Oluwaseun; Kimchi, Eyal Y.; Westover, M. Brandon
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Delirium is a common and frequently underdiagnosed complication in acutely hospitalized patients, and its severity is associated with worse clinical outcomes. We propose a physiologically based method to quantify delirium severity as a tool that can help close this diagnostic gap: the Electroencephalographic Confusion Assessment Method Severity Score (E-CAM-S).
Design:
Retrospective cohort study.
Setting:
Single-center tertiary academic medical center.
Patients:
Three-hundred seventy-three adult patients undergoing electroencephalography to evaluate altered mental status between August 2015 and December 2019.
Interventions:
None.
Measurements and Main Results:
We developed the E-CAM-S based on a learning-to-rank machine learning model of forehead electroencephalography signals. Clinical delirium severity was assessed using the Confusion Assessment Method Severity (CAM-S). We compared associations of E-CAM-S and CAM-S with hospital length of stay and inhospital mortality. E-CAM-S correlated with clinical CAM-S (R = 0.67; p < 0.0001). For the overall cohort, E-CAM-S and CAM-S were similar in their strength of association with hospital length of stay (correlation = 0.31 vs 0.41, respectively; p = 0.082) and inhospital mortality (area under the curve = 0.77 vs 0.81; p = 0.310). Even when restricted to noncomatose patients, E-CAM-S remained statistically similar to CAM-S in its association with length of stay (correlation = 0.37 vs 0.42, respectively; p = 0.188) and inhospital mortality (area under the curve = 0.83 vs 0.74; p = 0.112). In addition to previously appreciated spectral features, the machine learning framework identified variability in multiple measures over time as important features in electroencephalography-based prediction of delirium severity.
Conclusions:
The E-CAM-S is an automated, physiologic measure of delirium severity that predicts clinical outcomes with a level of performance comparable to conventional interview-based clinical assessment.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Ms. van Sleuwen, Dr. Sun, and Dr. Eckhardt are co-first authors.
Drs. Kimchi and Westover are co-senior authors.
Ms. van Sleuwen and Drs. Sun, Eckhardt, Kimchi, and Westover were involved in design of the work. Ms. van Sleuwen, Dr. Neelagiri, Mr. Westmeijer, Dr. Rajan, Dr. Velpula Krishnamurthy, Mr. Leone, and Drs. Panneerselvam, Quadri, and Westover were involved in data collection. Ms. van Sleuwen, Dr. Sun, Dr. Neelagiri, Mr. Westmeijer, Mr. Leone, and Dr. Kimchi were involved in data preparation and analysis. Ms. van Sleuwen van Sleuwen and Drs. Sun, Eckhardt, Akeju, Kimchi, and Westover were involved in drafting the work. All authors were involved in revising critically.
Drs. Kimchi’s and Westover’s institutions received funding from the National Institutes of Health (NIH). Drs. Kimchi and Westover received support for article research from the NIH. Dr. Westover received funding from Beacon Biosignals. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: mwestover@mgh.harvard.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedDaverio, Marco; Sperotto, Francesca; Stefani, Chiara; Mondardini, Maria Cristina; Tessari, Anna; Biban, Paolo; Izzo, Francesca; Montani, Cinzia; Lapi, Maria; Picconi, Enzo; Racca, Fabrizio; Marinosci, Geremia Zito; Savron, Fabio; Wolfler, Andrea; Amigoni, Angela; on behalf of the Italian Network of PICU Study Group (TIPNet)
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
We aim to describe the use of continuous infusion of neuromuscular blocking agents in mechanically ventilated critically ill children and to test its association with in-hospital mortality.
Design:
Multicenter, registry-based, observational, two-cohort-comparison retrospective study using prospectively collected data from a web-based national registry.
Setting:
Seventeen PICUs in Italy.
Patients:
We included children less than 18 years who received mechanical ventilation and a neuromuscular blocking agent infusion from January 2010 to October 2017. A propensity score–weighted Cox regression analysis was used to assess the relationship between the use of neuromuscular blocking agents and in-hospital mortality.
Interventions:
None.
Measurements and Main Results:
Of the 23,227 patients admitted to the PICUs during the study period, 3,823 patients were included. Patients who received a continuous infusion of neuromuscular blocking agent were more likely to be younger (p < 0.001), ex-premature (p < 0.001), and presenting with less chronic respiratory insufficiency requiring home mechanical ventilation (p < 0.001). Reasons for mechanical ventilation significantly differed between patients who received a continuous infusion of neuromuscular blocking agent and patients who did not receive a continuous infusion of neuromuscular blocking agent, with a higher frequency of respiratory and cardiac diagnosis among patients who received neuromuscular blocking agents compared with other diagnoses (all p < 0.001). The covariates were well balanced in the propensity-weighted cohort. The mortality rate significantly differed among the two cohorts (patients who received a continuous infusion of neuromuscular blocking agent 21% vs patients who did not receive a continuous infusion of neuromuscular blocking agent 11%; p < 0.001 by weighted logistic regression). Patients who received a continuous infusion of neuromuscular blocking agent experienced longer mechanical ventilation and PICU stay (both p < 0.001 by weighted logistic regression). A weighted Cox regression analysis found the use of neuromuscular blocking agents to be a significant predictor of in-hospital mortality both in the unadjusted analysis (hazard ratio, 1.7; 95% CI, 1.3–2.2) and in the adjusted one (hazard ratio, 1.6; 95% CI, 1.2–2.1).
Conclusions:
Thirteen percent of mechanically ventilated children in PICUs received neuromuscular blocking agents. When adjusting for selection bias with a propensity score approach, the use of neuromuscular blocking agent was found to be a significant predictor of in-hospital mortality.
Drs. Daverio and Sperotto contributed equally as first authors.
Dr. Biban received funding from Getinge and Chiesi Pharmaceutical. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: marco.daverio.va@gmail.com; marco.daverio@aopd.veneto.it
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedHiggins, Thomas L.; Freeseman-Freeman, Laura; Stark, Maureen M.; Henson, Kathy N.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To develop a model to benchmark mortality in hospitalized patients using accessible electronic medical record data.
Design:
Univariate analysis and multivariable logistic regression were used to identify variables collected during the first 24 hours following admission to test for risk factors associated with the end point of hospital mortality. Models were built using specific diagnosis (International Classification of Diseases, 9th Edition or International Classification of Diseases, 10th Edition) captured at discharge, rather than admission diagnosis, which may be discordant. Variables were selected based, in part, on prior the Acute Physiology and Chronic Health Evaluation methodology and included primary diagnosis information plus three aggregated indices (physiology, comorbidity, and support). A Physiology Index was created using parsimonious nonlinear modeling of heart rate, mean arterial pressure, temperature, respiratory rate, hematocrit, platelet counts, and serum sodium. A Comorbidity Index incorporates new or ongoing diagnoses captured by the electronic medical record during the preceding year. A Support Index considered 10 interventions such as mechanical ventilation, selected IV drugs, and hemodialysis. Accuracy was determined using area under the receiver operating curve for discrimination, calibration curves, and modified Brier score for calibration.
Setting and Patients:
We used deidentified electronic medical record data from 74,434 adult inpatients (ICU and ward) at 15 hospitals from 2010 to 2013 to develop the mortality model and validated using data for additional 49,752 patients from the same 15 hospitals. A second revalidation was accomplished using data on 83,684 patients receiving care at six hospitals between 2014 and 2016. The model was also validated on a subset of patients with an ICU stay on day 1.
Interventions:
None.
Measurements and Main Results:
This model uses physiology, comorbidity, and support indices, primary diagnosis, age, lowest Glasgow Coma Score, and elapsed time since hospital admission to predict hospital mortality. In the initial validation cohort, observed mortality was 4.04% versus predicted mortality 4.12% (Student t test, p = 0.37). In the revalidation using a different set of hospitals, predicted and observed mortality were 2.66% and 2.99%, respectively. Area under the receiver operating curve were 0.902 (0.895–0.909) and 0.884 (0.877–0.891), respectively, and calibration curves show a close relationship of observed and predicted mortalities. In the evaluation of the subset of ICU patients on day1, the area under the receiver operating curve was 0.87, with an observed mortality of 8.78% versus predicted mortality of 8.93% (Student t test, p = 0.52) and a standardized mortality ratio of 0.98 (0.932–1.034).
Conclusions:
Variables considered by traditional ICU prognostic models accurately benchmark patient mortality for patients receiving care in multiple hospital locations, not only the ICU. Unlike Acute Physiology and Chronic Health Evaluation, this model relies on electronic medical record data alone and does not require personnel to collect the independent predictor variables. Assessing the model’s utility for benchmarking hospital performance will require prospective testing in a larger representative sample of hospitals.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http:/journals.lww.com/ccmjournal).
Supported, in part, by Cerner Corporation, Kansas City, MO.
Dr. Higgins received funding from Cerner Corporation, Center for Case Management, Natick, MA, and the American Association of Physician Leadership (board membership). Ms. Freeseman-Freeman and Ms. Henson are current, and Ms. Stark a former employee of Cerner Corporation, which markets the Health Facts database and the Cerner Millennium electronic medical record. Dr. Higgins is a consultant who received research support from Cerner Corporation.
This work was performed at Cerner Corporation, Kansas City, MO.
For information regarding this article, E-mail: higginstl@yahoo.com
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedBeuchat, Isabelle; Rossetti, Andrea O.; Novy, Jan; Schindler, Kaspar; Ruüegg, Stephan; Alvarez, Vincent
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To investigate electroencephalogram (EEG) features’ relation with mortality or functional outcome after disorder of consciousness, stratifying patients between continuous EEG and routine EEG.
Design:
Retrospective analysis of data from a randomized controlled trial.
Setting:
Multiple adult ICUs.
Patients:
Data from 364 adults with acute disorder of consciousness, randomized to continuous EEG (30–48 hr; n = 182) or repeated 20-minute routine electroencephalogram (n = 182).
Interventions:
None.
MEASUREMENTS AND MAIN RESULTS:
Correlations between electrographic features and mortality and modified Rankin scale at 6 months (good 0–2) were assessed. Background continuity, higher frequency, and reactivity correlated with survival and good modified Rankin scale. Rhythmic and periodic patterns carried dual prognostic information: lateralized periodic discharges were associated with mortality and bad modified Rankin scale. Generalized rhythmic delta activity correlated with survival, good modified Rankin scale, and lower occurrence of status epilepticus. Presence of sleep-spindles and continuous EEG background was associated with good outcome in the continuous EEG subgroup. In the routine EEG group, a model combining background frequency, continuity, reactivity, sleep-spindles, and lateralized periodic discharges was associated with mortality at 70.91% (95% CI, 59.62–80.10%) positive predictive value and 63.93% (95% CI, 58.67–68.89%) negative predictive value. In the continuous EEG group, a model combining background continuity, reactivity, generalized rhythmic delta activity, and lateralized periodic discharges was associated with mortality at 84.62% (95%CI, 75.02–90.97) positive predictive value and 74.77% (95% CI, 68.50–80.16) negative predictive value.
Conclusions:
Standardized EEG interpretation provides reliable prognostic information. Continuous EEG provides more information than routine EEG.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by The Swiss National Science Foundation (grant 320030_169379). It had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and decision to submit the article for publication.
