Considerations for medical nutrition therapy management of the critically ill patient with hematological malignancies: A narrative review

Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies. In consequence, these critically ill patients frequently present with malnutrition and pathophysiological alterations that create challenges for the delivery of medical nutrition therapy (MNT) in the ICU. Frequent screening, gauging tolerance, and monitoring nutrition status are mandatory to provide individualized MNT and achieve nutrition objectives. The present review discusses how HM impact GI function and nutrition status, the importance of MNT in patients with HM, and specific considerations for guidance in providing adequate MNT to these patients when admitted to the ICU.

Duration of the first prone positioning maneuver and its association with 90-day mortality in patients with acute respiratory failure due to COVID-19: A retrospective study of time terciles

OBJECTIVE

To investigate the association between the duration of the first prone positioning maneuver (PPM) and 90-day mortality in patients with C-ARDS.

DESIGN

Retrospective, observational, and analytical study.

SETTING

COVID-19 ICU of a tertiary hospital.

PATIENTS

Adults over 18 years old, with a confirmed diagnosis of SARS-CoV-2 disease requiring PPM.

INTERVENTIONS

Multivariable analysis of 90-day survival.

MAIN VARIABLES OF INTEREST

Duration of the first PPM, number of PPM sessions, 90-day mortality.

RESULTS

271 patients undergoing PPM were analyzed: first tertile (n = 111), second tertile (n = 95) and third tertile (n = 65). The results indicated that the median duration of PDP was 14 h (95% CI: 10-16 h) in the first tertile, 19 h (95% CI: 18-20 h) in the second tertile and 22 h (95% CI: 21-24 h) in the third tertile. Comparison of survival curves using the Logrank test did not reach statistical significance (p = 0.11). Cox Regression analysis showed an association between the number of pronation sessions (patients receiving between 2 and 5 sessions (HR = 2.19; 95% CI: 1.07-4.49); and those receiving more than 5 sessions (HR = 6.05; 95% CI: 2.78-13.16) and 90-day mortality.

CONCLUSIONS

while the duration of PDP does not appear to significantly influence 90-day mortality, the number of pronation sessions is identified as a significant factor associated with an increased risk of mortality.

Routes of SARS-Cov2 transmission in the intensive care unit: A multicentric prospective study

BACKGROUND

The risk of SARS-CoV-2 transmission to health care workers in intensive care units (ICU) and the contribution of airborne and fomites to SARS-CoV-2 transmission remain unclear. To assess the rate of air and surface contamination and identify risk factors associated with this contamination in patients admitted to the ICU for acute respiratory failure due to SARS-CoV-2 pneumonia.

METHODS

Prospective multicentric non-interventional study conducted from June 2020 to November 2020 in 3 French ICUs. For each enrolled patient, 3 predefined surfaces were swabbed, 2 air samples at 1 m and 3 m from the patient's mouth and face masks of 3 health care workers (HCW) were collected within the first 48 h of SARS-CoV-2 positive PCR in a respiratory sample. Droplet digital PCR and quantitative PCR were performed on different samples, respectively.

RESULTS

Among 150 included patients, 5 (3.6%, 95%CI: 1.2% to 8.2%) had positive ddPCR on air samples at 1 m or 3 m. Seventy-one patients (53.3%, CI95%: 44.5% to 62.0%) had at least one surface positive. Face masks worn by HCW were positive in 6 patients (4.4%, CI: 1.6% to 9.4%). The threshold of RT-qPCR of the respiratory sample performed at inclusion (odds ratio, OR= 0.88, 95%CI: 0.83 to 0.93, p < 0.0001) and the presence of diarrhea (OR= 3.28, 95%CI: 1.09 to 9.88, p = 0.037) were significantly associated with the number of contaminated surfaces.

CONCLUSION

In this study, including patients admitted to the ICU for acute respiratory failure " contact route " of transmission, i.e. through fomites, seems dominant. While presence of SARS-CoV-2 in the air is rare in this specific population, the presence of diarrhea is associated to surface contamination around Covid patients.

