New avenues for reducing intensive care needs in patients with chronic spinal cord injury

Relatively soon after their accident, patients suffering a spinal cord injury (SCI) begin generally experiencing the development of significant, often life-threatening secondary complications. Many of which are associated with chronic physical inactivity-related immune function problems and increasing susceptibility to infection that repeatedly requires intensive care treatment. Therapies capable of repairing the spinal cord or restoring ambulation would normally prevent many of these problems but, as of now, there is no cure for SCI. Thus, management strategies and antibiotics remain the standard of care although antimicrobial resistance constitutes a significant challenge for patients with chronic SCI facing recurrent infections of the urinary tract and respiratory systems. Identifying alternative therapies capable of safe and potent actions upon these serious health concerns should therefore be considered a priority. This editorial presents some of the novel approaches currently in development for the prevention of specific infections after SCI. Among them, brain-permeable small molecule therapeutics acting centrally on spinal cord circuits that can augment respiratory capabilities or bladder functions. If eventually approved by regulatory authorities, some of these new avenues may potentially become clinically-relevant therapies capable of indirectly preventing the occurrence and/or severity of these life-threatening complications in people with paraplegic or tetraplegic injuries.

Ball-shaped right atrial mass in renal cell carcinoma: A case report

BACKGROUND

Renal cell carcinoma (RCC) is an aggressive tumor, with an incidental discovery in most patients. Classic presentation is rare, and it has a high frequency of local and distant metastasis at the time of detection.

CASE SUMMARY

We present a rare case of a 58-year-old man with a ball-shaped thrombus in the right atrium at the time of first incidental identification of RCC in the emergency department. Cardiac metastasis, especially thrombus in the right atrium, is rare. It could either be a bland thrombus or a tumor thrombus, and physicians should consider this potentially fatal complication of RCC early at the time of initial presentation.

CONCLUSION

Ball-shaped lesions in the right atrium are rare, and bland thrombus should be differentiated from tumor thrombus secondary to intracardiac metastasis.

Stress cardiomyopathy in critical care: A case series of 109 patients

BACKGROUND

Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized.

AIM

To describe a case series of patients with SC admitted to critical care units.

METHODS

We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.

RESULTS

Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.

CONCLUSION

Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Association between neutrophil-to-lymphocyte ratio and hematoma expansion in spontaneous intracerebral hemorrhage: A systematic review and meta-analysis

BACKGROUND

Hematoma expansion (HE) typically portends a poor prognosis in spontaneous intracerebral hemorrhage (ICH). Several radiographic and laboratory values have been proposed as predictive markers of HE.

AIM

To perform a systematic review and meta-analysis on the association of neutrophil-to-lymphocyte ratio (NLR) and HE in ICH. A secondary outcome examined was the association of NLR and perihematomal (PHE) growth.

METHODS

Three databases were searched (PubMed, EMBASE, and Cochrane) for studies evaluating the effect of NLR on HE and PHE growth. The inverse variance method was applied to estimate an overall effect for each specific outcome by combining weighted averages of the individual studies' estimates of the logarithm odds ratio (OR). Given heterogeneity of the studies, a random effect was applied. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The study was conducted following the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The protocol was registered in PROSPERO (No. CRD42024549924).

RESULTS

Eleven retrospective cohort studies involving 2953 patients were included in the meta-analysis. Among those, HE was investigated in eight studies, whereas PHE growth was evaluated in three. Blood sample was obtained on admission in ten studies, and at 24 hours in one study. There was no consensus on cut-off value among the studies. NLR was found to be significantly associated with higher odds of HE (OR = 1.09, 95%CI: 1.04-1.15, I 2 = 86%, P < 0.01), and PHE growth (OR = 1.28, 95%CI: 1.19-1.38, I 2 = 0%, P < 0.01). Qualitative analysis of each outcome revealed overall moderate risk of bias mainly due to lack of control for systemic confounders.

CONCLUSION

The available literature suggests that a possible association may exist between NLR on admission and HE, and PHE growth. Future studies controlled for systemic confounders should be designed to consolidate this finding. If confirmed, NLR could be added as a readily available and inexpensive biomarker to identify a subgroup of patients at higher risk of developing HE.