Dr. Beuchat reports a research grant from the Swiss National Science Foundation not related to this study. Drs. Rossetti, Schindler, Rüegg, and Alvarez report a research grant from the Swiss National Foundation related to this study (grant 320030_169379). Dr. Rüegg’s institution received funding from Arvelle Pharmaceuticals, GW Pharma, and Sandoz Pharmaceuticals. He reports fundings from the Swiss EEG Bulletin. Dr. Novy has disclosed that he does not have any potential conflicts of interest.
For information regarding this article, E-mail: vincent.alvarez@hopitalvs.ch
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedSu, Chenglei; Xiao, Yan; Zhang, Guozhen; Liang, Lian; Li, Hui; Cheng, Cheng; Jin, Tao; Bradley, Jennifer; Peberdy, Mary A.; Ornato, Joseph P.; Mangino, Martin J.; Tang, Wanchun
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To investigate the therapeutic potential and underlying mechanisms of exogenous nicotinamide adenine dinucleotide+ on postresuscitation myocardial and neurologic dysfunction in a rat model of cardiac arrest.
Design:
Thirty-eight rats were randomized into three groups: 1) Sham, 2) Control, and 3) NAD. Except for the sham group, untreated ventricular fibrillation for 6 minutes followed by cardiopulmonary resuscitation was performed in the control and NAD groups. Nicotinamide adenine dinucleotide+ (20 mg/kg) was IV administered at the onset of return of spontaneous circulation.
Setting:
University-affiliated research laboratory.
Subjects:
Sprague-Dawley rats.
Interventions:
Nicotinamide adenine dinucleotide+.
Measurements and Main Results:
Hemodynamic and myocardial function were measured at baseline and within 4 hours following return of spontaneous circulation. Survival analysis and Neurologic Deficit Score were performed up to 72 hours after return of spontaneous circulation. Adenosine triphosphate (adenosine triphosphate) level was measured in both brain and heart tissue. Mitochondrial respiratory chain function, acetylation level, and expression of Sirtuin3 and NADH dehydrogenase (ubiquinone) 1 alpha subcomplex, 9 (NDUFA9) in isolated mitochondrial protein from both brain and heart tissue were evaluated at 4 hours following return of spontaneous circulation. The results demonstrated that nicotinamide adenine dinucleotide+ treatment improved mean arterial pressure (at 1 hr following return of spontaneous circulation, 94.69 ± 4.25 mm Hg vs 89.57 ± 7.71 mm Hg; p < 0.05), ejection fraction (at 1 hr following return of spontaneous circulation, 62.67% ± 6.71% vs 52.96% ± 9.37%; p < 0.05), Neurologic Deficit Score (at 24 hr following return of spontaneous circulation, 449.50 ± 82.58 vs 339.50 ± 90.66; p < 0.05), and survival rate compared with that of the control group. The adenosine triphosphate level and complex I respiratory were significantly restored in the NAD group compared with those of the control group. In addition, nicotinamide adenine dinucleotide+ treatment activated the Sirtuin3 pathway, down-regulating acetylated-NDUFA9 in the isolated mitochondria protein.
Conclusions:
Exogenous nicotinamide adenine dinucleotide+ treatment attenuated postresuscitation myocardial and neurologic dysfunction. The responsible mechanisms may involve the preservation of mitochondrial complex I respiratory capacity and adenosine triphosphate production, which involves the Sirtuin3-NDUFA9 deacetylation.
Drs. Su and Xiao contributed equally.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by the project of People’s Livelihood Science and Technology—basic research on medical and health application of Soochow, Jiangsu Province, China (No. SYS20 19075) and Zoll Foundation (2020).
Drs. Xiao and Tang received support for article research from the project of People’s Livelihood Science and Technology (No. SYS20 19075) and the Zoll Foundation (2020). Dr. Bradley received support for article research from the Weil Family Foundation. Dr. Ornato received funding from the Richmond Ambulance Authority and Elsevier Publishing; he disclosed that he serves as Medical Director for the city’s Emergency Medical Services and as American Editor of the journal Resuscitation. Dr. Mangino’s institution received internal funding from Virginia Commonwealth University School of Medicine and the Weil Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: wanchun.tang@vcuhealth.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedSpoormans, Eva M.; Lemkes, Jorrit S.; Janssens, Gladys N.; van der Hoeven, Nina W.; Jewbali, Lucia S. D.; Dubois, Eric A.; Meuwissen, Martijn; Rijpstra, Tom A.; Bosker, Hans A.; Blans, Michiel J.; Bleeker, Gabe B.; Baak, Remon; Vlachojannis, Georgios J.; Eikemans, Bob J. W.; Girbes, Armand R. J.; van der Harst, Pim; van der Horst, Iwan C. C.; Voskuil, Michiel; van der Heijden, Joris J.; Beishuizen, Albertus; Stoel, Martin; Camaro, Cyril; van der Hoeven, Hans; Henriques, José P.; Vlaar, Alexander P. J.; Vink, Maarten A.; van den Bogaard, Bas; Heestermans, Ton A. C. M.; de Ruijter, Wouter; Delnoij, Thijs S. R.; Crijns, Harry J. G. M.; Jessurun, Gillian A. J.; Oemrawsingh, Pranobe V.; Gosselink, Marcel T. M.; Plomp, Koos; Magro, Michael; van de Ven, Peter M.; van Royen, Niels; Elbers, Paul W. G.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The optimal targeted temperature in patients with shockable rhythm is unclear, and current guidelines recommend targeted temperature management with a correspondingly wide range between 32°C and 36°C. Our aim was to study survival and neurologic outcome associated with targeted temperature management strategy in postarrest patients with initial shockable rhythm.
Design:
Observational substudy of the Coronary Angiography after Cardiac Arrest without ST-segment Elevation trial.
Setting:
Nineteen hospitals in The Netherlands.
Patients:
The Coronary Angiography after Cardiac Arrest trial randomized successfully resuscitated patients with shockable rhythm and absence of ST-segment elevation to a strategy of immediate or delayed coronary angiography. In this substudy, 459 patients treated with mild therapeutic hypothermia (32.0–34.0°C) or targeted normothermia (36.0–37.0°C) were included. Allocation to targeted temperature management strategy was at the discretion of the physician.
Interventions:
None.
Measurements and Main Results:
After 90 days, 171 patients (63.6%) in the mild therapeutic hypothermia group and 129 (67.9%) in the targeted normothermia group were alive (hazard ratio, 0.86 [95% CI, 0.62–1.18]; log-rank p = 0.35; adjusted odds ratio, 0.89; 95% CI, 0.45–1.72). Patients in the mild therapeutic hypothermia group had longer ICU stay (4 d [3–7 d] vs 3 d [2–5 d]; ratio of geometric means, 1.32; 95% CI, 1.15–1.51), lower blood pressures, higher lactate levels, and increased need for inotropic support. Cerebral Performance Category scores at ICU discharge and 90-day follow-up and patient-reported Mental and Physical Health Scores at 1 year were similar in the two groups.
Conclusions:
In the context of out-of-hospital cardiac arrest with shockable rhythm and no ST-elevation, treatment with mild therapeutic hypothermia was not associated with improved 90-day survival compared with targeted normothermia. Neurologic outcomes at 90 days as well as patient-reported Mental and Physical Health Scores at 1 year did not differ between the groups.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by unrestricted research grants from The Netherlands Heart Institute, Biotronik, and AstraZeneca.
Dr. Lemkes received funding from The Netherlands Heart Institute (NHLI) and Biotronik. Drs. Lemkes and Vlachojannis received funding from AstraZeneca. Dr. Rijpstra’s institution received funding from Principle Investigator. Dr. Vlachojannis’ institution received funding from MicroPort and Daiichi Sankyo; he received funding from Abbott. Dr. Vlachojannis reports receiving grant support from MicroPort Orthopedics and Daiichi Sankyo. Dr. van Royen’s institution received funding from Biotronik, AstraZeneca, the NHLI, Abbott, and Medtronic; he received funding from Novartis, MicroPort, Castor, Rainmed, Biotronik, Abbott, Medtronic, and Philips; he received support for article research from the NLHI. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Trial registration number: Netherlands trial register: trial NL4857 (NTR4973).
For information regarding this article, E-mail: j.lemkes@amsterdamumc.nl
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedPrescott, Brenton R.; Saglam, Hanife; Duskin, Jonathan A.; Miller, Matthew I.; Thakur, Arnav S.; Gholap, Eesha A.; Hutch, Meghan R.; Smirnakis, Stelios M.; Zafar, Sahar F.; Dupuis, Josée; Benjamin, Emelia J.; Greer, David M.; Ong, Charlene J.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To describe the prevalence and associated risk factors of new onset anisocoria (new pupil size difference of at least 1 mm) and its subtypes: new onset anisocoria accompanied by abnormal and normal pupil reactivities in patients with acute neurologic injuries.
Design:
We tested the association of patients who experienced new onset anisocoria subtypes with degree of midline shift using linear regression. We further explored differences between quantitative pupil characteristics associated with first-time new onset anisocoria and nonnew onset anisocoria at preceding observations using mixed effects logistic regression, adjusting for possible confounders.
Setting:
All quantitative pupil observations were collected at two neuro-ICUs by nursing staff as standard of care.
Patients:
We conducted a retrospective two-center study of adult patients with intracranial pathology in the ICU with at least a 24-hour stay and three or more quantitative pupil measurements between 2016 and 2018.
Measurements and Main Results:
We studied 221 patients (mean age 58, 41% women). Sixty-three percent experienced new onset anisocoria. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity occurring at any point during hospitalization was significantly associated with maximum midline shift (β = 2.27 per mm; p = 0.01). The occurrence of new onset anisocoria accompanied by objective evidence of normal pupil reactivity was inversely associated with death (odds ratio, 0.34; 95% CI, 0.16–0.71; p = 0.01) in adjusted analyses. Subclinical continuous pupil size difference distinguished first-time new onset anisocoria from nonnew onset anisocoria in up to four preceding pupil observations (or up to 8 hr prior). Minimum pupil reactivity between eyes also distinguished new onset anisocoria accompanied by objective evidence of abnormal pupil reactivity from new onset anisocoria accompanied by objective evidence of normal pupil reactivity prior to first-time new onset anisocoria occurrence.
Conclusions:
New onset anisocoria occurs in over 60% of patients with neurologic emergencies. Pupil reactivity may be an important distinguishing characteristic of clinically relevant new onset anisocoria phenotypes. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity was associated with midline shift, and new onset anisocoria accompanied by objective evidence of normal pupil reactivity had an inverse relationship with death. Distinct quantitative pupil characteristics precede new onset anisocoria occurrence and may allow for earlier prediction of neurologic decline. Further work is needed to determine whether quantitative pupillometry sensitively/specifically predicts clinically relevant anisocoria, enabling possible earlier treatments.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Prescott contributed to data collection, data cleaning, statistical analysis, interpretation of results, article drafting, and figure and table creation. Dr. Saglam contributed to data collection, imaging review, and table creation. Dr. Duskin contributed to imaging chart review and table creation. Mr. Miller contributed to table creation, article revisions, and submission. Mr. Thakur contributed to data collection and table creation. Ms. Gholap contributed to data collection and table creation. Ms. Hutch contributed to data collection, statistical analysis, and article revisions. Dr. Smirnakis contributed to data collection and critical revisions to the article. Dr. Zafar contributed to data collection and critical revisions to the article. Dr. Dupuis contributed to statistical analysis plan and review, and critical revisions to the article. Dr. Benjamin provided critical revisions to the article. Dr. Greer contributed to study design, interpretation of results, and critical revisions to the article. Dr. Ong contributed to study design, data collection, statistical analysis, interpretation of results, article drafting, table creation, and critical revisions.