Analysis of factors associated with mortality due to sepsis resulting from device-related infections

INTRODUCTION

Health care-associated infections (HAIs) contribute to morbidity and mortality and to the dissemination of multidrug-resistant organisms. Children admitted to the intensive care unit undergo invasive procedures that increase their risk of developing HAIs and sepsis. The aim of the study was to analyse factors associated with mortality due to sepsis arising from HAIs.

PATIENTS AND METHODS

We conducted a case-control study in a 7-bed multipurpose paediatric intensive care unit in a tertiary care teaching hospital. The sample consisted of 90 children admitted between January 2014 and December 2018. The case group consisted of patients who died from sepsis associated with the main health care-associated infections; the control group consisted of patients who survived sepsis associated with the same infections.

RESULTS

Death was associated with age less than or equal to 12 months, presence of comorbidity, congenital disease, recurrent ventilator-associated pneumonia and septic shock. In the multiple regression analysis, heart disease (OR, 12.48; CI 2.55-60.93; P = .002), infection by carbapenem-resistant bacteria (OR, 31.51; CI 4.01-247.25; P = .001), cancer (OR, 58.23; CI 4.54-746.27; P = .002), and treatment with adrenaline (OR, 13.14; CI 1.35-128.02; P = .003) continued to be significantly associated with death.

CONCLUSIONS

Hospital sepsis secondary to carbapenem-resistant bacteria contributed to a high mortality rate in this cohort. Children with heart disease or neoplasia or who needed vasopressor drugs had poorer outcomes.

Effectiveness of Helmet-CPAP in mild to moderate coronavirus type 2 hypoxemia: An observational study

OBJECTIVE

To determine the relative effectiveness of Helmet-CPAP (H_CPAP) with respect to high-flow nasal cannula oxygen therapy (HFNO) in avoiding greater need for intubation or mortality in a medium complexity hospital in Chile during the year 2021.

DESIGN

Cohort analytical study, single center.

SETTING

Units other than intensive care units.

PATIENTS

Records of adults with mild to moderate hypoxemia due to coronavirus type 2.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Need for intubation or mortality.

RESULTS

159 patients were included in the study, with a ratio by support of 2:10 (H_CPAP:HFNO). The 46.5% were women, with no significant differences by sex according to support (p = 0.99, Fisher test). The APACHE II score, for HFNO, had a median of 10.5, 3.5 units higher than H_CPAP (p < 0.01, Wilcoxon rank sum). The risk of intubation in HFNO was 42.1% and in H_CPAP 3.8%, with a significant risk reduction of 91% (95% CI: 36.9%-98.7%; p < 0.01). APACHE II does not modify or confound the support and intubation relationship (p > 0.2, binomial regression); however, it does confound the support and mortality relationship (p = 0.82, RR homogeneity test). Despite a 79.1% reduction in mortality risk with H_CPAP, this reduction was not statistically significant (p = 0.11, binomial regression).

CONCLUSIONS

The use of Helmet CPAP, when compared to HFNO, was an effective therapeutic ventilatory support strategy to reduce the risk of intubation in patients with mild to moderate hypoxemia caused by coronavirus type 2 in inpatient units other than intensive care. The limitations associated with the difference in size, age and severity between the arms could generate bias.

Is EIT-guided positive end-expiratory pressure titration for optimizing PEEP in ARDS the white elephant in the room? A systematic review with meta-analysis and trial sequential analysis

