Management of critical care emergencies in children with autism spectrum disorder

BACKGROUND

Managing critical care emergencies in children with autism spectrum disorder (ASD) presents unique challenges due to their distinct sensory sensitivities, communication difficulties, and behavioral issues. Effective strategies and protocols are essential for optimal care in these high-stress situations.

AIM

To systematically evaluate and synthesize current evidence on best practices for managing critical care emergencies in children with ASD. The review focuses on key areas, including sensory-friendly environments, communication strategies, behavioral management, and the role of multidisciplinary approaches.

METHODS

A comprehensive search was conducted across major medical databases, including PubMed, Embase, and Cochrane Library, for studies published between 2000 and 2023. Studies were selected based on their relevance to critical care management in children with ASD, encompassing randomized controlled trials, observational studies, qualitative research, and case studies. Data were extracted and analyzed to identify common themes, successful strategies, and areas for improvement.

RESULTS

The review identified 50 studies that met the inclusion criteria. Findings highlighted the importance of creating sensory-friendly environments, utilizing effective communication strategies, and implementing individualized behavioral management plans. These findings, derived from a comprehensive review of current evidence, provide valuable insights into the best practices for managing critical care emergencies in children with ASD. Sensory modifications, such as reduced lighting and noise, visual aids, and augmentative and alternative communication tools, enhanced patient comfort and cooperation. The involvement of multidisciplinary teams was crucial in delivering holistic care. Case studies provided practical insights and underscored the need for continuous refinement of protocols.

CONCLUSION

The review emphasizes the need for a tailored approach to managing critical care emergencies for children with ASD. Sensory-friendly adjustments, effective communication, and behavioral strategies supported by a multidisciplinary team are integral to improving outcomes. Despite progress, ongoing refinement of care practices and protocols is necessary. This ongoing process addresses remaining challenges and engages healthcare professionals in continuous improvement of care for children with ASD in critical settings.

Incidence and outcome of rhabdomyolysis after type A aortic dissection surgery: A retrospective analysis

BACKGROUND

Rhabdomyolysis (RML) as an etiological factor causing acute kidney injury (AKI) is sparsely reported in the literature.

AIM

To study the incidence of RML after surgical repair of an ascending aortic dissection (AAD) and to correlate with the outcome, especially regarding renal function. To pinpoint the perioperative risk factors associated with the development of RML and adverse renal outcomes after aortic dissection repair.

METHODS

Retrospective single-center cohort study conducted in a tertiary cardiac center. We included all patients who underwent AAD repair from 2011-2017. Post-operative RML workup is part of the institutional protocol; studied patients were divided into two groups: Group 1 with RML (creatine kinase above cut-off levels 2500 U/L) and Group 2 without RML. The potential determinants of RML and impact on patient outcome, especially postoperative renal function, were studied. Other outcome parameters studied were markers of cardiac injury, length of ventilation, length of stay in the intensive care unit), and length of hospitalization.

RESULTS

Out of 33 patients studied, 21 patients (64%) developed RML (Group RML), and 12 did not (Group non-RML). Demographic and intraoperative factors, notably body mass index, duration of surgery, and cardiopulmonary bypass, had no significant impact on the incidence of RML. Preoperative visceral/peripheral malperfusion, though not statistically significant, was higher in the RML group. A significantly higher incidence of renal complications, including de novo postoperative dialysis, was noticed in the RML group. Other morbidity parameters were also higher in the RML group. There was a significantly higher incidence of AKI in the RML group (90%) than in the non-RML group (25%). All four patients who required de novo dialysis belonged to the RML group. The peak troponin levels were significantly higher in the RML group.

CONCLUSION

In this study, we noticed a high incidence of RML after aortic dissection surgery, coupled with an adverse renal outcome and the need for post-operative dialysis. Prompt recognition and management of RML might improve the renal outcome. Further large-scale prospective trials are warranted to investigate the predisposing factors and influence of RML on major morbidity and mortality outcomes.