Dr. Ong receives support from National Institutes of Health (NIH)/National Institute of Neurologic Disorders and Stroke K23NS116033 and the Peter Paul Young Career Development Foundation at Boston University. Dr. Benjamin is supported, in part, by a 2R01 Research Project Grant HL092577; a 1R01 Research Project Grant HL141434 01A1; 2U54HL120163; 1R01AG066010; 1R01AG066914; and American Heart Association, AHA_18SFRN34110082. Dr. Greer receives support from R01 NS102574. Dr. Smirnakis receives support from a 2R01 Research Project Grant EY024019. Dr. Zafar receives support from K23NS114201. Dr. Smirnakis’ institution received funding from Emmetropia; he received funding from Biogen and Amgen. Dr. Zafar’s institution received funding from Sage Therapeutics. Dr. Benjamin received support for article research from the NIH. Dr. Ong’s institution received funding from NIH 2KL2TR001411. The authors whose names are listed immediately above certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this article. The remaining authors have disclosed that they do not have any potential conflicts of interest.
New onset anisocoria occurs frequently in the neuro-ICU. Anisocoria accompanied by abnormal pupil reactivity is significantly associated with increased midline shift, whereas anisocoria without abnormal pupil reactivity was more likely a nonemergent finding.
For information regarding this article, E-mail: charlene.ong@bmc.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedBeesley, Sarah J.; Powell, Alex; Groat, Danielle; Butler, Jorie; Hopkins, Ramona O.; Rozenblum, Ronen; Aboumatar, Hanan; Butler, Allison M.; Sugarman, Jeremy; Francis, Leslie; Brown, Samuel M.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Access to personal health records in an ICU by persons involved in the patient’s care (referred to broadly as “family members” below) has the potential to increase engagement and reduce the negative psychologic sequelae of such hospitalizations. Currently, little is known about patient preferences for information sharing with a designated family member in the ICU. We sought to understand the information-sharing preferences of former ICU patients and their family members and to identify predictors of information-sharing preferences.
Design:
We performed an internet survey that was developed by a broad, multidisciplinary team of stakeholders. Formal pilot testing of the survey was conducted prior to internet survey administration to study subjects.
Setting:
Internet survey.
Subjects:
Subjects included English-speaking adults who had an ICU experience or a family member with ICU experience between 2013 and 2016. We used panel sampling to ensure an ethnically representative sample of the U.S. population.
Interventions:
None.
Measurements and Main Results:
One thousand five hundred twenty surveys were submitted, and 1,470 were included in analysis. The majority of respondents (93.6%) stated that they would want to share present and past medical history, either all or that related to their ICU stay, with a designated family member of their choosing. The majority (79%) would also want their designated family member to be able to access that information from a home computer. Although most respondents preferred to share all types of information, they indicated varying levels of willingness to share specific types of more sensitive information. Information-sharing preferences did not differ by age, sex, ethnicity, or type of prior experience in the ICU (i.e., patient or family member).
Conclusions:
In the context of an ICU admission, sharing personal health information with a person of the patient’s choosing appears desirable for most patients and family members. Policies and implementation of regulations should take this into consideration.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by The Gordon and Betty Moore Foundation.
Drs. Beesley and Rozenblum received support for article research from The Gordon and Betty Moore Foundation. Dr. Powell received funding from the University of Utah School of Medicine. Dr. Butler disclosed government work. Dr. Hopkins’ institution received funding from Intermountain Research and Medical Foundation. Drs. Rozenblum’s, Aboumatar’s, and Brown’s institutions received funding from The Gordon and Betty Moore Foundation. Dr. Rozenblum disclosed having equity in Hospitech Respiration Ltd. Dr. Sugarman is a member of Merck KGaA’s Bioethics Advisory Panel and Stem Cell Research Oversight Committee; a member of IQVIA’s Ethics Advisory Panel; a member of Aspen Neurosciences Scientific Advisory Board; a member of a Merck Data Monitoring Committee; a consultant to Biogen; and a consultant to Portola Pharmaceuticals Inc. None of these activities are related to the material discussed in this article. Dr. Sugarman received funding from Merck KGaA Bioethics Advisory Panel and Stem Cell Research Oversight Committee, IQVIA Ethics Advisory Panel, and Merck Data Monitoring Committee. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: sarah.beesley@imail.org
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedKouch, Michael; Green, Adam; Damuth, Emily; Noel, Christopher; Bartock, Jason; Rosenbloom, Michael; Schorr, Christa; Rios, Robert; Loperfido, Nancy; Puri, Nitin
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program.
Design:
A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program.
Setting:
An adult ICU in a tertiary academic medical center in Camden, NJ.
Patients:
Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation.
Interventions:
Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists.
Measurements and Main Results:
Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1).
Conclusions:
There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Kouch, Green, Damuth, Noel, Bartock, Rosenbloom, Schorr, Rios, and Puri contributed substantially to the conception and design of the study, Drs. Kouch, Green, Loperfido, and Puri contributed to the acquisition of data, and Drs. Kouch, Green, Schorr, and Puri contributed to the analysis and interpretation of the data. Drs. Kouch, Green, and Puri drafted the article, and Drs. Damuth, Noel, Bartock, Rosenbloom, Schorr, Rios, and Loperfido provided critical revision of the article. All authors provided the final approval of the version submitted for publication.
Supported solely from institutional and/or departmental sources.
The authors have disclosed that they do not have any potential conflicts of interest.
This work was performed at Cooper University Hospital, Cooper University Medical School at Rowan University, Camden, NJ.
For information regarding this article, E-mail: Kouch-michael@cooperhealth.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedFarhat, Abdelaziz; Li, Xilong; Huet, Beverley; Tweed, Jefferson; Morriss, Michael C.; Raman, Lakshmi
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
This project aims to describe brain injuries on routine neuroimaging in a large single-center neonatal and pediatric cohort supported by extracorporeal membrane oxygenation. The study also aims to examine the association of these injuries with neurocognitive outcomes in survivors and identify laboratory findings associated with neurologic injury.
Design:
Retrospective observational single-center cohort study.
Setting:
Tertiary care PICU.
Patients:
Pediatric patients with noncardiac indications for extracorporeal membrane oxygenation supported by venoarterial or venovenous extracorporeal membrane oxygenation, with on-extracorporeal membrane oxygenation brain CT or postextracorporeal membrane oxygenation brain CT/MRI.
Interventions:
Extracorporeal membrane oxygenation support.
MEASUREMENTS AND MAIN RESULTS:
Occurrence of brain injury on CT and MRI was reviewed; injuries were scored. Clinical and laboratory results associated with injury were identified. Survivor neurocognitive outcomes were obtained using the Pediatric Overall Performance Category scale and Pediatric Cerebral Performance Category scale. Of 132 imaged patients, 98 (74%) had radiological evidence of brain injury. Mean injury score was 6.5 (± 3.8). Head ultrasounds and clinician suspicion performed poorly in suspecting the presence of injury. Of 104 respondents to neurodevelopmental assessments, 61 (59%) had normal scores; 12.5%, 17%, and 11.5% had mild, moderate, or severe disability. A neuroimaging score greater than 10 was associated with an unfavorable outcome on the Pediatric Cerebral Performance Category (odds ratio, 3.4; p < 0.01) and Pediatric Overall Performance Category (odds ratio, 1.7; p < 0.05). Ischemic injury correlated with worse neurodevelopmental outcome. Preextracorporeal membrane oxygenation lactate, Vasoactive-Inotropic Scores, transaminitis, elevated bilirubin and creatinine levels, and thrombocytopenia were associated with injury occurrence.
Conclusions:
Brain injury is frequent in extracorporeal membrane oxygenation patients, although the majority of survivors have favorable neurocognitive outcomes. More research is needed in order to understand the etiology of such injuries. Head ultrasound and clinician suspicion are not sensitive in detecting extracorporeal membrane oxygenation–related brain injuries. Protocolizing postextracorporeal membrane oxygenation imaging with brain MRI allows the identification of injuries and provision of timely neurocognitive intervention.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by Children’s Health. Also supported, in part, by the National Center for Advancing Translational Sciences of the National Institutes of Health under the Center for Translational Medicine’s award number UL1TR001105.
The content is solely the responsibility of the authors and does not necessarily represent the official views of Children’s Health or the National Institutes of Health.
Dr. Farhat received funding from Children’s Health through the Children’s Clinical Research Advisory Council Fellow Award and the National Center for Advancing Translational Sciences (UL1TR001105); he received support for article research from the National Institutes of Health. Dr. Li disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: Lakshmi.Raman@UTsouthwestern.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedPatel, Jayshil J.; Ortiz-Reyes, Alfonso; Dhaliwal, Rupinder; Clarke, John; Hill, Aileen; Stoppe, Christian; Lee, Zheng-Yii; Heyland, Daren K.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To conduct a systematic review and meta-analysis to evaluate the impact of IV vitamin C on outcomes in critically ill patients.
Data Sources:
Systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Register of Controlled Trials.
Study Selection:
Randomized controlled trials testing IV vitamin C in critically ill patients.
Data Abstraction:
Two independent reviewers abstracted patient characteristics, treatment details, and clinical outcomes.
Data Synthesis:
Fifteen studies involving 2,490 patients were identified. Compared with placebo, IV vitamin C administration is associated with a trend toward reduced overall mortality (relative risk, 0.87; 95% CI, 0.75–1.00; p = 0.06; test for heterogeneity I2 = 6%). High-dose IV vitamin C was associated with a significant reduction in overall mortality (relative risk, 0.70; 95% CI, 0.52–0.96; p = 0.03), whereas low-dose IV vitamin C had no effect (relative risk, 0.94; 95% CI, 0.79–1.07; p = 0.46; test for subgroup differences, p = 0.14). IV vitamin C monotherapy was associated with a significant reduction in overall mortality (relative risk, 0.64; 95% CI, 0.49–0.83; p = 0.006), whereas there was no effect with IV vitamin C combined therapy. No trial reported an increase in adverse events related to IV vitamin C.
Conclusions:
IV vitamin C administration appears safe and may be associated with a trend toward reduction in overall mortality. High-dose IV vitamin C monotherapy may be associated with improved overall mortality, and further randomized controlled trials are warranted.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
The study was registered in the International Prospective Register of Systematic Reviews (CRD42021244074).
Dr. Hill disclosed relations with Woerwag Pharma supplying the investigational product for a study regarding vitamin C in cardiac surgery patients. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: jpatel2@mcw.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedLee, Dong Hun; Cho, Yong Soo; Lee, Byung Kook; Lee, Hyoung Youn; Jeung, Kyung Woon; Jung, Yong Hun; Park, Kyu Nam; Kim, Youn-Jung; Chae, Minjung Kathy; Seo, Dong-Woo; on behalf of the KORHN Investigators
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
We investigated awakening time and characteristics of awakening compared nonawakening and factors contributing to poor neurologic outcomes in out-of-hospital cardiac arrest survivors in no withdrawal of life-sustaining therapy settings.
Design:
Retrospective analysis of the Korean Hypothermia Network Pro registry.
Setting:
Multicenter ICU.