Electrical Impedance Tomography (EIT) is a novel real-time lung imaging technology for personalized ventilation adjustments, indicating promising results in animals and humans. The present study aimed to assess its clinical utility for improved ventilation and oxygenation compared to traditional protocols. Comprehensive electronic database screening was done until 30th November, 2023. Randomized controlled trials, controlled clinical trials, comparative cohort studies, and assessments of EIT-guided PEEP titration and conventional methods in adult ARDS patients regarding outcome, ventilatory parameters, and P/F ratio were included. Our search retrieved five controlled cohort studies and two RCTs with 515 patients and overall reduced risk of mortality [RR = 0.68; 95% CI: 0.49 to 0.95; I2 = 0%], better dynamic compliance [MD = 3.46; 95% CI: 1.59 to 5.34; I2 = 0%] with no significant difference in PaO2/FiO2 ratio [MD = 6.5; 95%CI -13.86 to 26.76; I2 = 74%]. The required information size except PaO2/FiO2 was achieved for a power of 95% based on the 50% reduction in risk of mortality, 10% improved compliance as the cumulative Z-score of the said outcomes crossed the alpha spending boundary and did not dip below the inner wedge of futility. EIT-guided individualized PEEP titration is a novel modality; further well-designed studies are needed to substantiate its utility.

Astragalus polysaccharide-containing 3D-printed scaffold for traumatized skin repair and proteomic study

Astragalus polysaccharide-containing 3D-printed scaffold shows great potential in traumatic skin repair. This study aimed to investigate its repairing effect and to combine it with proteomic technology to deeply resolve the related protein expression changes. Thirty SD rats were divided randomly into three groups (n = 10 per group): the sham-operated group, the model group and the scaffold group. Subsequently, we conducted a comparative analysis on trauma blood perfusion, trauma healing rate, histological changes, the expression of the YAP/TAZ signalling pathway and angiogenesis-related factors. Additionally, neonatal skin tissues were collected for proteomic analysis. The blood perfusion volume and wound healing recovery in the scaffold group were better than that in the model group (p < 0.05). The protein expression of STAT3, YAP, TAZ and expression of vascular-related factor A (VEGFA) in the scaffold group was higher than that in the model group (p < 0.05). Proteomic analysis showed that there were 207 differential proteins common to the three groups. Mitochondrial function, immune response, redox response, extracellular gap and ATP metabolic process were the main groups of differential protein changes. Oxidative phosphorylation, metabolic pathway, carbon metabolism, calcium signalling pathway, etc. were the main differential metabolic pathway change groups. Astragalus polysaccharide-containing 3D-printed scaffold had certain reversals of protein disorder. The Astragalus polysaccharide-containing 3D-printed scaffold may promote the VEGFs by activating the YAP/TAZ signalling pathway with the help of STAT3 into the nucleus, accelerating early angiogenesis of the trauma, correcting the protein disorder of the trauma and ultimately realizing the repair of the wound.

What is cardiogenic shock? New clinical criteria urgently needed

PURPOSE OF REVIEW

Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods.

RECENT FINDINGS

Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure.

SUMMARY

Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.

Postintensive care syndrome in patients and family members. Analysis of COVID-19 and non-COVID-19 cohorts, with face-to-face follow-up at three months and one year

OBJECTIVE

Compare prevalence and profile of post-intensive care patient (P-PICS) and family/caregiver (F-PICS) syndrome in two cohorts (COVID and non-COVID) and analyse risk factors for P-PICS.

DESIGN

Prospective, observational cohort (March 2018-2023), follow-up at three months and one year.

SETTING

14-bed polyvalent Intensive Care Unit (ICU), Level II Hospital.

PATIENTS OR PARTICIPANTS

265 patients and 209 relatives. Inclusion criteria patients: age > 18 years, mechanical ventilation > 48 h, ICU stay > 5 days, delirium, septic shock, acute respiratory distress syndrome, cardiac arrest. Inclusion criteria family: those who attended.

INTERVENTIONS

Follow-up 3 months and 1 year after hospital discharge.

MAIN VARIABLES OF INTEREST

Patients: sociodemographic, clinical, evolutive, physical, psychological and cognitive alterations, dependency degree and quality of life. Main caregivers: mental state and physical overload.