Post-reperfusion syndrome in liver transplant recipients: What is new in prevention and management?

Post-reperfusion syndrome (PRS) in liver transplant recipients remains one of the most dreaded complications in liver transplant surgery. PRS can impact the short-term and long-term patient and graft outcomes. The definition of PRS has evolved over the years, from changes in arterial blood pressures and heart and/or decreases in the systemic vascular resistance and cardiac output to including the fibrinolysis and grading the severity of PRS. However, all that did not reflect on the management of PRS or its impact on the outcomes. In recent years, new scientific techniques and new technology have been in the pipeline to better understand, manage and maybe prevent PRS. These new methods and techniques are still in the infancy, and they have to be proven not in prevention and management of PRS but their effects in the patient and graft outcomes. In this article, we will review the long history of PRS, its definition, etiology, management and most importantly the new advances in science and technology to prevent and properly manage PRS.

Venous excess ultrasound: A mini-review and practical guide for its application in critically ill patients

Advancements in healthcare technology have improved mortality rates and extended lifespans, resulting in a population with multiple comorbidities that complicate patient care. Traditional assessments often fall short, underscoring the need for integrated care strategies. Among these, fluid management is particularly challenging due to the difficulty in directly assessing volume status especially in critically ill patients who frequently have peripheral oedema. Effective fluid management is essential for optimal tissue oxygen delivery, which is crucial for cellular metabolism. Oxygen transport is dependent on arterial oxygen levels, haemoglobin concentration, and cardiac output, with the latter influenced by preload, afterload, and cardiac contractility. A delicate balance of these factors ensures that the cardiovascular system can respond adequately to varying physiological demands, thereby safeguarding tissue oxygenation and overall organ function during states of stress or illness. The Venous Excess Ultrasound (VExUS) Grading System is instrumental in evaluating fluid intolerance, providing detailed insights into venous congestion and fluid status. It was originally developed to assess the risk of acute kidney injury in postoperative cardiac patients, but its versatility has enabled broader applications in nephrology and critical care settings. This mini review explores VExUS's application and its impact on fluid management and patient outcomes in critically ill patients.

Causative bacteria of ventilator-associated pneumonia in intensive care unit in Bahrain: Prevalence and antibiotics susceptibility pattern

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs two calendar days following endotracheal intubation or after that. It is the most common infection encountered among intubated patients. VAP incidence showed wide variability between countries.

AIM

To define the VAP incidence in the intensive care unit (ICU) in the central government hospital in Bahrain and review the risk factors and the predominant bacterial pathogens with their antimicrobial susceptibility pattern.

METHODS

The research was a prospective cross-sectional observational study over six months from November 2019 to June 2020. It included adult and adolescent patients (> 14 years old) admitted to the ICU and required intubation and mechanical ventilation. VAP was diagnosed when it occurred after 48 h after endotracheal intubation using the clinical pulmonary infection score, which considers the clinical, laboratory, microbiological, and radiographic evidence.

RESULTS

The total number of adult patients admitted to the ICU who required intubation and mechanical ventilation during the study period was 155. Forty-six patients developed VAP during their ICU stay (29.7%). The calculated VAP rate was 22.14 events per 1000 ventilator days during the study period, with a mean age of 52 years ± 20. Most VAP cases had late-onset VAP with a mean number of ICU days before the development of VAP of 9.96 ± 6.55. Gram-negative contributed to most VAP cases in our unit, with multidrug-resistant Acinetobacter being the most identified pathogen.

CONCLUSION

The reported VAP rate in our ICU was relatively high compared to the international benchmark, which should trigger a vital action plan for reinforcing the implementation of the VAP prevention bundle.