Patients:
Adult (≥ 18 yr) comatose out-of-hospital cardiac arrest survivors who underwent targeted temperature management at 33–36°C between October 2015 and December 2018.
Interventions:
None.
Measurements and Main Results:
We measured the time from the end of rewarming to awakening, defined as a total Glasgow Coma Scale score greater than or equal to 9 or Glasgow Coma Scale motor score equals to 6. The primary outcome was awakening time. The secondary outcome was 6-month neurologic outcomes (poor outcome: Cerebral Performance Category 3–5). Among 1,145 out-of-hospital cardiac arrest survivors, 477 patients (41.7%) regained consciousness 30 hours (6–71 hr) later, and 116 patients (24.3%) awakened late (72 hr after the end of rewarming). Young age, witnessed arrest, shockable rhythm, cardiac etiology, shorter time to return of spontaneous circulation, lower serum lactate level, absence of seizures, and multisedative requirement were associated with awakening. Of the 477 who woke up, 74 (15.5%) had poor neurologic outcomes. Older age, liver cirrhosis, nonshockable rhythm, noncardiac etiology, a higher Sequential Organ Failure Assessment score, and higher serum lactate levels were associated with poor neurologic outcomes. Late awakeners were more common in the poor than in the good neurologic outcome group (38/74 [51.4%] vs 78/403 [19.4%]; p < 0.001). The awakening time (odds ratio, 1.005; 95% CIs, 1.003–1.008) and late awakening (odds ratio, 3.194; 95% CIs, 1.776–5.746) were independently associated with poor neurologic outcomes.
Conclusions:
Late awakening after out-of-hospital cardiac arrest was common in no withdrawal of life-sustaining therapy settings and the probability of awakening decreased over time.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Lee and Cho contributed equally.
Supported, in part, by a grant (HCRI 20048) Chonnam National University Hwasun Hospital Institute for Biomedical Science.
The authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: bbukkuk@hanmail.net
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedKachmar, Alicia G.; Watson, R. Scott; Wypij, David; Perry, Mallory A.; Curley, Martha A. Q.; For the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Investigative Team
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Socioeconomic factors may impact healthcare resource use and health-related quality of life, but their association with postcritical illness outcomes is unknown. This study examines the associations between socioeconomic status, resource use, and health-related quality of life in a cohort of children recovering from acute respiratory failure.
Design:
Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial.
Setting:
Thirty-one PICUs.
Patients:
Children with acute respiratory failure enrolled whose parent/guardians consented for follow-up.
Measurements and Main Results:
Resource use included in-home care, number of healthcare providers, prescribed medications, home medical equipment, emergency department visits, and hospital readmission. Socioeconomic status was estimated by matching residential address to census tract–based median income. Health-related quality of life was measured using age-based parent-report instruments. Resource use interviews with matched census tract data (n = 958) and health-related quality of life questionnaires (n = 750/958) were assessed. Compared with high-income children, low-income children received care from fewer types of healthcare providers (β = –0.4; p = 0.004), used less newly prescribed medical equipment (odds ratio = 0.4; p < 0.001), and had more emergency department visits (43% vs 33%; p = 0.04). In the youngest cohort (< 2 yr old), low-income children had lower quality of life scores from physical ability (–8.6 points; p = 0.01) and bodily pain/discomfort (+8.2 points; p < 0.05). In addition, health-related quality of life was lower in those who had more healthcare providers and prescribed medications. In older children, health-related quality of life was lower if they had prescribed medications, emergency department visits, or hospital readmission.
Conclusions:
Children recovering from acute respiratory failure have ongoing healthcare resource use. Yet, lower income children use less in-home and outpatient services and use more hospital resources. Continued follow-up care, especially in lower income children, may help identify those in need of ongoing healthcare resources and those at-risk for decreased health-related quality of life.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research, National Institutes of Health (U01HL086622 to Dr. Curley and U01 HL086649 to Dr. Wypij).
Dr. Kachmar received funding from the Rita and Alex Hillman Foundation. Drs. Watson, Wypij, and Curley received support for article research from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute. Dr. Perry has disclosed that he does not have any potential conflicts of interest.
For information regarding this article, E-mail: akachmar@nursing.upenn.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedChen, Chung-Ting; Lin, Jin-Wei; Wu, Cheng-Hsueh; Kuo, Raymond Nien-Chen; Shih, Chia-Hui; Hou, Peter Chuanyi; Yen, David Hung-Tsang; How, Chorng-Kuang
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Although several risk factors for outcomes of out-of-hospital cardiac arrest patients have been identified, the cumulative risk of their combinations is not thoroughly clear, especially after targeted temperature management. Therefore, we aimed to develop a risk score to evaluate individual out-of-hospital cardiac arrest patient risk at early admission after targeted temperature management regarding poor neurologic status at discharge.
Design:
Retrospective observational cohort study.
Setting:
Two large academic medical networks in the United States.
Patients:
Out-of-hospital cardiac arrest survivors treated with targeted temperature management with age of 18 years old or older.
Interventions:
None.
Measurements and Main Results:
Based on the odds ratios, five identified variables (initial nonShockable rhythm, Leucocyte count < 4 or > 12 K/μL after targeted temperature management, total Adrenalin [epinephrine] ≥ 5 mg, lack of oNlooker cardiopulmonary resuscitation, and Time duration of resuscitation ≥ 20 min) were assigned weighted points. The sum of the points was the total risk score known as the SLANT score (range 0–21 points) for each patient. Based on our risk prediction scores, patients were divided into three risk categories as moderate-risk group (0–7), high-risk group (8–14), and very high-risk group (15–21). Both the ability of our risk score to predict the rates of poor neurologic outcomes at discharge and in-hospital mortality were significant under the Cochran-Armitage trend test (p < 0.001 and p < 0.001, respectively).
Conclusions:
The risk of poor neurologic outcomes and in-hospital mortality of out-of-hospital cardiac arrest survivors after targeted temperature management is easily assessed using a risk score model derived using the readily available information. Its clinical utility needed further investigation.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
The authors have disclosed that they do not have any potential conflicts of interest.
This work was performed in Brigham and Women’s Hospital, Boston, MA, and Taipei Veterans General Hospital, Taipei, Taiwan.
Address requests for reprints to: Chorng-Kuang How, MD, PhD, Department of Emergency, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Rd, Taipei 112, Taiwan. E-mail: ckhow@vghtpe.gov.tw
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedKillien, Elizabeth Y.; Rivara, Frederick P.; Dervan, Leslie A.; Smith, Mallory B.; Watson, R. Scott
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To evaluate which individual elements of health-related quality of life contribute most to decline in overall health-related quality of life status following pediatric critical care.
Design:
Retrospective cohort study.
Setting:
Seattle Children’s Hospital.
Patients:
ICU patients age 1 month to 18 years admitted between December 2011 and February 2017.
Interventions:
None.
Measurements and Main Results:
We assessed health-related quality of life decline from baseline to postdischarge (median, 6 wk) and determined the individual items of the Pediatric Quality of Life Inventory Infant Scales (< 2 yr) and Generic Core Scales (2–18 yr) with the highest prevalence of decline. We used multivariable regression to estimate the risk of decline in each of seven thematic categories by patient age, baseline health status, diagnosis, Pediatric Risk of Mortality score, and ICU length of stay. Decline from baseline health-related quality of life occurred in 22.5% of 539 patients. Items most commonly affected for infants less than 2 years were primarily emotional (cranky/crying, sleep, and self-soothing). Children 2–18 years most commonly experienced declines in physical functioning (play/exercise, lifting, and pain). Across the entire cohort, declines in categories of energy (31.5%), activity (31.0%), sleep (28.0%), and fear (24.7%) were most commonly endorsed. Risk of decline in each category varied with patient age, medical complexity, and diagnosis.
Conclusions:
Deconditioning, sleep, fear, and pain are important targets for intervention to improve health-related quality of life outcomes for critically ill children.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http:/journals.lww.com/ccmjournal).
Supported, in part, by the National Institute of Child Health and Human Development grant 5 T32 HD057822-08.
Dr. Killien’s institution received funding from the National Institute of Child Health and Human Development (NICHD). Drs. Killien and Smith received support for article research from the National Institutes of Health. Dr. Smith received funding from a NICHD T32 training grant (T32 HD057822-11). The remaining authors have disclosed that they do not have any potential conflicts of interest.
This work was performed at Seattle Children’s Hospital, Seattle, WA.
For information regarding this article, E-mail: elizabeth.killien@seattlechildrens.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedWang, Yi Tian; Lang, Jenna K.; Haines, Kimberley J.; Skinner, Elizabeth H.; Haines, Terry P.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Significant variability exists in physical rehabilitation modalities and dosage used in the ICU. Our objective was to investigate the effect of physical rehabilitation in ICU on patient outcomes, the impact of task-specific training, and the dose-response profile.
Data Sources:
A systematic search of Ovid MEDLINE, Cochrane Library, EMBASE, and CINAHL plus databases was undertaken on the May 28, 2020.
Study Selection:
Randomized controlled trials and controlled clinical trials investigating physical rehabilitation commencing in the ICU in adults were included. Outcomes included muscle strength, physical function, duration of mechanical ventilation, ICU and hospital length of stay, mortality, and health-related quality of life. Two independent reviewers assessed titles, abstracts, and full texts against eligibility criteria.
Data Extraction:
Details on intervention for all groups were extracted using the template for intervention description and replication checklist.
Data Synthesis:
Sixty trials were included, with a total of 5,352 participants. Random-effects pooled analysis showed that physical rehabilitation improved physical function at hospital discharge (standardized mean difference, 0.22; 95% CI, 0.00–0.44), reduced ICU length of stay by 0.8 days (mean difference, –0.80 d; 95% CI, –1.37 to –0.23 d), and hospital length of stay by 1.75 days (mean difference, –1.75 d; 95% CI, –3.03 to –0.48 d). Physical rehabilitation had no impact on the other outcomes. The intervention was more effective in trials where the control group received low-dose physical rehabilitation and in trials that investigated functional exercises.
Conclusions:
Physical rehabilitation in the ICU improves physical function and reduces ICU and hospital length of stay. However, it does not appear to impact other outcomes.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Skinner and Prof. T. P. Haines should be considered as joint senior authors.
Mr. Wang is the guarantor of this review; he conceived this review and designed the first draft of its protocol; he screened records for inclusion into the review, managed review data, performed statistical inferences, and participated in drafting the final article; and he takes full responsibility for the integrity of the data and the accuracy of the data analysis. Ms. Lang screened records for inclusion into the review, managed review data, and participated in the drafting of the final article. Dr. Skinner conceived this review and designed the first draft of its protocol; she participated in the drafting of the final article. Dr. K. J. Haines participated in the drafting of the final article. Prof. T. P. Haines conceived this review and designed the first draft of its protocol; he performed statistical inferences and participated in the drafting of the final article. All authors read and approved the final article.
Mr. Wang received funding from the Australian Postgraduate Award. Dr. Skinner’s institution (Western Health) received funding from the Australian Institute of Musculoskeletal Science. Prof. T. P. Haines received funding from K&L Gates Law Firm and Minter Ellison Law Firm. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: mwang@phcn.vic.gov.au
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMayampurath, Anoop; Hagopian, Raffi; Venable, Laura; Carey, Kyle; Edelson, Dana; Churpek, Matthew; for the American Heart Association's Get With the Guidelines-Resuscitation Investigators
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Prognostication of neurologic status among survivors of in-hospital cardiac arrests remains a challenging task for physicians. Although models such as the Cardiac Arrest Survival Post-Resuscitation In-hospital score are useful for predicting neurologic outcomes, they were developed using traditional statistical techniques. In this study, we derive and compare the performance of several machine learning models with each other and with the Cardiac Arrest Survival Post-Resuscitation In-hospital score for predicting the likelihood of favorable neurologic outcomes among survivors of resuscitation.