RESULTS

64.9% PICS-P, no differences between groups. COVID patients more physical alterations than non-COVID (P = .028). These more functional deterioration (P = .005), poorer quality of life (P = .003), higher nutritional alterations (P = .004) and cognitive deterioration (P < .001). 19.1% PICS-F, more frequent in relatives of non-COVID patients (17.6% vs. 5.5%; P = .013). Independent predictors of PICS-P: first years of the study (OR: 0.484), higher comorbidity (OR: 1.158), delirium (OR: 2.935), several reasons for being included (OR: 3.171) and midazolam (OR: 4.265).

CONCLUSIONS

Prevalence PICS-P and PICS-F between both cohorts was similar. Main factors associated with the development of SPCI-P were: higher comorbidity, delirium, midazolan, inclusion for more than one reason and during the first years.

Geriatric Nutritional Risk Index and 30-Day Postoperative Mortality in Geriatric Burn Patients

INTRODUCTION

The geriatric nutritional risk index (GNRI) can easily identify malnutrition-associated morbidity and mortality. We investigated the association between preoperative GNRI and 30-d mortality in geriatric burn patients who underwent surgery.

METHODS

The study involved geriatric burn patients (aged ≥ 65 y) who underwent burn surgery between 2012 and 2022. The GNRI was computed using the following formula: 1.489 × serum albumin concentration (mg/L) + 41.7 × patient body weight/ideal body weight. Patients were dichotomized into the high GNRI (≥ 82) and low GNRI (< 82) groups. GNRI was evaluated as an independent predictor of 30-d postoperative mortality. The study also evaluated the association between GNRI and sepsis, the need for continuous renal replacement therapy (CRRT), major adverse cardiac events (MACE), and pneumonia.

RESULTS

Out of 270 patients, 128 (47.4%) had low GNRI (< 82). Multivariate Cox regression analysis revealed that low GNRI was significantly associated with 30-d postoperative mortality (hazard ratio: 1.874, 95% confidence interval [CI]: 1.146-3.066, P = 0.001). Kaplan-Meier analysis revealed that the 30-day mortality rate differed significantly between the low and high GNRI groups (log-rank test, P < 0.001). The 30-d postoperative mortality (hazard ratio: 2.677, 95% CI: 1.536-4.667, P < 0.001) and the incidence of sepsis (odds ratio [OR]: 2.137, 95% CI: 1.307-3.494, P = 0.004), need for CRRT (OR: 1.919, 95% CI: 1.101-3.344, P = 0.025), MACE (OR: 1.680, 95% CI: 1.018-2.773, P = 0.043), and pneumonia (OR: 1.678, 95% CI: 1.019-2.764, P = 0.044), were significantly higher in the low GNRI group than in the high GNRI group.

CONCLUSIONS

Preoperative low GNRI was associated with increased 30-d postoperative mortality, sepsis, need for CRRT, MACE, and pneumonia in geriatric burn patients.

Free Flap Failure and Contracture Recurrence in Delayed Burn Reconstruction: A Systematic Review and Meta-analysis

Background

Free tissue transfer is often considered a last resort in burn reconstruction due to its complexity and associated risks. A comprehensive review on free flap outcomes in delayed burn reconstruction is currently lacking. The study aimed to evaluate the available evidence on the failure and contracture recurrence rates in free flap delayed burn reconstruction.

Methods

A systematic review and meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The protocol was registered on PROSPERO (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The measured outcomes were free flap loss and contracture recurrence rate.

Results

Of the 1262 retrieved articles, 40 qualified for inclusion, reporting on 1026 free flaps performed in 928 patients. The mean age was 29.25 years [95% confidence interval (CI), 24.63-33.88]. Delayed burn reconstruction was performed at an average of 94.68 months [95% CI, - 9.34 to 198.70] after initial injury, with a follow-up period of 23.02 months [95% CI, 4.46-41.58]. Total flap loss rate was 3.80% [95% CI, 2.79-5.16] and partial flap loss rate was 5.95% [95% CI, 4.65-7.57]. Interestingly, burn contracture recurrence rate was 0.62% [95% CI, 0.20-1.90].