Enhancing the awakening to family engagement bundle with music therapy

Survivors of prolonged intensive care unit (ICU) admissions may present undesirable long-term outcomes. In particular, physical impairment and cognitive dysfunction have both been described in patients surviving episodes requiring mechanical ventilation and sedation. One of the strategies to prevent the aforementioned outcomes involves the implementation of a bundle composed by: (1) Spontaneous awakening trial; (2) Spontaneous breathing trial; (3) Choosing proper sedation strategies; (4) Delirium detection and management; (5) Early ICU mobility; and (6) Family engagement (ABCDEF bundle). The components of this bundle contribute in shortening length of stay on mechanical ventilation and reducing incidence of delirium. Since the first description of the ABCDEF bundle, other relevant therapeutic factors have been proposed, such as introducing music therapy. This mini-review describes the current evidence supporting the use of the ABCDEF bundle, as well as current knowledge on the implementation of music therapy.

Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review

Septic shock treatment remains a major challenge for intensive care units, despite the recent prominent advances in both management and outcomes. Vasopressors serve as a cornerstone of septic shock therapy, but there is still controversy over the timing of administration. Specifically, it remains unclear whether vasopressors should be used early in the course of treatment. Here, we provide a systematic review of the literature on the timing of vasopressor administration. Research was systematically identified through PubMed, Embase and Cochrane searching according to PRISMA guidelines. Fourteen studies met the eligibility criteria and were included in the review. The pathophysiological basis for early vasopressor use was classified, with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII. We found that mortality was 28.1%-47.7% in the early vasopressors group, and 33.6%-54.5% in the control group. We also investigated the issue of vasopressor responsiveness. Furthermore, we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use. Based on the literature review, we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.

Knowledge and awareness of infection control practices among nursing professionals: A cross-sectional survey from South Asia and the Middle East

BACKGROUND

The proficiency of nursing professionals in the infection prevention and control (IPC) practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.

AIM

To test knowledge of nurses working in intensive care units (ICU) in South Asia and Middle East countries on IPC practices.

METHODS

An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks.

RESULTS

A total of 1333 nurses from 13 countries completed the survey. The average score was 72.8% and 36% of nurses were proficient (mean score > 80%). 43% and 68.3% of respondents were from government and teaching hospitals, respectively. 79.2% of respondents worked in < 25 bedded ICUs and 46.5% in closed ICUs. Statistically, a significant association was found between the knowledge and expertise of nurses, the country's per-capita income, type of hospitals, accreditation and teaching status of hospitals and type of ICUs. Working in high- and upper-middle-income countries (β = 4.89, 95%CI: 3.55 to 6.22) was positively associated, and the teaching status of the hospital (β = -4.58, 95%CI: -6.81 to -2.36) was negatively associated with the knowledge score among respondents.

CONCLUSION

There is considerable variation in knowledge among nurses working in ICU. Factors like income status of countries, public vs private and teaching status of hospitals and experience are independently associated with nurses' knowledge of IPC practices.

Critical care specialists, the missing link in organ procurement for transplantation

The procurement process for organ donation begins with the identification of potential organ donors in emergency or critical care units (CCU), followed by their clinical evaluation, diagnostic procedures, and therapeutic interventions, mostly conducted in CCUs. It concludes with the request for organ donation and, if accepted, the retrieval of organs. Despite most interventions occurring in detection units, there has been a neglect of the strategic role played by critical care specialists (CCS) in managing and caring for brain-dead or near-brain-death patients. Questions arise: Are they willing to undertake this responsibility? Do they fully comprehend the nature of organ procurement? Are they aware of the specific interventions required to maintain possible organ donors in optimal physiological condition? Our objective is to examine the role of CCS in organ procurement and propose ways to enhance it, ultimately aiming to increase and enhance organ donation rates.

Rationale for integration of palliative care in the medical intensive care: A narrative literature review

Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.