Once more unto the breach, dear friends, once more

The first issue of the World Journal of Critical Care Medicine (WJCCM), whose preparatory work was initiated on December 16, 2010, will be published on February 4, 2012. The WJCCM Editorial Board has now been established and consists of 105 distinguished experts from 27 countries. Our purpose of launching the WJCCM is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Steroids in acute respiratory distress syndrome: A panacea or still a puzzle?

Acute respiratory distress syndrome (ARDS) is a unique entity marked by various etiologies and heterogenous pathophysiologies. There remain concerns regarding the efficacy of particular medications for each severity level apart from respiratory support. Among several pharmacotherapies which have been examined in the treatment of ARDS, corticosteroids, in particular, have demonstrated potential for improving the resolution of ARDS. Nevertheless, it is imperative to consider the potential adverse effects of hyperglycemia, susceptibility to hospital-acquired infections, and the development of intensive care unit acquired weakness when administering corticosteroids. Thus far, a multitude of trials spanning several decades have investigated the role of corticosteroids in ARDS. Further stringent trials are necessary to identify particular subgroups before implementing corticosteroids more widely in the treatment of ARDS. This review article provides a concise overview of the most recent evidence regarding the role and impact of corticosteroids in the management of ARDS.

Outcome of COVID-19 infection in patients on antihypertensives: A cross-sectional study

BACKGROUND

Patients with coronavirus disease 2019 (COVID-19) infection frequently have hypertension as a co-morbidity, which is linked to adverse outcomes. Antihypertensives may affect the outcome of COVID-19 infection.

AIM

To assess the effects of antihypertensive agents on the outcomes of COVID-19 infection.

METHODS

A total of 260 patients were included, and their demographic data and clinical profile were documented. The patients were categorized into nonhypertensive, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), calcium channel blocker (CCB), a combination of ACEI/ARB and CCB, and beta-blocker groups. Biochemical, hematological, and inflammatory markers were measured. The severity of infection, intensive care unit (ICU) intervention, and outcome were recorded.

RESULTS

The mean age of patients was approximately 60-years-old in all groups, except the nonhypertensive group. Men were predominant in all groups. Fever was the most common presenting symptom. Acute respiratory distress syndrome was the most common complication, and was mostly found in the CCB group. Critical cases, ICU intervention, and mortality were also higher in the CCB group. Multivariable logistic regression analysis revealed that age, duration of antihypertensive therapy, erythrocyte sedimentation rate, high-sensitivity C-reactive protein, and interleukin 6 were significantly associated with mortality. The duration of antihypertensive therapy exhibited a sensitivity of 70.8% and specificity of 55.7%, with a cut-off value of 4.5 years and an area under the curve of 0.670 (0.574-0.767; 95% confidence interval) for COVID-19 outcome.

CONCLUSION

The type of antihypertensive medication has no impact on the clinical sequence or mortality of patients with COVID-19 infection. However, the duration of antihypertensive therapy is associated with poor outcomes.

Recovery after acute kidney injury requiring kidney replacement therapy in patients with left ventricular assist device: A meta-analysis

BACKGROUND

Acute kidney injury (AKI) is a common and severe complication after left ventricular assist device (LVAD) implantation with an incidence of 37%; 13% of which require kidney replacement therapy (KRT). Severe AKI requiring KRT (AKI-KRT) in LVAD patients is associated with high short and long-term mortality compared with AKI without KRT. While kidney function recovery is associated with better outcomes, its incidence is unclear among LVAD patients with severe AKI requiring KRT.

AIM

To identify studies evaluating the recovery rates from severe AKI-KRT after LVAD placement, which is defined by regained kidney function resulting in the discontinuation of KRT. Random-effects and generic inverse variance method of DerSimonian-Laird were used to combine the effect estimates obtained from individual studies.

METHODS

A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.

RESULTS

A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.

CONCLUSION

Recovery from severe AKI-KRT after LVAD occurs approximately 50.5%, and it has not significantly changed over the years despite advances in medicine.