Design:
Analysis of the Get With The Guidelines-Resuscitation registry.
Setting:
Seven-hundred fifty-five hospitals participating in Get With The Guidelines-Resuscitation from January 1, 2001, to January 28, 2017.
Patients:
Adult in-hospital cardiac arrest survivors.
Interventions:
None.
Measurements and Main Results:
Of 117,674 patients in our cohort, 28,409 (24%) had a favorable neurologic outcome, as defined as survival with a Cerebral Performance Category score of less than or equal to 2 at discharge. Using patient characteristics, pre-existing conditions, prearrest interventions, and periarrest variables, we constructed logistic regression, support vector machines, random forests, gradient boosted machines, and neural network machine learning models to predict favorable neurologic outcome. Events prior to October 20, 2009, were used for model derivation, and all subsequent events were used for validation. The gradient boosted machine predicted favorable neurologic status at discharge significantly better than the Cardiac Arrest Survival Post-Resuscitation In-hospital score (C-statistic: 0.81 vs 0.73; p < 0.001) and outperformed all other machine learning models in terms of discrimination, calibration, and accuracy measures. Variables that were consistently most important for prediction across all models were duration of arrest, initial cardiac arrest rhythm, admission Cerebral Performance Category score, and age.
Conclusions:
The gradient boosted machine algorithm was the most accurate for predicting favorable neurologic outcomes in in-hospital cardiac arrest survivors. Our results highlight the utility of machine learning for predicting neurologic outcomes in resuscitated patients.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Mayampurath and Hagopian contributed equally to the work.
Dr. Mayampurath received funding from the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute and Litmus Health. He is supported by a career development award from the National Heart, Lung, and Blood Institute (K01HL148390). He has performed consulting services for Litmus Health (Austin, TX). Dr. Edelson received funding from the Department of Defense (E01W81XWH2110009), the University of Chicago through a patent pending (ARCD.P0535US.P2) for risk stratification algorithms for hospitalized patients, and AgileMD (San Francisco, CA) and has ownership interest in AgileMD, which licenses electronic Cardiac Arrest Risk Triage, a patient risk analytic. She received research support and honoraria from Philips Healthcare (Andover, MA) and research support from EarlySense (Tel Aviv, Israel). Dr. Churpek received funding from the NIH and Early Sense (Tel Aviv, Israel). He has a patent pending (ARCD. P0535US.P2) for risk stratification algorithms for hospitalized patients and has received research support from EarlySense, and he is supported by an R01 from the National Institute of General Medical Sciences (R01 GM123193). The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: mchurpek@medicine.wisc.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMaharaj, Ritesh; Harrison, David A.; Rowan, Kathryn
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Differences in decisions to limit life-sustaining therapy are often supported by perceptions that patients receive unnecessary and expensive treatment which provide negligible survival benefit. However, the assumption behind those beliefs—that is, that life-sustaining therapy provides no significant marginal survival benefit—remains unproven. Our objective was to quantify the effects of variations in decisions to withdraw or withhold life-sustaining treatment on 180-day mortality in critically ill patients.
Design:
Retrospective observational cohort study of a national clinical database.
Setting:
Adult ICUs participating in the Intensive Care National Audit and Research Center Case Mix Program in the United Kingdom.
Patients:
Adult patients admitted to general ICUs between April 1, 2009, and March 31, 2016.
Measurements and Main Results:
During the study period, 795,721 patients were admitted to 247 ICUs across the United Kingdom. A decision to withdraw or withhold life-sustaining treatment was made for 92,327 patients (11.6%). A multilevel model approach was used to estimate ICU-level practice variation. The ICU-level practice variation was then used as an instrument to measure the effects of decision to withdraw or withhold life-sustaining treatment on 180-day mortality. The marginal population was estimated to be 5.9% of the total cohort. A decision to withdraw or withhold life-sustaining treatment was associated with a marginal increase in 180-day mortality of 25.6% (95% CI, 23.2–27.9%).
Conclusions:
Decision to withdraw or withhold life-sustaining treatment in critically ill adults in the United Kingdom was associated with increased 180-day mortality in the marginal patients. The increased mortality from a decision to withdraw or withhold life-sustaining treatment in the marginal patient may be informative when establishing patients’ preferences and evaluating the cost-effectiveness of intensive treatments.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Maharaj and Harrison had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Harrison and Rowan contributed equally to this work. All authors contributed to concept and design, and acquisition, analysis, or interpretation of data. Dr. Maharaj contributed to drafting of the article. All authors contributed to critical revision of the article for important intellectual content. Drs. Maharaj and Harrison contributed to statistical analysis.
The authors have disclosed that they do not have any potential conflicts of interest.
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of Intensive Care National Audit and Research Center.
For information regarding this article, E-mail: maharajr@lse.ac.uk
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedStevic, Neven; Argaud, Laurent; Loufouat, Joseph; Kreitmann, Louis; Desmurs, Laurent; Ovize, Michel; Bidaux, Gabriel; Cour, Martin
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To determine whether continuous IV infusion of molar sodium lactate would limit cardiac arrest–induced neurologic injury and cardiovascular failure.
Design:
Randomized blinded study (animal model).
Setting:
University animal research facility.
Subjects:
Twenty-four adult male “New Zealand White” rabbits.
Interventions:
Anesthetized rabbits underwent 12.5 minutes of asphyxial cardiac arrest and were randomized to receive either normal saline (control group, n = 12) or molar sodium lactate (molar sodium lactate group, n = 12) at a rate of 5 mL/kg/hr during the whole 120-minute reperfusion period.
Measurements and Main Results:
Pupillary reactivity (primary outcome), levels of S100β protein, in vitro brain mitochondria functions, cardiovascular function, and fluid balance were assessed. Molar sodium lactate reduced brain injury, with a higher proportion of animals exhibiting pupillary reactivity to light (83% vs 25% in the CTRL group, p = 0.01) and lower S100β protein levels (189 ± 42 vs 412 ± 63 pg/mL, p < 0.01) at the end of the protocol. Molar sodium lactate significantly prevented cardiac arrest–induced decrease in oxidative phosphorylation and mitochondrial calcium–retention capacity compared with controls. At 120 minutes of reperfusion, survival did not significantly differ between the groups (10/12, 83% in the molar sodium lactate group vs nine of 12, 75% in the control group; p > 0.99), but hemodynamics were significantly improved in the molar sodium lactate group compared with the control group (higher mean arterial pressure [49 ± 2 vs 29 ± 3 mm Hg; p < 0.05], higher cardiac output [108 ± 4 vs 58 ± 9 mL/min; p < 0.05], higher left ventricle surface shortening fraction [38% ± 3% vs 19% ± 3%; p < 0.05], and lower left ventricular end-diastolic pressure [3 ± 1 vs 8 ± 2 mm Hg; p < 0.01]). While fluid intake was similar in both groups, fluid balance was higher in control animals (11 ± 1 mL/kg) than that in molar sodium lactate-treated rabbits (1 ± 3 mL/kg; p < 0.01) due to lower diuresis.
Conclusions:
Molar sodium lactate was effective in limiting the severity of the postcardiac arrest syndrome. This preclinical study opens up new perspectives for the treatment of cardiac arrest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by a research grant from the “ALLP Groupe ADENE.”
The work was performed at Université de Lyon, INSERM UMR1060 (CarMeN), IRIS team, Lyon, France.
The authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: martin.cour@chu-lyon.fr
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMehta, Sangeeta; Ahluwalia, Nanki; Heybati, Kiyan; Burns, Karen E. A.; Owais, Sawayra; Cook, Deborah J.; for the Canadian Critical Care Trials Group
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Diverse perspectives improve the quality of scholarly initiatives. The demographic and professional diversity of scientists who contribute to critical care research and publications has not been described for the Canadian Critical Care Trials Group. Our objective was to describe the diversity of authors of publications from the Canadian Critical Care Trials Group.
Design:
We conducted a quantitative content analysis of peer-reviewed articles published on behalf of the Canadian Critical Care Trials Group.
Setting:
All peer-reviewed articles that were published on behalf of the Canadian Critical Care Trials Group between 1994 and October 2020.
Subjects:
For each publication, we recorded the study design, the number of authors, and national or international collaboration. For the lead author, the senior author, and each coauthor, we recorded the following facets of diversity: gender, professional role, medical discipline, geographic location, academic stage, and visible minority status.
Interventions:
None.
Measurements and Main Results:
We identified 354 eligible publications; 74% (263/354) reported observational cohort studies, randomized trials, and surveys. Of 4,246 authors, 1,205 were unique individuals. The mean (SD) number of authors per publication was 12 (7.1). Of all 4,246 authors, 37% were women, and 13.7% were members of a visible minority group. Of all lead or senior authors, 40% and 34% respectively were women; 15% of lead and 10% of senior authors were members of a visible minority group. Three-quarters (73%) of publications listed authors from more than one profession, and more than half (54%) listed authors from more than one medical discipline. Nearly half of publications (45%) listed authors who were early career faculty, 33% listed authors who were trainees, and 67% listed authors who were from visible minority groups. Authors from different provinces and from different countries were listed in 67% and 40% of publications, respectively.
Conclusions:
Authors of Canadian Critical Care Trials Group publications are diverse with regard to demographic and professional characteristics.
Dr. Burns disclosed that she holds a career award from the Physician Services Incorporated Foundation and that she is the current chair of the Women in Critical Care Interest Group of the American Thoracic Society. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: Geeta.mehta@sinaihealth.ca
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedZier, Judith L.; Newman, Nicole A.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To describe the unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child.
DESIGN:
Case report based on clinical observation and medical record review.
SETTING:
Community Children’s Hospital.
PATIENT:
Two-year old child.
INTERVENTIONS:
Following hypoxic-ischemic brain injury, the child was taken to the operating room for withdrawal of life-sustaining treatment during controlled donation after circulatory determination of death.
MEASUREMENTS AND MAIN RESULTS:
In addition to direct observation by experienced pediatric critical care providers, the child was monitored with electrocardiography, pulse oximetry, and invasive blood pressure via femoral arterial catheter in addition to direct observation by experienced pediatric critical care providers. Unassisted return of spontaneous circulation occurred greater than 2 minutes following circulatory arrest and was accompanied by return of respiration.
Conclusions:
We provide the first report of unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child. In our case, return of spontaneous circulation occurred in the setting of controlled donation after circulatory determination of death and was accompanied by return of respiration. Return of spontaneous circulation greater than 2 minutes following circulatory arrest in our patient indicates that 2 minutes of observation is insufficient to ensure that cessation of circulation is permanent after withdrawal of life-sustaining treatment in a child.
This work was performed at Children’s Minnesota, Minneapolis, MN.
Dr. Zier received funding from Y-mAbs Therapeutics, Inc; she disclosed she is a member of the Clinical Policy Board of LifeSource. Dr. Newman has disclosed that she does not have any potential conflicts of interest.