Potential role of vitamin D in patients with diabetes, dyslipidaemia, and COVID-19

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 has become a worldwide public health crisis. Studies have demonstrated that diabetes and dyslipidaemia are common comorbidities and could be high-risk factors for severe COVID-19. Vitamin D, a group of fat-soluble compounds responsible for intestinal absorption of calcium, magnesium, and phosphate, has been widely used as a dietary supplement for the prevention and treatment of numerous diseases, including infectious and non-infectious diseases, due to its high cost-effectiveness; safety; tolerability; and anti-thrombotic, anti-inflammatory, antiviral, and immunomodulatory properties. In this letter to the editor, we mainly discuss the potential role of vitamin D in patients with diabetes, dyslipidaemia, and COVID-19.

Optic nerve sheath diameters in nontraumatic brain injury: A scoping review and role in the intensive care unit

BACKGROUND

Neuromonitoring in medical intensive care units is challenging as most patients are unfit for invasive intracranial pressure (ICP) modalities or unstable to transport for imaging. Ultrasonography-based optic nerve sheath diameter (ONSD) is an attractive option as it is reliable, repeatable and easily performed at the bedside. It has been sufficiently validated in traumatic brain injury (TBI) to be incorporated into the guidelines. However, currently the data for non-TBI patients is inconsistent for a scientific recommendation to be made.

AIM

To compile the existing evidence for understanding the scope of ONSD in measuring ICP in adult non-traumatic neuro-critical patients.

METHODS

PubMed, Google Scholar and research citation analysis databases were searched for studies in adult patients with non-traumatic causes of raised ICP. Studies from 2010 to 2024 in English languages were included.

RESULTS

We found 37 articles relevant to our search. The cutoff for ONSD in predicting ICP varied from 4.1 to 6.3 mm. Most of the articles used cerebrospinal fluid opening pressure followed by raised ICP on computed tomography/magnetic resonance imaging as the comparator parameter. ONSD was also found to be a reliable outcome measure in cases of acute ischaemic stroke, intracerebral bleeding and intracranial infection. However, ONSD is of doubtful utility in septic metabolic encephalopathy, dysnatremias and aneurysmal subarachnoid haemorrhage.

CONCLUSION

ONSD is a useful tool for the diagnosis of raised ICP in non-traumatic neuro-critically ill patients and may also have a role in the prognostication of a subset of patients.

Transformative impact of point-of-care testing in critical care

The advent of point-of-care testing (POCT) has revolutionized the approach to patient management, especially for pediatric care. POCT provides rapid, on-the-spot biochemical and microbiological evaluations, bypassing delays typically associated with central laboratory testing, enabling swift clinical decision-making. Additionally, POCT has proven to be a valuable prognostic tool for monitoring electrolyte, lactate, creatinine levels, often a marker of severe illness and poor outcomes. POCT enables its faster identification, allowing for prompt interventions. This capability is essential in managing conditions like sepsis, where timely treatment can significantly impact survival rates. However, the implementation of POCT is not without its challenges. Variability in sample handling, particularly with heparinized syringes, can affect the accuracy of certain measurements, such as potassium levels. The absence of comprehensive follow-up data and cost-effectiveness analyses in some studies indicate the need for continued research to optimize the use of POCT. In conclusion, POCT is a transformative tool in critical care, offering prompt and reliable assessments that significantly enhance patient management. As technology advances, the integration of POCT into emergency departments and intensive critical care units holds great promise for improving the quality of healthcare and patient survival rates.

Need for oxygen therapy and ventilatory support in premature infants in a hospital in Southern Brazil

BACKGROUND

Prematurity in newborns is a condition that is associated with worse hospital outcomes when compared to birth to term. A preterm infant (PI) is classified when gestational age (GA) < 37 wk.

AIM

To analyze prognostic indicators related to the use of oxygen therapy, non-invasive ventilation (continuous positive airway pressure) and mechanical ventilation (MV) in PI.

METHODS

This is a retrospective cohort. The sample was composed of PIs from a private hospital in southern Brazil. We included neonates with GA < 37 wk of gestation in the period of January 1, 2018 to December 31, 2018. For data collection, electronic records were used in the Tasy PhilipsTM system, identifying the variables: maternal age, type of birth, prenatal information, GA, Apgar score, birth weight, neonatal morbidities, vital signs in the 1st hour at birth, need for oxygen therapy, continuous positive airway pressure and MV, hospitalization in the neonatal intensive care unit, length of stay and discharge or death.