Plasma D-dimer level in early and late-onset neonatal sepsis

BACKGROUND

Neonatal sepsis is a life-threatening disease. Early diagnosis is essential, but no single marker of infection has been identified. Sepsis activates a coagulation cascade with simultaneous production of the D-dimers due to lysis of fibrin. D-dimer test reflects the activation of the coagulation system.

AIM

To assess the D-dimer plasma level, elaborating its clinicopathological value in neonates with early-onset and late-onset neonatal sepsis.

METHODS

The study was a prospective cross-sectional study that included ninety neonates; divided into three groups: Group I: Early-onset sepsis (EOS); Group II: Late-onset sepsis (LOS); and Group III: Control group. We diagnosed neonatal sepsis according to our protocol. C-reactive protein (CRP) and D-dimer assays were compared between EOS and LOS and correlated to the causative microbiological agents.

RESULTS

D-dimer was significantly higher in septic groups with a considerably higher number of cases with positive D-dimer. Neonates with LOS had substantially higher levels of D-dimer than EOS, with no significant differences in CRP. Neonates with LOS had a significantly longer hospitalization duration and higher gram-negative bacteriemia and mortality rates than EOS (P < 0.01). Gram-negative bacteria have the highest D-dimer levels (Acinetobacter, Klebsiella, and Pseudomonas) and CRP (Serratia, Klebsiella, and Pseudomonas); while gram-positive sepsis was associated with relatively lower levels. D-dimer had a significant negative correlation with hemoglobin level and platelet count; and a significant positive correlation with CRP, hospitalization duration, and mortality rates. The best-suggested cut-off point for D-dimer in neonatal sepsis was 0.75 mg/L, giving a sensitivity of 72.7% and specificity of 86.7%. The D-dimer assay has specificity and sensitivity comparable to CRP in the current study.

CONCLUSION

The current study revealed a significant diagnostic value for D-dimer in neonatal sepsis. D-dimer can be used as an adjunct to other sepsis markers to increase the sensitivity and specificity of diagnosing neonatal sepsis.

One approach to circulation and blood flow in the critical care unit

Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine. Understanding the applicability of some of the basic but, at the same time, complex physiological processes occurring during a state of illness is sometimes neglected and/or presented to the practitioners as point-of-care protocols to follow. Furthermore, managing hemodynamic shock has shown us that the human body is designed to fight to sustain life and that the compensatory mechanisms within organ systems are extraordinary. In this review article, we have created a minimalistic guide to the clinical information relevant when assessing critically ill patients with failing circulation. Measures such as organ blood flow, circulating volume, and hemodynamic biomarkers of shock are described. In addition, we will describe historical scientific events that led to some of our current medical practices and its validation for clinical decision making, and we present clinical advice for patient care and medical training.

Interest of D-dimer level, severity of COVID-19 and cost of management in Gabon

BACKGROUND

Coronavirus disease 2019 (COVID-19) is strongly associated with an increased risk of thrombotic events, including severe outcomes such as pulmonary embolism. Elevated D-dimer levels are a critical biomarker for assessing this risk. In Gabon, early implementation of anticoagulation therapy and D-dimer testing has been crucial in managing COVID-19. This study hypothesizes that elevated D-dimer levels are linked to increased COVID-19 severity.

AIM

To determine the impact of D-dimer levels on COVID-19 severity and their role in guiding clinical decisions.

METHODS

This retrospective study analyzed COVID-19 patients admitted to two hospitals in Gabon between March 2020 and December 2023. The study included patients with confirmed COVID-19 diagnoses and available D-dimer measurements at admission. Data on demographics, clinical outcomes, D-dimer levels, and healthcare costs were collected. COVID-19 severity was classified as non-severe (outpatients) or severe (inpatients). A multivariable logistic regression model was used to assess the relationship between D-dimer levels and disease severity, with adjusted odds ratios (OR) and 95%CI.