For information regarding this article, E-mail: zier@crccs.com
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedPetitjeans, Fabrice; Leroy, Sandrine; Pichot, Cyrille; Ghignone, Marco; Quintin, Luc; Constantin, Jean-Michel
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Tsai, Min-Shan; Chen, Wen-Jone; Chen, Wei-Ting; Tien, Yu-Tzu; Chang, Wei-Tien; Ong, Hooi-Nee; Huang, Chien-Hua
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To evaluate whether the recommended observation period of 7 days for cardiac arrest survivors is sufficient for conscious recovery and to identify the variables associated with eventual neurologic recovery among patients with delayed awakening.
Design:
A retrospective cohort study.
Setting:
A single tertiary medical center.
Patients:
Five-hundred twenty-nine nontraumatic adult cardiac arrest survivors with prearrest favorable neurologic function (Cerebral Performance Category 1–2) who survived to hospital discharge during 2011–2019.
Interventions:
The enrolled patients were classified into favorable (Cerebral Performance Category 1–2) and poor (Cerebral Performance Category 3–4) neurologic recovery according to their neurologic function at hospital discharge. Among patients with favorable neurologic recovery, those who recovered within 7 days were assigned to the early recovery group or after 7 days as the late recovery group.
Measurements and Main Results:
There were 395 patients exhibiting favorable neurologic recovery (n = 357 in the early group, n = 38 in late group) and 134 patients exhibiting poor neurologic recovery (poor recovery group). Among patients who remained unconscious on day 7, delayed awakening was associated with male sex (odds ratio [OR], 3.905; 95% CI, 1.153–13.221), prehospital return of spontaneous circulation (OR, 7.628; 95% CI, 2.084–27.922), therapeutic hypothermia (OR, 4.320; 95% CI, 1.624–11.488), and extracorporeal cardiopulmonary resuscitation (OR, 4.508; 95% CI, 1.414–14.371). Being transferred from another hospital, however, was less likely to be associated with delayed awakening (OR, 0.061; 95% CI, 0.009–0.431). The median duration for patients to regain clear consciousness in the late recovery group was 12.12 days. No patient who recovered consciousness had an unfavorable electroencephalography pattern, however, in patients with poor recovery, the 7-day electroencephalography showed 45 patients with generalized suppression (33.6%), two with burst suppression (1.5%), 14 with seizure/epileptic discharge (10.5%), and one with status epilepticus (0.7%).
Conclusions:
Up to 9.6% of cardiac arrest patients with favorable outcomes recover consciousness after the recommended 7 days of observation, indicating the observation time of 7 days seems justified but longer duration may be needed. The results of the culturally and clinically isolated population may limit the application to other population.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
This study was performed in National Taiwan University Hospital.
The authors have disclosed that they do not have any potential conflicts of interest.
The authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: wjchen1955@ntu.edu.tw; chhuang730@gmail.com
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedPetit, Matthieu; Fetita, Catalin; Gaudemer, Augustin; Treluyer, Ludovic; Lebreton, Guillaume; Franchineau, Guillaume; Hekimian, Guillaume; Chommeloux, Juliette; Pineton de Chambrun, Marc; Brechot, Nicolas; Luyt, Charles-Edouard; Combes, Alain; Schmidt, Matthieu
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To determine the characteristics and outcomes of patients prone-positioned during extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and lung CT pattern associated with improved respiratory system static compliance after that intervention.
Design:
Retrospective, single-center study over 8 years.
Settings:
Twenty-six bed ICU in a tertiary center.
Measurements and Main Results:
A propensity score–matched analysis compared patients with prone-positioning during extracorporeal membrane oxygenation and those without. An increase of the static compliance greater than or equal to 3 mL/cm H2O after 16 hours of prone-positioning defined prone-positioning responders. The primary outcome was the time to successful extracorporeal membrane oxygenation weaning within 90 days of postextracorporeal membrane oxygenation start, with death as a competing risk. Among 298 venovenous extracorporeal membrane oxygenation–treated adults with severe acute respiratory distress syndrome, 64 were prone-positioning extracorporeal membrane oxygenation. Although both propensity score–matched groups had similar extracorporeal membrane oxygenation durations, prone-positioning extracorporeal membrane oxygenation patients’ 90-day probability of being weaned-off extracorporeal membrane oxygenation and alive was higher (0.75 vs 0.54, p = 0.03; subdistribution hazard ratio [95% CI], 1.54 [1.05–2.58]) and 90-day mortality was lower (20% vs 42%, p < 0.01) than that for no prone-positioning extracorporeal membrane oxygenation patients. Extracorporeal membrane oxygenation–related complications were comparable for the two groups. Patients without improved static compliance had higher percentages of nonaerated or poorly aerated ventral and medial-ventral lung regions (p = 0.047).
Conclusions:
Prone-positioning during venovenous extracorporeal membrane oxygenation was safe and effective and was associated with a higher probability of surviving and being weaned-off extracorporeal membrane oxygenation at 90 days. Patients with greater normally aerated lung tissue in the ventral and medial-ventral regions on quantitative lung CT-scan performed before prone-positioning are more likely to improve their static compliance after that procedure during extracorporeal membrane oxygenation.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Combes received grants from Getinge and personal fees from Getinge, Baxter, and Xenios outside the submitted work. Dr. Schmidt received personal fees from Getinge, Drager, 3M, and Xenios, outside the submitted work. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: matthieu.schmidt@aphp.fr
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMacDonald, Andrew J.; Subramanian, Ram M.; Olson, Jody C.; Speiser, Jaime L.; Durkalski-Mauldin, Valerie L.; Abraldes, Juan G.; Bigam, David L.; Flynn, Mary M.; Rapaka, Babusai; Shropshire, Brianne M.; Vora, Ravi S.; Karvellas, Constantine J.; for the U.S. Acute Liver Failure Study Group
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The molecular adsorbent recirculating system removes water-soluble and albumin-bound toxins and may be beneficial for acute liver failure patients. We compared the rates of 21-day transplant-free survival in acute liver failure patients receiving molecular adsorbent recirculating system therapy and patients receiving standard medical therapy.
Design:
Propensity score–matched retrospective cohort analysis.
Setting:
Tertiary North American liver transplant centers.
Patients:
Acute liver failure patients receiving molecular adsorbent recirculating system at three transplantation centers (n = 104; January 2009–2019) and controls from the U.S. Acute Liver Failure Study Group registry.
Interventions:
Molecular adsorbent recirculating system treatment versus standard medical therapy (control).
Measurements and Main Results:
One-hundred four molecular adsorbent recirculating system patients were propensity score–matched (4:1) to 416 controls. Using multivariable conditional logistic regression adjusting for acute liver failure etiology (acetaminophen: n = 248; vs nonacetaminophen: n = 272), age, vasopressor support, international normalized ratio, King’s College Criteria, and propensity score (main model), molecular adsorbent recirculating system was significantly associated with increased 21-day transplant-free survival (odds ratio, 1.90; 95% CI, 1.07–3.39; p = 0.030). This association remained significant in several sensitivity analyses, including adjustment for acute liver failure etiology and propensity score alone (“model 2”; molecular adsorbent recirculating system odds ratio, 1.86; 95% CI, 1.05–3.31; p = 0.033), and further adjustment of the “main model” for mechanical ventilation, and grade 3/4 hepatic encephalopathy (“model 3”; molecular adsorbent recirculating system odds ratio, 1.91; 95% CI, 1.07–3.41; p = 0.029). In acetaminophen-acute liver failure (n = 51), molecular adsorbent recirculating system was associated with significant improvements (post vs pre) in mean arterial pressure (92.0 vs 78.0 mm Hg), creatinine (77.0 vs 128.2 µmol/L), lactate (2.3 vs 4.3 mmol/L), and ammonia (98.0 vs 136.0 µmol/L; p ≤ 0.002 for all). In nonacetaminophen acute liver failure (n = 53), molecular adsorbent recirculating system was associated with significant improvements in bilirubin (205.2 vs 251.4 µmol/L), creatinine (83.1 vs 133.5 µmol/L), and ammonia (111.5 vs 140.0 µmol/L; p ≤ 0.022 for all).
Conclusions:
Treatment with molecular adsorbent recirculating system is associated with increased 21-day transplant-free survival in acute liver failure and improves biochemical variables and hemodynamics, particularly in acetaminophen-acute liver failure.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by the National Institutes of Health grant U-01 58369 (from the National Institute of Diabetes and Digestive and Kidney Diseases).
Dr. Durkalski-Maudlin’s institution received funding from the National Institutes of Health (NIH) and the National Institute of Diabetes and Digestive and Kidney Diseases. Drs. Durkalski-Maudlin and Karvellas received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: dean.karvellas@ualberta.ca
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedIsta, Erwin; Redivo, Juliana; Kananur, Paurav; Choong, Karen; Colleti, Jose Jr; Needham, Dale M.; Awojoodu, Ronke; Kudchadkar, Sapna R.; on behalf of the International PARK-PICU Investigators
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To evaluate current international practice in PICUs regarding components of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment” (“ABCDEF”) bundle.
Design:
Online surveys conducted between 2017 and 2019.
Setting:
One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study.
Interventions:
None.
Measurements and Main Results:
Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children’s hospitals. Median size was 16 beds (interquartile range, 10–24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions.
Conclusions:
ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Choong’s institution received funding from the Alternative Funding Plan Innovation Fund; she received funding from McMaster University. Dr. Needham received funding from Haisco-USA Pharmaceuticals, Novartis Pharma, and GlaxoSmithKline; he disclosed that he is a principal investigator on a National Institutes of Health (NIH) funded, multicentered randomized trial (R01HL132887) funded by an unrestricted research grant to the University of Vermont from Baxter Healthcare Corporation. Dr. Kudchadkar received support for article research from the NIH. Dr. Kudchadkar was supported by an Anesthesiology and Critical Care Medicine Clinical Research Core StAARter Gran from Johns Hopkins University and the Johns Hopkins Clinical and Translational Science Award Number 5KL2RR025006 from the National Center for Advancing Translational Sciences of the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: w.ista@erasmusmc.nl
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedLe Moigne, Guillaume; Nazir, Souha; Pateau, Victoire; Courtois, Emmanuelle; L’Her, Erwan
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The mechanisms of high-flow nasal cannula are still debated but may be mediated by the generation of low positive end-expiratory pressure and a washout of the airway dead space. The aims of this study were to assess the effects of high-flow nasal cannula on tidal volume using a noninvasive method using a time-of-flight camera, under various conditions.
Design:
A physiologic evaluation in healthy volunteers.
SETTING:
An university hospital ICU.
Subjects:
Ten healthy volunteers were included in a physiologic study (CamOpt study, ClinicalTrials.gov identifier: NCT04096183).
Interventions:
All volunteers were submitted to 12 different conditions (i.e., gas flow [baseline = 0; 30–60 L/min]; mouth [open/closed]; respiratory rate [baseline; baseline + 10 breaths/min]). Tidal volume measurements were performed every minute, during a 6-minute recording period. In all combinations, reference respiratory rate was measured by using chronometric evaluation, over a 30–second period (RRREF), and by using the time-of-flight camera (RRTOF).