RESULTS

In total, 90 PI records were analyzed. The median (p25-p75) of GA was 34.0 (31.9-35.4) wk, and there were 45 (50%) males. The most common morbidity among PIs was the acute respiratory discomfort syndrome, requiring hospitalization in the neonatal intensive care unit in 76 (84.4%) cases. The utilization rate of oxygen therapy, continuous positive airway pressure and MV was 12 (13.3%), 37 (41.1%) and 13 (14.4%), respectively. The median (p25-p75) length of stay was 12.0 (5.0-22.2) d, with 10 (11.1%) deaths. A statistical association was observed with the use of MV and GA < 28 wk, lower maternal age, low birth weight, Apgar < 8 and neonatal deaths.

CONCLUSION

The identification of factors related to the need for MV in prematurity may help in the indication of a qualified team and technologies to promptly meet the unforeseen events that may occur after birth.

Regional dynamic cerebral autoregulation across anterior and posterior circulatory territories: A detailed exploration and its clinical implications

Cerebral autoregulation (CA) is the mechanism that maintains stable cerebral blood flow (CBF) despite fluctuations in systemic blood pressure, crucial for brain homeostasis. Recent evidence highlights distinct regional variations in CA between the anterior (carotid) and posterior (vertebrobasilar) circulations. Non-invasive neuromonitoring techniques, such as transcranial Doppler, transfer function analysis, and near-infrared spectroscopy, facilitate the dynamic assessment of CBF and autoregulation. Studies indicate a robust autoregulatory capacity in the anterior circulation, characterized by rapid adjustments in vascular resistance. On the contrary, the posterior circulation, mainly supplied by the vertebral arteries, may have a lower autoregulatory capacity. in acute brain injuries such as intracerebral and subarachnoid hemorrhage, and traumatic brain injuries, dynamic CA can be significantly altered in the posterior circulation. Proposed physiological mechanisms of impaired CA in the posterior circulation include: (1) Decreased sympathetic innervation of the vasculature impairing compensatory vasoreactivity; (2) Endothelial dysfunction; (3) Increased cerebral metabolic rate of oxygen consumption within the visual cortex causing CBF-metabolism (i.e., neurovascular) uncoupling; and (4) Impaired blood-brain barrier integrity leading to impaired astrocytic mediated release of vasoactive substances (e.g. nitric oxide, potassium, and calcium ions). Furthermore, more research is needed on the effects of collateral circulation, as well as the circle of Willis variants, such as the fetal-type posterior cerebral artery, on dynamic CA. Improving our understanding of these mechanisms is crucial to improving the diagnosis, prognosis, and management of various cerebrovascular disorders.

Approaches to neuroprotection in pediatric neurocritical care

Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit. After primary neurologic insults, there may be cerebral brain tissue that remains at risk of secondary insults, which can lead to worsening neurologic injury and unfavorable outcomes. A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children. This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes. Here, we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.

Successfully non-surgical management of flail chest as first manifestation of multiple myeloma: A case report

BACKGROUND

Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of a patient diagnosed with multiple myeloma and sternal fracture in association with multiple bilateral rib fractures and thoracic kyphosis, who developed a severe acute respiratory failure, thus complicating the initial presentation of multiple myeloma. We discuss the therapeutic implications of this uncommon presentation.