RESULTS

A total of 3004 patients were included, with a mean age of 50.17 years, and the majority were female (53.43%). Elevated D-dimer levels were found in 65.81% of patients, and 57.21% of these experienced severe COVID-19. Univariate analysis showed that patients with elevated D-dimer levels had 3.33 times higher odds of severe COVID-19 (OR = 3.33, 95%CI: 2.84-3.92, P < 0.001), and this association remained significant in the multivariable analysis, adjusted for age, sex, and year of collection. The financial analysis revealed a substantial burden, particularly for uninsured patients.

CONCLUSION

D-dimer predicts COVID-19 severity and guides treatment, but the high cost of anticoagulant therapy highlights the need for policies ensuring affordable access in resource-limited settings like Gabon.

Medicinal nicotine in COVID-19 acute respiratory distress syndrome, the new corticosteroid

The cholinergic anti-inflammatory pathway (CAP) refers to the anti-inflammatory effects mediated by the parasympathetic nervous system. Existence of this pathway was first demonstrated when acetylcholinesterase inhibitors showed benefits in animal models of sepsis. CAP functions via the vagus nerve. The systemic anti-inflammatory effects of CAP converges on the α7 nicotinic acetylcholine receptor on splenic macrophages, leading to suppression of pro-inflammatory cytokines and simultaneous stimulation of anti-inflammatory cytokines, including interleukin 10. CAP offers a novel mechanism to mitigate inflammation. Electrical vagal nerve stimulation has shown benefits in patients suffering from rheumatoid arthritis. Direct agonists like nicotine and GTS-1 have also demonstrated anti-inflammatory properties in models of sepsis and acute respiratory distress syndrome, as have acetylcholinesterase inhibitors like Galantamine and Physostigmine. Experience with coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome indicates that immunomodulators have a protective role in patient outcomes. Dexamethasone is the only medication currently in use that has shown to improve clinical outcomes. This is likely due to the suppression of what is referred to as a cytokine storm, which is implicated in the lethality of viral pneumonia. Nicotine transdermal patch activates CAP and harvests its anti-inflammatory potential by means of an easily administered depot delivery mechanism. It could prove to be a promising, safe and inexpensive additional tool in the currently limited armamentarium at our disposal for management of COVID-19 induced acute hypoxic respiratory failure.

Diabetic foot attack: Managing severe sepsis in the diabetic patient

Diabetic foot attack (DFA) is the most severe presentation of diabetic foot disease, with the patient commonly displaying severe sepsis, which can be limb or life threatening. DFA can be classified into two main categories: Typical and atypical. A typical DFA is secondary to a severe infection in the foot, often initiated by minor breaches in skin integrity that allow pathogens to enter and proliferate. This form often progresses rapidly due to the underlying diabetic pathophysiology of neuropathy, microvascular disease, and hyperglycemia, which facilitate infection spread and tissue necrosis. This form of DFA can present as one of a number of severe infective pathologies including pyomyositis, necrotizing fasciitis, and myonecrosis, all of which can lead to systemic sepsis and multi-organ failure. An atypical DFA, however, is not primarily infection-driven. It can occur secondary to either ischemia or Charcot arthropathy. Management of the typical DFA involves prompt diagnosis, aggressive infection control, and a multidisciplinary approach. Treatment can be guided by the current International Working Group on the Diabetic Foot/Infectious Diseases Society of America guidelines on diabetic foot infections, and the combined British Orthopaedic Foot and Ankle Society-Vascular Society guidelines. This article highlights the importance of early recognition, comprehensive management strategies, and the need for further research to establish standardized protocols and improve clinical outcomes for patients with DFA.

Early clinical outcomes of two regimens of prophylactic antibiotics in cardiac surgical patients with delayed sternal closure

BACKGROUND

Delayed sternal closure (DSC) can be a lifesaving approach for certain patients who have undergone cardiac surgery. The value of the type of prophylactic antibiotics in DSC is still debatable.

AIM

To investigate clinical outcomes of different prophylactic antibiotic regimens in patients who had DSC after cardiac surgery.

METHODS

This was a retrospective observational single-center study. Fifty-three consecutive patients who underwent cardiac surgery and had an indication for DSC were included. Patients were subjected to two regimens of antibiotics: Narrow-spectrum and broad-spectrum regimens.