Measurements and Main Results:
Tidal volume increased while increasing gas flow whatever the respiratory rate and mouth condition (p < 0.001). Similar results were observed whatever the experimental conditions (p < 0.01), except one (baseline respiratory rate + 10 breaths/min and mouth closed). Tidal volume increased while decreasing respiratory rate (p < 0.001) and mouth closing (p < 0.05). Proportion of tidal volume greater than 10, 15, and 20 mL/kg changed while increasing the flow. RRTOF was in agreement with RRREF (intraclass correlation coefficient, 0.96), with a low mean bias (0.55 breaths/min) and acceptable deviation.
Conclusions:
Time-of-flight enables to detect tidal volume changes under various conditions of high-flow nasal cannula application. Tidal volume increased significantly while increasing gas flow and mouth closing. Such technique might be useful to monitor the risk of patient self-inflicted lung injury or under assistance.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
The research was funded by Brest University Hospital.
Dr. L’Her is the cofounder and shareholder of Oxynov, a biomedical R&D Canadian Company; he received support for article research from Brest University Hospital. He is also consultant for GE Healthcare, Smiths, Sedana Medical, and Vygon. Drs. Nazir and L’Her disclosed they have a patent pending for the time-of-flight monitoring system. Dr. Nazir disclosed work for hire. Ms. Pateau is part of employee for Oxynov. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: erwan.lher@chu-brest.fr
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedRass, Verena; Ianosi, Bogdan-Andrei; Lindlbauer, Moritz; Lindner, Anna; Kofler, Mario; Schiefecker, Alois J.; Pfausler, Bettina; Beer, Ronny; Helbok, Raimund
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Patients suffering from spontaneous subarachnoid hemorrhage frequently require mechanical ventilation. Here, we aimed to identify factors associated with prolonged mechanical ventilation in subarachnoid hemorrhage patients and to create a new predictive score for prolonged mechanical ventilation.
Design:
Prospective cohort study with retrospective data analysis.
Setting:
Neurocritical care unit at a tertiary academic medical center.
Patients:
Two hundred ninety-seven consecutive nontraumatic adult subarachnoid hemorrhage patients.
Methods:
In patients with mechanical ventilation, we identified factors associated with mechanical ventilation greater than 48 hours, greater than 7 days, and greater than 14 days compared with mechanical ventilation less than or equal to 48 hours, less than or equal to 7 days, or less than or equal to 14 days in multivariable generalized linear models. Ventilated patients who died before 48 hours, 7 days, or 14 days and those never ventilated were excluded from the respective analysis. We incorporated those factors into a new prognostic score (the RAISE score) to predict prolonged mechanical ventilation greater than 7 days. The calculation was based on a random dataset of 60% of subarachnoid hemorrhage patients and was internally validated.
INTERVENTIONS:
None.
MEASUREMENTS AND MAIN RESULTS:
Patients were 57 years old (interquartile range, 47–68 yr) and presented with a median Hunt and Hess grade of 3 (1–5). Two hundred forty-two patients (82%) required mechanical ventilation for 9 days (2–20 d). In multivariable analysis, a higher Acute Physiology Score was associated with mechanical ventilation greater than 48 hours, greater than 7 days, and greater than 14 days, a higher Hunt and Hess grade with greater than 7 days and greater than 14 days. Early neuroimaging findings were associated with mechanical ventilation greater than 48 hours (hydrocephalus; high-grade Subarachnoid Hemorrhage Early Brain Edema Score), greater than 7 days (high-grade Subarachnoid Hemorrhage Early Brain Edema Score, co-occurrence of intracerebral bleeding) but not with prolonged mechanical ventilation greater than 14 days. The RAISE score, including age, Acute Physiology Score, Hunt and Hess grade, Subarachnoid Hemorrhage Early Brain Edema Score, and the co-occurrence of intracerebral hemorrhage accurately stratified patients by prolonged mechanical ventilation greater than 7 days (C-statistic 0.932). A RAISE score of 12 predicted 60% likelihood of mechanical ventilation greater than 7 days.
Conclusions:
Initial disease severity and neuroimaging findings detected within 24 hours after ICU admission were associated with the need for prolonged mechanical ventilation in patients with subarachnoid hemorrhage. These results may be helpful for patient families and caregivers to better anticipate the course of therapy.
This work was performed at Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Beer’s institution received funding from the Austrian Science fund (FWF) (KLI 375); he received support for article research from the FWF. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: Raimund.helbok@tirol-kliniken.at; raimund.helbok@i-med.ac.at
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedGutierrez, Cristina; Brown, Anne Rain T.; May, Heather P.; Beitinjaneh, Amer; Stephens, R. Scott; Rajendram, Prabalini; Nates, Joseph L.; Pastores, Stephen M.; Dharshan, Ananda; de Moraes, Alice Gallo; Hensley, Matthew K.; Feng, Lei; Brudno, Jennifer N.; Athale, Janhavi; Ghosh, Monalisa; Kochenderfer, James N.; Arias, Alejandro S.; Lin, Yi; McEvoy, Colleen; Mead, Elena; Westin, Jason; Kostelecky, Natalie; Mian, Agrima; Herr, Megan M.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome.
Design:
Retrospective cohort study
Setting:
Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative.
Patients:
Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019.
Interventions:
Demographics, toxicities, specific interventions, and outcomes were collected.
Results:
One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3–4 toxicities (66.7%); 15.2% had grade 3–4 cytokine release syndrome and 64% grade 3–4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64–not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival.
Conclusions:
This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Gutierrez and Brown contributed equally to this study and will share first co-authorship.
Drs. Gutierrez and Brown contributed equally to and had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Gutierrez, Brown, May, Beitinjaneh, Stephens, Rajendram, Pastores, Dharshan, de Moraes, Hensley, Brudno, Athale, Ghosh, Lin, Kostelecky, and Herr contributed to data acquisition, review of data, and addressed any inconsistencies raised by Drs. Gutierrez and Brown. Dr. Feng conducted statistical analysis, and all authors have interpreted the data. Drs. Gutierrez and Brown drafted the article, and all authors have provided critical revision for content. All authors have read and approved the final article.
This study was supported in part by the National Institutes of Health (NIH) through Cancer Center Support Grant P30CA016672 and in part by the Intramural Research Program of the NIH Clinical Center, National Cancer Institute, and National Heart, Lung, and Blood Institute, respectively.
This data was accepted to be presented as abstracts and an oral presentation at the Society of Critical Care Medicine Congress in Orlando, FL, 2020. Drs. Gutierrez, Brudno, and Athale received support for article research from the National Institutes of Health. Dr. Gutierrez disclosed the off-label product use of anakinra; she disclosed that she served, and will serve again, in the advisory board for Legend Biotech and Janssen in August 2020. Drs. Gutierrez, May, and McEvoy disclosed the off-label product use of Siltuximab. Dr. Brown received funding from La Jolla Pharmaceutical outside the submitted work. Dr. May disclosed the off-label product use of Corticosteroids. Dr. Beitinjaneh received funding from KITE pharmaceuticals on August 2018. Drs. Brudno and Kochenderfer disclosed government work. Dr. Kochenderfer’s institution received funding from KITE pharmaceuticals, Bristol Meyers Squibb, and Kyverna; he is the principal investigator of Cooperative Research and Development Agreements with Kite, a Gilead Company and Celgene. Dr. Lin as Principal Investigator Mayo Clinic receives compensation for research activities and clinical trials with Kite/Gilead, Janssen, Celgene, BlueBird Bio, Merck, Boston Scientific, Gamida, and Takeda; advisory board with Kite/Gilead, Novartis, Janssen, Legend BioTech, JUNO, Bristol-Myers-Squibb (BMS), Celgene, BlueBird Bio, and Ethos; Data and Safety Monitoring Board: Sorrento; and steering committee: Celgene, Janssen, and Legend BioTech. Dr. McEvoy received funding from United Therapeutics. Dr. Westin received funding from BMS, Novartis, Kite Gilead, Juno Celgene, Genentech, AstraZeneca, Morphosys, and ADC Therapeutics. The remaining authors have disclosed that they do not have any potential conflicts of interest.
The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the National Institutes of Health. A subset of data from one center was published as a Letter to the Editor in the American Journal of Respiratory and Critical Care Medicine. The study did not include all patients from the chimeric antigen receptor-ICU initiative, its dataset, or measure same outcomes.
The study was conducted in accordance with the amended Declaration of Helsinki, local Institutional Review Boards approved the protocol and waived informed consent. MD Anderson Cancer Center was the leading center with protocol approval PA19-0365.
Local Institutional Review Boards approved the protocol and waived informed consent.
Data use agreements were established independently with each institution and de-identified data were made available and analyzed at MD Anderson Cancer Center. Availability of data from each center will be upon approval from each Institutional Review Board.
For information regarding this article, E-mail: CGutierrez4@mdanderson.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedNishikimi, Mitsuaki; Yagi, Tsukasa; Shoaib, Muhammad; Takegawa, Ryosuke; Rasul, Rehana; Hayashida, Kei; Okuma, Yu; Yin, Tai; Choudhary, Rishabh C.; Becker, Lance B.; Kim, Junhwan
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Cardiac arrest and subsequent resuscitation have been shown to deplete plasma phospholipids. This depletion of phospholipids in circulating plasma may contribute to organ damage postresuscitation. Our aim was to identify the diminishment of essential phospholipids in postresuscitation plasma and develop a novel therapeutic approach of supplementing these depleted phospholipids that are required to prevent organ dysfunction postcardiac arrest, which may lead to improved survival.
Design:
Clinical case control study followed by translational laboratory study.
Setting:
Research institution.
Patients/Subjects:
Adult cardiac arrest patients and male Sprague-Dawley rats.
Interventions:
Resuscitated rats after 10-minute asphyxial cardiac arrest were randomized to be treated with lysophosphatidylcholine specie or vehicle.
Measurements and Main Results:
We first performed a phospholipid survey on human cardiac arrest and control plasma. Using mass spectrometry analysis followed by multivariable regression analyses, we found that plasma lysophosphatidylcholine levels were an independent discriminator of cardiac arrest. We also found that decreased plasma lysophosphatidylcholine was associated with poor patient outcomes. A similar association was observed in our rat model, with significantly greater depletion of plasma lysophosphatidylcholine with increased cardiac arrest time, suggesting an association of lysophosphatidylcholine levels with injury severity. Using a 10-minute cardiac arrest rat model, we tested supplementation of depleted lysophosphatidylcholine species, lysophosphatidylcholine(18:1), and lysophosphatidylcholine(22:6), which resulted in significantly increased survival compared with control. Furthermore, the survived rats treated with these lysophosphatidylcholine species exhibited significantly improved brain function. However, supplementing lysophosphatidylcholine(18:0), which did not decrease in the plasma after 10-minute cardiac arrest, had no beneficial effect.
Conclusions:
Our data suggest that decreased plasma lysophosphatidylcholine is a major contributor to mortality and brain damage postcardiac arrest, and its supplementation may be a novel therapeutic approach.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Nishikimi and Yagi contributed equally.
This work was supported, in part, by Zoll Foundation.
Dr. Kim’s institution received funding from the Zoll Foundation. Dr. Becker’s institution received funding from Philips, United Therapeutics, and Nihon Kohden; he received funding from ZOLL Medical, the National Institutes of Health, PCORI, and BrainCool. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: jkim46@northwell.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedWisløff-Aase, Kristin; Skulstad, Helge; Beitnes, Jan Otto; Lundblad, Runar; Halvorsen, Per Steinar; Fiane, Arnt; Espinoza, Andreas
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Targeted temperature management (32–36°C) is used for neuroprotection in cardiac arrest survivors. The isolated effects of hypothermia on myocardial function, as used in clinical practice, remain unclear. Based on experimental results, we hypothesized that hypothermia would reversibly impair diastolic function with less tolerance to increased heart rate in patients with uninsulted hearts.