CASE SUMMARY

A 56-year-old man presented to Hematological Department after he had been experiencing worsening back pain over the last five months, with easy fatigability and progressive weight loss. He had no history of previous trauma. The chemical blood tests were compatible with a diagnosis of multiple myeloma. A radiographic bone survey of all major bones revealed, in addition to multiple bilateral rib fractures, a sternal fracture and compression fracture at T9, T10, T11 and L1 vertebrae. Subcutaneous fat biopsy was positive for amyloid. We started treatment with bortezomib and dexamethasone. After 24 h of treatment, he presented dyspnea secondary to flail chest. He required urgent intubation and ventilatory support being transferred to intensive care unit for further management. The patient remained connected to mechanical ventilation (positive pressure) as treatment which stabilized the thorax. A second cycle of bortezomib plus dexamethasone was started and analgesia was optimized. The condition of the patient improved, as evidenced by callus formation on successive computed tomography scans. The patient was taken off the ventilator one month later, and he was extubated successfully, being able to breathe unaided without paradoxical motion.

CONCLUSION

This case highlights the importance of combination between bortezomib and dexamethasone to induce remission of multiple myeloma and the initiation of positive airway pressure with mechanical ventilation to stabilize chest wall to solve the respiratory failure. This combined approach allowed to obtain a quick and complete resolution of the clinical situation.

Patient–ventilator asynchrony in Saudi Arabia: Where we stand?

Patient–ventilator asynchrony in Saudi Arabia practices is common, and more emphasis on how to mitigate such a clinical problem is needed. This letter is intended to shed the light on the current national evidence of patient–ventilator asynchrony and how to step ahead for better patients' ventilation management.

Advances in post intensive care unit care: A narrative review

As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.

Predictive value of thrombocytopenia for bloodstream infection in patients with sepsis and septic shock

BACKGROUND

Thrombocytopenia is common in patients with sepsis and septic shock.

AIM

To analyse the decrease in the number of platelets for predicting bloodstream infection in patients with sepsis and septic shock in the intensive care unit.

METHODS

A retrospective analysis of patients admitted with sepsis and septic shock in Xingtai People Hospital was revisited. Patient population characteristics and laboratory data were collected for analysis.

RESULTS

The study group consisted of 85 (39%) inpatients with bloodstream infection, and the control group consisted of 133 (61%) with negative results or contamination. The percentage decline in platelet counts (PPCs) in patients positive for pathogens [57.1 (41.3-74.6)] was distinctly higher than that in the control group [18.2 (5.1-43.1)] (P < 0.001), whereas the PPCs were not significantly different among those with gram-positive bacteraemia, gram-negative bacteraemia, and fungal infection. Using receiver operating characteristic curves, the area under the curve of the platelet drop rate was 0.839 (95%CI: 0.783-0.895).

CONCLUSION

The percentage decline in platelet counts is sensitive in predicting bloodstream infection in patients with sepsis and septic shock. However, it cannot identify gram-positive bacteraemia, gram-negative bacteraemia, and fungal infection.

Predicting the risk of mortality in children with dengue-induced hepatitis admitted to the paediatric intensive care unit

BACKGROUND

Dengue-associated acute liver failure (PALF) accounts for a high mortality rate in children admitted to the pediatric intensive care unit (PICU). To date, there is a lack of data on clinical algorithms for estimating the risk of mortality in pediatric patients with dengue-induced severe hepatitis (DISH).

AIM

To determine the prevalence of PALF and identify the predictors of mortality among patients with DISH.

METHODS

This single-institution retrospective study was performed at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcome was in-hospital mortality in pediatric patients with DISH, which was defined as either aspartate aminotransferase > 350 IU/L or alanine aminotransferase > 400 IU/L. Prognostic models for estimating the risk of death among patients with DISH were developed using a predefined set of clinical covariables and hepatic biomarkers on PICU admission and during the first 72 hours of admission. Area under the curve, multivariable logistic regression, and multiple imputation using the chained equation for missing values were performed. Backward stepwise model selection based on the Akaike information criterion was employed. Bootstrapping, calibration slope, and Brier score were used to assess the final models.