RESULTS

The main outcome measures were length of hospital and intensive care unit (ICU) stay, duration of mechanical ventilation, and mortality. Of the 53 patients, 12 (22.6%) received narrow-spectrum antibiotics, and 41 (77.4%) received broad-spectrum antibiotics. The mean age was 59.0 ± 12.1 years, without significant differences between the groups. The mean duration of antibiotic use was significantly longer in the broad-spectrum than the narrow-spectrum group (11.9 ± 8.7 vs 3.4 ± 2.0 d , P < 0.001). The median duration of open chest was 3.0 (2.0-5.0) d for all patients, with no difference between groups (P = 0.146). The median duration of mechanical ventilation was significantly longer in the broad-spectrum group [60.0 (Δ interquartile range (IQR) 170.0) h vs 50.0 (ΔIQR 113.0) h, P = 0.047]. Similarly, the median length of stay for both ICU and hospital were significantly longer in the broad-spectrum group [7.5 (ΔIQR 10.0) d vs 5.0 (ΔIQR 5.0) d, P = 0.008] and [27.0 (ΔIQR 30.0) d vs 19.0 (ΔIQR 21.0) d, P = 0.031]. Five (9.8%) patients were readmitted to the ICU and 18 (34.6%) patients died without a difference between groups.

CONCLUSION

Prophylactic broad-spectrum antibiotics did not improve clinical outcomes in patients with DSC post-cardiac surgery but was associated with longer ventilation duration, length of ICU and hospital stays vs narrow-spectrum antibiotics.

Generalizable items and modular structure for computerised physician staffing calculation on intensive care units

Intensive care medicine remains one of the most cost-driving areas within hospitals with high personnel costs. Under the scope of limited budgets and reimbursement, realistic needs are essential to justify personnel staffing. Unfortunately, all existing staffing models are top-down calculations with a high variability in results. We present a workload-oriented model, integrating quality of care, efficiency of processes, legal, educational, controlling, local, organisational and economic aspects. In our model, the physician's workload solely related to the intensive care unit depends on three tasks: Patient-oriented tasks, divided in basic tasks (performed in every patient) and additional tasks (necessary in patients with specific diagnostic and therapeutic requirements depending on their specific illness, only), and non patient-oriented tasks. All three tasks have to be taken into account for calculating the required number of physicians. The calculation tool further allows to determine minimal personnel staffing, distribution of calculated personnel demand regarding type of employee due to working hours per year, shift work or standby duty. This model was introduced and described first by the German Board of Anesthesiologists and the German Society of Anesthesiology and Intensive Care Medicine in 2008 and since has been implemented and updated 2012 in Germany. The modular, flexible nature of the Excel-based calculation tool should allow adaption to the respective legal and organizational demands of different countries. After 8 years of experience with this calculation, we report the generalizable key aspects which may help physicians all around the world to justify realistic workload-oriented personnel staffing needs.

COVID-19 and resuscitation: La tournée of traditional Chinese medicine?

BACKGROUND

As it has been established in previous publications of the author, the current extra-hospital statistics referring to cardiopulmonary resuscitation (CPR) are far from being minimally satisfactory (14%-17% success). Since the appearance of acquired immune deficiency syndrome, its application has been increasingly undermined as other subsequent pandemics (H1N1, Ebola, coronavirus disease 2019) seriously infringing lay rescuers intervention during classical CPR steps (mouth-to-mouth ventilation), forcing to modify vital support protocols. Both KI-1 Yong quan and PC-9 Zhong chong alternative rescue maneuvers could come to aid those victims of impending death situation due to both cardiac arrest or stroke, upgrading current survival rates of said unfortunate patients.

AIM

To validate a complementary resuscitation maneuver originated in Chinese Medicine knowledge, carefully integrated into international CPR protocols [World Journal of Critical Care Medicine (WJCCM), August 2013].