Design:
Prospective clinical study, from June 2015 to May 2018.
Setting:
Cardiothoracic surgery operation room, Oslo University Hospital.
Patients:
Twenty patients with left ventricular ejection fraction greater than 55%, undergoing ascending aorta graft-replacement connected to cardiopulmonary bypass were included.
Interventions:
Left ventricular function was assessed during reduced cardiopulmonary bypass support at 36°C, 32°C prior to graft-replacement, and at 36°C postsurgery. Electrocardiogram, hemodynamic, and echocardiographic recordings were made at spontaneous heart rate and 90 beats per minute at comparable loading conditions.
Measurements and Main Results:
Hypothermia decreased spontaneous heart rate, and R-R interval was prolonged (862 ± 170 to 1,156 ± 254 ms, p < 0.001). Although systolic and diastolic fractions of R-R interval were preserved (0.43 ± 0.07 and 0.57 ± 0.07), isovolumic relaxation time increased and diastolic filling time was shortened. Filling pattern changed from early to late filling. Systolic function was preserved with unchanged myocardial strain and stroke volume index, but cardiac index was reduced with maintained mixed venous oxygen saturation. At increased heart rate, systolic fraction exceeded diastolic fraction (0.53 ± 0.05 and 0.47 ± 0.05) with diastolic impairment. Strain and stroke volume index were reduced, the latter to 65% of stroke volume index at spontaneous heart rate. Cardiac index decreased, but mixed venous oxygen saturation was maintained. After rewarming, myocardial function was restored.
Conclusions:
In patients with normal left ventricular function, hypothermia impaired diastolic function. At increased heart rate, systolic function was subsequently reduced due to impeded filling. Changes in left ventricular function were rapidly reversed after rewarming.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http:/journals.lww.com/ccmjournal).
The authors have disclosed that they do not have any potential conflicts of interest.
The work was performed at Oslo University Hospital, Rikshospitalet, Oslo, Norway.
For information regarding this article, E-mail: uxwisk@ous-hf.no
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedLeung, Sharon; Pastores, Stephen M.; Oropello, John M.; Lilly, Craig M.; Galvagno, Samuel M. Jr; Badjatia, Neeraj; Jacobi, Judith; Herr, Daniel L.; Oliveira, Jason David; for the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions.
Data Sources and Study Selection:
Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product.
Data Extraction and Synthesis:
The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations.
Conclusions:
Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Galvagno’s institution received funding from the Department of Defense; he received funding from Northwest Anesthesia Seminars and from expert defense for medicolegal work. Dr. Jacobi received funding from Visante, Merck, Pfizer, American Society of Health System Pharmacists, and a Pharmacy Continuing Education group. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: pastores@mskcc.org
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedPound, Gemma M.; Jones, Daryl; Eastwood, Glenn M.; Paul, Eldho; Hodgson, Carol L.; The Australia and New Zealand Cardiac Arrest Outcome and Determinants of ECMO (ANZ-CODE) Investigators
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
To evaluate the functional outcome and health-related quality of life of in-hospital cardiac arrest survivors at 6 and 12 months.
Design:
A longitudinal cohort study.
Setting:
Seven metropolitan hospitals in Australia.
Patients:
Data were collected for hospitalized adults (≥ 18 yr) who experienced in-hospital cardiac arrest, defined as “a period of unresponsiveness, with no observed respiratory effort and the commencement of external cardiac compressions.”
Interventions:
None.
Measurements and Main Results:
Prior to hospital discharge, patients were approached for consent to participate in 6-month and 12-month telephone interviews. Outcomes included the modified Rankin Scale, Barthel Index, Euro-Quality of Life 5 Dimension 5 Level, return to work and hospital readmissions. Forty-eight patients (80%) consented to follow-up interviews. The mean age of participants was 67.2 (± 15.3) years, and 33 of 48 (68.8%) were male. Good functional outcome (modified Rankin Scale score ≤ 3) was reported by 31 of 37 participants (83.8%) at 6 months and 30 of 33 (90.9%) at 12 months. The median Euro-Quality of Life-5D index value was 0.73 (0.33–0.84) at 6 months and 0.76 (0.47–0.88) at 12 months. The median Euro-Quality of Life-Visual Analogue Scale score at 6 months was 70 (55–80) and 75 (50–87.5) at 12 months. Problems in all Euro-Quality of Life-5D-5 L dimension were reported frequently at both time points. Hospital readmission was reported by 23 of 37 patients (62.2%) at 6 months and 16 of 33 (48.5%) at 12 months. Less than half of previously working participants had returned to work by 12 months.
Conclusions:
The majority of in-hospital cardiac arrest survivors had a good functional outcome and health-related quality of life at 6 months, and this was largely unchanged at 12 months. Despite this, many reported problems with mobility, self-care, usual activities, pain, and anxiety/depression. Return to work rates was low, and hospital readmissions were common.
Ms. Pound contributed to concept and study design, visualization, data acquisition, statistical analysis and data interpretation, writing—original draft preparation, and project administration. Prof. Jones, Dr. Eastwood, and Prof. Hodgson contributed to concept and study design, visualization, validation, writing—review and editing, supervision, and project administration. Dr. Paul contributed to statistical analysis and data interpretation, and writing—review and editing. All authors read and approved the final article.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
The authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: carol.hodgson@monash.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMehta, Anuj B.; Matlock, Daniel; Douglas, Ivor S.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Availability of long-term acute care hospitals has been associated with hospital discharge practices. It is unclear if long-term acute care hospital availability can influence patient care decisions. We sought to determine the association of long-term acute care hospital availability at different hospitals with the likelihood of tracheostomy.
Design:
Retrospective cohort study.
Setting:
California Patient Discharge Database, 2016–2018.
Patients:
Adult patients receiving mechanical ventilation for respiratory failure.
Interventions:
None.
Measurements and Main Results:
Using the California Patient Discharge Database 2016–2018, we identified all mechanically ventilated patients and those who received tracheostomy. We determine the association between tracheostomy and the distance between each hospital and the nearest long-term acute care hospital and the number of long-term acute care hospital beds within 20 miles of each hospital. Among 281,502 hospitalizations where a patient received mechanical ventilation, 22,899 (8.1%) received a tracheostomy. Patients admitted to a hospital closer to a long-term acute care hospital compared with those furthest from a long-term acute care hospital had 38.9% (95% CI, 33.3–44.6%) higher odds of tracheostomy (closest hospitals 8.7% vs furthest hospitals 6.3%, adjusted odds ratio = 1.65; 95% CI, 1.40–1.95). Patients had a 32.4% (95% CI, 27.6–37.3%) higher risk of tracheostomy when admitted to a hospital with more long-term acute care hospital beds in the immediate vicinity (most long-term acute care hospital beds within 20 miles 8.9% vs fewest long-term acute care hospital beds 6.7%, adjusted odds ratio = 1.54; 95% CI, 1.31–1.80). Distance to the nearest long-term acute care hospital was inversely correlated with hospital risk-adjusted tracheostomy rates (ρ = –0.25; p < 0.0001). The number of long-term acute care hospital beds within 20 miles was positively correlated with hospital risk-adjusted tracheostomy rates (ρ = 0.22; p < 0.0001).
Conclusions:
Proximity and availability of long-term acute care hospital beds were associated with patient odds of tracheostomy and hospital tracheostomy practices. These findings suggest a hospital effect on tracheostomy decision-making over and above patient case-mix. Future studies focusing on shared decision-making for tracheostomy are needed to ensure goal-concordant care for prolonged mechanical ventilation.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Mehta and Douglas conceived the study and were responsible for data interpretation. Dr. Mehta was responsible for data collection and analysis and drafted the article. He had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. He conducted all aspects of data analysis. All authors provided critical revisions and meaningful input for the final draft. All authors approved the final draft of the article.
Dr. Mehta is supported by the National Institutes of Health (NIH) K23HL141704 (primary funding source); he is supported by NIH R01HL136403. Dr. Mehta’s institution received funding from the NIH. Dr. Matlock is supported by NIH R01HL136403. Dr. Douglas is supported by NIH R01NR016459.
For information regarding this article, E-mail: anuj.mehta@cuanschutz.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedSchwab, Kristin; Buhr, Russell G.; Grossetreuer, Anne V.; Balaji, Lakshman; Lee, Edward S.; Moskowitz, Ari L.; for the American Heart Association’s Get With the Guidelines-Resuscitation Investigators
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Objectives:
Airway management during in-hospital cardiac arrest represents a fundamental component of resuscitative efforts, yet little is known about temporal trends in intubation during in-hospital cardiac arrest. Our objective was to investigate changes in in-hospital cardiac arrest airway management over time and in response to national guideline updates.
Design:
Observational cohort study of a prospectively collected database.
Setting:
Multicenter study of hospitals participating in the “Get With The Guidelines—Resuscitation” registry from January 1, 2001, to December 31, 2018.
Subjects:
Adult patients who experienced an in-hospital cardiac arrest and did not have an invasive airway in place prior to the arrest.
Interventions:
The primary outcome was the rate of intra-arrest intubation from 2001 to 2018. We constructed multivariable regression models with generalized estimating equations to determine the annual adjusted odds of intubation. We also assessed the timing of intubation relative to the onset of pulselessness and other arrest measures. We used an interrupted time-series analysis to assess the association between the 2010 Advanced Cardiac Life Support guideline update and intubation rates.
Measurements and Main Results:
One thousand sixty-six eight hundred patients from 797 hospitals were included. From 2001 to 2018, the percentage of patients intubated during an arrest decreased from 69% to 55% for all rhythms, 73% to 60% for nonshockable rhythms, and 58% to 36% for shockable rhythms (p < 0.001 for trend for all 3 groups). The median time from onset of pulselessness to intubation increased from 5 minutes in 2001 (interquartile range, 2–8 min) to 6 minutes in 2018 (interquartile range, 4–10 min) (p < 0.001 for trend). Following the 2010 guideline update, there was a downward step change and a steeper decrease over time in the rate of intubation as compared to the preintervention period (p < 0.001).
Conclusions:
Endotracheal intubation rates during in-hospital cardiac arrest have decreased significantly over time, with a more substantial decline following the updated 2010 guideline that prioritized chest compressions over airway management.
This work was performed at University of California, Los Angeles, CA, and Beth Israel Deaconess Medical Center.
New affiliation for Dr. Moskowitz: Division of Critical Care Medicine, Montefiore Medical Center, the Bronx, NY.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Dr. Buhr’s institution received funding from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS); he received funding from the NIH/ NCATS (KL2TR001882), the National Heart, Lung, and Blood Institute (NHLBI), and the University of California Office of the President; he received personal consulting fees from Mylan/Theravance Biopharma and GlaxoSmithKline; he disclosed he is employed part-time by the Veterans Health Administration; he received support for article research from the NIH. This work does not necessarily represent the views and opinions of the Department of Veterans Affairs. Dr. Balaji. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: KSchwab@mednet.ucla.edu
Copyright © by 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Læs mere Tjek på PubMedMarini, John J.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021
Wessman, Brian T.; Mohr, Nicholas M.
Critical Care Medicine, 19.11.2021
Tilføjet 30.11.2021