RESULTS

A total of 459 children with DISH were included in the analysis. The median patient age was 7.7 years (interquartile range: 4.3-10.1 years). The prevalence of dengue-associated PALF in children with DISH was 18.3%. Thirty-nine DISH patients developing PALF (8.5%) died. Hepatic biomarkers, including the international normalized ratio (INR) ≥ 2.11 and total serum bilirubin (≥ 1.7 mg/dL), showed high predictive values for mortality (all P values < 0.001). Multivariable models showed the significant clinical predictors of death from dengue-induced PALF in patients with DISH, including reduced level of consciousness (pain and unresponsive levels on the Alert, Verbal, Pain, Unresponsive scale), high vasoactive-inotropic score (> 30), and elevated levels of blood lactate, INR, and serum bilirubin. The final prognostic model demonstrated high discrimination, Brier score, and an acceptable calibration slope.

CONCLUSION

The prevalence of PALF in children with DISH is 18.3%. We developed robust prognostic models to estimate the risk of death in hospitalized children with severe dengue-induced hepatitis.

Driving pressure in acute respiratory distress syndrome for developing a protective lung strategy: A systematic review

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a critical condition characterized by acute hypoxemia, non-cardiogenic pulmonary edema, and decreased lung compliance. The Berlin definition, updated in 2012, classifies ARDS severity based on the partial pressure of arterial oxygen/fractional inspired oxygen fraction ratio. Despite various treatment strategies, ARDS remains a significant public health concern with high mortality rates.

AIM

To evaluate the implications of driving pressure (DP) in ARDS management and its potential as a protective lung strategy.

METHODS

We conducted a systematic review using databases including EbscoHost, MEDLINE, CINAHL, PubMed, and Google Scholar. The search was limited to articles published between January 2015 and September 2024. Twenty-three peer-reviewed articles were selected based on inclusion criteria focusing on adult ARDS patients undergoing mechanical ventilation and DP strategies. The literature review was conducted and reported according to PRISMA 2020 guidelines.

RESULTS

DP, the difference between plateau pressure and positive end-expiratory pressure, is crucial in ARDS management. Studies indicate that lower DP levels are significantly associated with improved survival rates in ARDS patients. DP is a better predictor of mortality than tidal volume or positive end-expiratory pressure alone. Adjusting DP by optimizing lung compliance and minimizing overdistension and collapse can reduce ventilator-induced lung injury.

CONCLUSION

DP is a valuable parameter in ARDS management, offering a more precise measure of lung stress and strain than traditional metrics. Implementing DP as a threshold for safety can enhance protective ventilation strategies, potentially reducing mortality in ARDS patients. Further research is needed to refine DP measurement techniques and validate its clinical application in diverse patient populations.

Characteristics and outcomes of trauma patients with unplanned intensive care unit admissions: Bounce backs and upgrades comparison

BACKGROUND

The need for an emergency upgrade of a hospitalized trauma patient from the floor to the trauma intensive care unit (ICU) is an unanticipated event with possible life-threatening consequences. Unplanned ICU admissions are associated with increased morbidity and mortality and are an indicator of trauma service quality. Two different types of unplanned ICU admissions include upgrades (patients admitted to the floor then moved to the ICU) and bounce backs (patients admitted to the ICU, discharged to the floor, and then readmitted to the ICU). Previous studies have shown that geriatric trauma patients are at higher risk for unfavorable outcomes.

AIM

To analyze the characteristics, management and outcomes of trauma patients who had an unplanned ICU admission during their hospitalization.

METHODS

This institutional review board approved, retrospective cohort study examined 203 adult trauma patients with unplanned ICU admission at an urban level 1 trauma center over a six-year period (2017-2023). This included 134 upgrades and 69 bounce backs. Analyzed variables included: (1) Age; (2) Sex; (3) Comorbidities; (4) Mechanism of injury (MOI); (5) Injury severity score (ISS); (6) Glasgow Coma Scale (GCS); (7) Type of injury; (8) Transfusions; (9) Consultations; (10) Timing and reason for unplanned admission; (11) Intubations; (12) Surgical interventions; (13) ICU and hospital lengths of stay; and (14) Mortality.