METHODS

The model to verify its statistical validity of quoted research was the Retrospective Cohort Study, which redeems the "semiotic paradigm" that gave rise to medical semiotics. Its value strives in the differential detail if the deceased patients are considered the control group instead of the patients that may be deceased. Thus, combining the semiotic paradigm with the Retrospective Cohort Study allows us to manage the collateral potential lethal effects of the random process in cases of extreme emergencies.

RESULTS

The statistic results provided by the methodological analysis of this work were previously published in WJCCM August 2013, ISSN 2220-3141). In a total of 89 patients in which the Yong quan maneuver was tested, 75 survived and 14 died. In order to compare this data with the percentages of survivors in the other maneuvers, we stipulate the assumption that if 89 patients are the 100% of the sample, how many patients would survive if the survival rate is 6.4% in CPR, 30% in defibrillation and 48% in CPR + defibrillation. By this way we obtained the approximate values of patients that would survive when applying these classical resuscitation maneuvers. Then we obtained the format of the tables to perform the exact Fisher test with the help of a statistical processor; the consequent result in a valuation of P < 0.0001 was considered "extremely statistically significant".

CONCLUSION

The author herein provides a methodological-statistical analysis of such contribution which does not imply any cost at all and could even help prevent the withdrawal of classical CPR practices.

Shock index and its variants as predictors of mortality in severe traumatic brain injury

BACKGROUND

The increase in severe traumatic brain injury (sTBI) incidence is a worldwide phenomenon, resulting in a heavy disease burden in the public health systems, specifically in emerging countries. The shock index (SI) is a physiological parameter that indicates cardiovascular status and has been used as a tool to assess the presence and severity of shock, which is increased in sTBI. Considering the high mortality of sTBI, scrutinizing the predictive potential of SI and its variants is vital.

AIM

To describe the predictive potential of SI and its variants in sTBI.

METHODS

This study included 71 patients (61 men and 10 women) divided into two groups: Survival (S; n = 49) and Non-survival (NS; n = 22). The responses of blood pressure and heart rate (HR) were collected at admission and 48 h after admission. The SI, reverse SI (rSI), rSI multiplied by the Glasgow Coma Score (rSIG), and Age multiplied SI (AgeSI) were calculated. Group comparisons included Shapiro-Wilk tests, and independent samples t-tests. For predictive analysis, logistic regression, receiver operator curves (ROC) curves, and area under the curve (AUC) measurements were performed.

RESULTS

No significant differences between groups were identified for SI, rSI, or rSIG. The AgeSI was significantly higher in NS patients at 48 h following admission (S: 26.32 ± 14.2, and NS: 37.27 ± 17.8; P = 0.016). Both the logistic regression and the AUC following ROC curve analysis showed that only AgeSI at 48 h was capable of predicting sTBI outcomes.

CONCLUSION

Although an altered balance between HR and blood pressure can provide insights into the adequacy of oxygen delivery to tissues and the overall cardiac function, only the AgeSI was a viable outcome-predictive tool in sTBI, warranting future research in different cohorts.

Point-of-care ultrasonography in cirrhosis-related acute kidney injury: How I do it

Discerning the etiology of acute kidney injury (AKI) in cirrhotic patients remains a formidable challenge due to diverse and overlapping causes. The conventional approach of empiric albumin administration for suspected volume depletion may inadvertently lead to fluid overload. In the recent past, point-of-care ultrasonography (POCUS) has emerged as a valuable adjunct to clinical assessment, offering advantages in terms of diagnostic accuracy, rapidity, cost-effectiveness, and patient satisfaction. This review provides insights into the strategic use of POCUS in evaluating cirrhotic patients with AKI. The review distinguishes basic and advanced POCUS, emphasizing a 5-point basic POCUS protocol for efficient assessment. This protocol includes evaluations of the kidneys and urinary bladder for obstructive nephropathy, lung ultrasound for detecting extravascular lung water, inferior vena cava (IVC) ultrasound for estimating right atrial pressure, internal jugular vein ultrasound as an alternative to IVC assessment, and focused cardiac ultrasound for assessing left ventricular (LV) systolic function and identifying potential causes of a plethoric IVC. Advanced POCUS delves into additional Doppler parameters, including stroke volume and cardiac output, LV filling pressures and venous congestion assessment to diagnose or prevent iatrogenic fluid overload. POCUS, when employed judiciously, enhances the diagnostic precision in evaluating AKI in cirrhotic patients, guiding appropriate therapeutic interventions, and minimizing the risk of fluid-related complications.

Anaesthesia in chronic dialysis patients: A narrative review

The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.

Elevated soluble fas blood concentrations in patients dying from spontaneous intracerebral hemorrhage

BACKGROUND

Several studies of spontaneous intracerebral hemorrhage (SICH) patients have shown apoptotic changes in brain samples after hematoma evacuation. However, there have been no data on the association between blood concentrations of soluble fas (sFas) (the main surface death receptor of the extrinsic apoptosis pathway) and the prognosis of spontaneous intracranial hypotension (SIH) patients.

AIM

To determine whether there is an association between blood sFas concentrations and SICH patient mortality.

METHODS

We included patients with severe and supratentorial SIH. Severe was defined as having Glasgow Coma Scale < 9. We determined serum sFas concentrations at the time of severe SICH diagnosis.

RESULTS

We found that non-surviving patients (n = 36) compared to surviving patients (n = 39) had higher ICH score (P = 0.001), higher midline shift (P = 0.004), higher serum sFas concentrations (P < 0.001), and lower rate of early hematoma evacuation (P = 0.04). Multiple logistic regression analysis showed an association between serum sFas concentrations and 30-d mortality (odds ratio = 1.070; 95% confidence interval = 1.014-1.129; P = 0.01) controlling for ICH score, midline shift, and early hematoma evacuation.

CONCLUSION

The association of blood sFas concentrations and SICH patient mortality is a novel finding in our study.

Low T3 vs low T3T4 euthyroid sick syndrome in septic shock patients: A prospective observational cohort study

BACKGROUND

Both phases of euthyroid sick syndrome (ESS) are associated with worse prognosis in septic shock patients. Although there are still no indications for supplementation therapy, there is no evidence that both phases (initial and prolonged) are adaptive or that only prolonged is maladaptive and requires supplementation.

AIM

To analyze clinical, hemodynamic and laboratory differences in two groups of septic shock patients with ESS.

METHODS

A total of 47 septic shock patients with ESS were divided according to values of their thyroid hormones into low T3 and low T3T4 groups. The analysis included demographic data, mortality scores, intensive care unit stay, mechanical ventilation length and 28-day survival and laboratory with hemodynamics.

RESULTS

The Simplified Acute Physiology Score II score (P = 0.029), dobutamine (P = 0.003) and epinephrine requirement (P = 0.000) and the incidence of renal failure and multiple organ failure (MOF) (P = 0.000) were significantly higher for the low T3T4. Hypoalbuminemia (P = 0.047), neutrophilia (P = 0.038), lymphopenia (P = 0.013) and lactatemia (P = 0.013) were more pronounced on T2 for the low T3T4 group compared to the low T3 group. Diastolic blood pressure at T0 (P = 0.017) and T1 (P = 0.007), as well as mean arterial pressure at T0 (P = 0.037) and T2 (P = 0.033) was higher for the low T3 group.

CONCLUSION

The low T3T4 population is associated with higher frequency of renal insufficiency and MOF, with worse laboratory and hemodynamic parameters. These findings suggest potentially maladaptive changes in the chronic phase of septic shock.

Community-acquired pneumonia: The importance of the early detection of drug-resistant organisms

Pneumonia is a disease associated with significant healthcare burden with over 1.5 million hospitalizations annually and is the eighth leading cause of death in the United States. While community-acquired pneumonia (CAP) is generally considered an acute time-limited illness, it is associated with high long-term mortality, with nearly one-third of patients requiring hospitalization dying within one year. An increasing trend of detecting multidrug-resistant (MDR) organisms causing CAP has been observed, especially in the Western world. In this editorial, we discuss about a publication by Jatteppanavar et al which reported that a case of a MDR organism was the culprit in developing pneumonia, bacteremia, and infective endocarditis that led to the patient's death. The early detection of these resistant organisms helps improve patient outcomes. Significant advances have been made in the biotechnological and research space, but preventive measures, diagnostic techniques, and treatment strategies need to be developed.