RESULTS

Unplanned ICU admissions comprised 4.2% of total ICU admissions. Main MOI was falls. Mean age was 70.7 years, ISS was 12.8 and GCS was 13.9. Main injuries were traumatic brain injury (37.4%) and thoracic injury (21.7%), and main reason for unplanned ICU admission was respiratory complication (39.4%). The 47.3% underwent a surgical procedure and 46.8% were intubated. Average timing for unplanned ICU admission was 2.9 days. Bounce backs occurred half as often as upgrades, however had higher rates of transfusions (63.8% vs 40.3%, P = 0.002), consultations (4.8 vs 3.0, P < 0.001), intubations (63.8% vs 38.1%%, P = 0.001), longer ICU lengths of stay (13.2 days vs 6.4 days, P < 0.001) and hospital lengths of stay (26.7 days vs 13.0 days, P < 0.001). Mortality was 25.6% among unplanned ICU admissions, 31.9% among geriatric unplanned ICU admissions and 11.9% among all trauma ICU patients.

CONCLUSION

Unplanned ICU admissions constituted 4.2% of total ICU admissions. Respiratory complications were the main cause of unplanned ICU admissions. Bounce backs occurred half as often as upgrades, but were associated with worse outcomes.

Sepsis in liver failure patients: Diagnostic challenges and recent advancements

Acute liver failure (ALF) and acute-on-chronic LF (ACLF) are prevalent hepatic emergencies characterized by an increased susceptibility to bacterial infections (BI), despite significant systemic inflammation. Literature indicates that 30%-80% of ALF patients and 55%-81% of ACLF patients develop BI, attributed to immunological dysregulation. Bacterial sepsis in these patients is associated with adverse clinical outcomes, including prolonged hospitalization and increased mortality. Early detection of bacterial sepsis is critical; however, distinguishing between sterile systemic inflammation and sepsis poses a significant challenge due to the overlapping clinical presentations of LF and sepsis. Conventional sepsis biomarkers, such as procalcitonin and C-reactive protein, have shown limited utility in LF patients due to inconsistent results. In contrast, novel biomarkers like presepsin and sTREM-1 have demonstrated promising discriminatory performance in this population, pending further validation. Moreover, emerging research highlights the potential of machine learning-based approaches to enhance sepsis detection and characterization. Although preliminary findings are encouraging, further studies are necessary to validate these results across diverse patient cohorts, including those with LF. This article provides a comprehensive review of the magnitude, impact, and diagnostic challenges associated with BI in LF patients, focusing on novel advancements in early sepsis detection and characterization.

Narrative review of traumatic pneumorrhachis

Pneumorrhachis (PR) is defined as presence of free air in the spinal canal. Traumatic PR is very rare, and its exact incidence and pathogenesis is unknown. A comprehensive literature search was performed using the PubMed, Cochrane Library, Google Scholar and Scopus databases to identify articles relevant to traumatic PR published till January 2023. A total of 34 resources were selected for inclusion in this narrative review. Traumatic PR can be classified anatomically into epidural and intradural types. In the epidural type, air is present peripherally in the spinal canal and the patients are usually asymptomatic. In contrast, in intradural PR, air is seen centrally in the spinal canal and patients present with neurological symptoms, and it is a marker of severe trauma. It is frequently associated with traumatic pneumocephalus, skull fractures or thoracic spine fracture. Computed tomography (CT) is considered to be the diagnostic modality of choice. Epidural PR is self-limited and patients are generally managed conservatively. Patients with neurological symptoms or persistent air in spinal canal require further evaluation for a potential source of air leak, with a need for surgical intervention. Differentiation between epidural and intradural PR is important, because the latter is an indication of severe underlying injury. CT imaging of the entire spine must be performed to look for extension of air, as well as to identify concomitant skull, torso or spinal injuries Most patients are asymptomatic and are managed conservatively, but a few may develop neurological symptoms that need further evaluation and management.