Scoring systems in critically ill: Which one to use in cancer patients?

BACKGROUND

Scoring systems have not been evaluated in oncology patients. We aimed to assess the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, APACHE IV, Simplified Acute Physiology Score (SAPS) II, SAPS III, Mortality Probability Model (MPM) II0 and Sequential Organ Failure Assessment (SOFA) score in critically ill oncology patients.

AIM

To compare the efficacy of seven commonly employed scoring systems to predict outcomes of critically ill cancer patients.

METHODS

We conducted a retrospective analysis of 400 consecutive cancer patients admitted in the medical intensive care unit over a two-year period. Primary outcome was hospital mortality and the secondary outcome measure was comparison of various scoring systems in predicting hospital mortality.

RESULTS

In our study, the overall intensive care unit and hospital mortality was 43.5% and 57.8%, respectively. All of the seven tested scores underestimated mortality. The mortality as predicted by MPM II0 predicted death rate (PDR) was nearest to the actual mortality followed by that predicted by APACHE II, with a standardized mortality rate (SMR) of 1.305 and 1.547, respectively. The best calibration was shown by the APACHE III score (χ 2 = 4.704, P = 0.788). On the other hand, SOFA score (χ 2 = 15.966, P = 0.025) had the worst calibration, although the difference was not statistically significant. All of the seven scores had acceptable discrimination with good efficacy however, SAPS III PDR and MPM II0 PDR (AUROC = 0.762), had a better performance as compared to others. The correlation between the different scoring systems was significant (P < 0.001).

CONCLUSION

All the severity scores were tested under-predicted mortality in the present study. As the difference in efficacy and performance was not statistically significant, the choice of scoring system used may depend on the ease of use and local preferences.

Current role of extracorporeal membrane oxygenation for the management of trauma patients: Indications and results

Extracorporeal membrane oxygenation (ECMO) has emerged as a vital circulatory life support measure for patients with critical cardiac or pulmonary conditions unresponsive to conventional therapies. ECMO allows blood to be extracted from a patient and introduced to a machine that oxygenates blood and removes carbon dioxide. This blood is then reintroduced into the patient’s circulatory system. This process makes ECMO essential for treating various medical conditions, both as a standalone therapy and as adjuvant therapy. Veno-venous (VV) ECMO primarily supports respiratory function and indicates respiratory distress. Simultaneously, veno-arterial (VA) ECMO provides hemodynamic and respiratory support and is suitable for cardiac-related complications. This study reviews recent literature to elucidate the evolving role of ECMO in trauma care, considering its procedural intricacies, indications, contraindications, and associated complications. Notably, the use of ECMO in trauma patients, particularly for acute respiratory distress syndrome and cardiogenic shock, has demonstrated promising outcomes despite challenges such as anticoagulation management and complications such as acute kidney injury, bleeding, thrombosis, and hemolysis. Some studies have shown that VV ECMO was associated with significantly higher survival rates than conventional mechanical ventilation, whereas other studies have reported that VA ECMO was associated with lower survival rates than VV ECMO. ECMO plays a critical role in managing trauma patients, particularly those with acute respiratory failure. Further research is necessary to explore the full potential of ECMO in trauma care. Clinicians should have a clear understanding of the indications and contraindications for the use of ECMO to maximize its benefits in treating trauma patients.

Psychological first aid in the intensive care unit

The intensive care unit (ICU) is a stressful environment for patients and their families as well as healthcare workers (HCWs). Distress, which is a negative emotional or physical response to a stressor is common in the ICU. Psychological first aid (PFA) is a form of mental health assistance provided in the immediate aftermath of disasters or other critical incidents to address acute distress and re-establish effective coping and functioning. The aim of this narrative review is to inform the development and utilization of PFA by HCWs in the ICU to reduce the burden of distress among patients, caregivers, and HCWs. This is the first such review to apply PFA to the ICU setting.