Conclusions

This systematic review provides a comprehensive evaluation of the free flap outcomes in delayed burn reconstruction. The flap loss rate was relatively low, given the complexity of the procedure and potential risks. Furthermore, burn contracture rate was found to be extremely low. This study demonstrates that free flaps are a safe and effective option for delayed burn reconstruction.

Veno-venal extracorporeal membrane oxygenation to support whole-lung lavage in a severe case of pulmonary alveolar proteinosis

We present the case of a 71-year-old woman with severe bilateral primary alveolar proteinosis admitted for bilateral whole lung lavage (WLL) with a double-lumen endotracheal tube. She had a cardiac arrest of respiratory origin during the procedure and recovered after one minute of advanced resuscitation. A second LLP was scheduled under respiratory support with veno-venous extracorporeal membrane oxygenation (VV-ECMO). During this second WLL the patient was completely VV-ECMO-dependent, and the procedure was successfully completed. She was gradually weaned over the next 48 h. The patient was finally discharged after clinical improvement and home oxygen therapy was discontinued. WLL is the treatment of choice for severe cases of alveolar proteinosis. In rare cases the intervention may be poorly tolerated due to the degree of lung involvement. This case illustrates how VV-ECMO support is an option that may benefit this subgroup of at-risk patients.

Electroencephalographic guided propofol-remifentanil TCI anesthesia with and without dexmedetomidine in a geriatric population: electroencephalographic signatures and clinical evaluation

Elderly and multimorbid patients are at high risk for developing unfavorable postoperative neurocognitive outcomes; however, well-adjusted and EEG-guided anesthesia may help titrate anesthesia and improve postoperative outcomes. Over the last decade, dexmedetomidine has been increasingly used as an adjunct in the perioperative setting. Its synergistic effect with propofol decreases the dose of propofol needed to induce and maintain general anesthesia. In this pilot study, we evaluate two highly standardized anesthetic regimens for their potential to prevent burst suppression and postoperative neurocognitive dysfunction in a high-risk population. Prospective, randomized clinical trial with non-blinded intervention. Operating room and post anesthesia care unit at Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile. 23 patients with scheduled non-neurologic, non-cardiac surgeries with age > 69 years and a planned intervention time > 60 min. Patients were randomly assigned to receive either a propofol-remifentanil based anesthesia or an anesthetic regimen with dexmedetomidine-propofol-remifentanil. All patients underwent a slow titrated induction, followed by a target controlled infusion (TCI) of propofol and remifentanil (n = 10) or propofol, remifentanil and continuous dexmedetomidine infusion (n = 13). We compared the perioperative EEG signatures, drug-induced changes, and neurocognitive outcomes between two anesthetic regimens in geriatric patients. We conducted a pre- and postoperative Montreal Cognitive Assessment (MoCa) test and measured the level of alertness postoperatively using a sedation agitation scale to assess neurocognitive status. During slow induction, maintenance, and emergence, burst suppression was not observed in either group; however, EEG signatures differed significantly between the two groups. In general, EEG activity in the propofol group was dominated by faster rhythms than in the dexmedetomidine group. Time to responsiveness was not significantly different between the two groups (p = 0.352). Finally, no significant differences were found in postoperative cognitive outcomes evaluated by the MoCa test nor sedation agitation scale up to one hour after extubation. This pilot study demonstrates that the two proposed anesthetic regimens can be safely used to slowly induce anesthesia and avoid EEG burst suppression patterns. Despite the patients being elderly and at high risk, we did not observe postoperative neurocognitive deficits. The reduced alpha power in the dexmedetomidine-treated group was not associated with adverse neurocognitive outcomes.

Construction of a Risk Prediction Model for the Occurrence of Acute Skin Failure in Critically Ill Patients: A Prospective Study

BACKGROUND

The risk factors for acute skin failure (ASF), a serious complication of the skin, are not fully understood.

PURPOSE

This study was designed to explore the risk factors for ASF in critically ill patients and construct a clinical prediction model.

METHODS

Intensive care unit patients were prospectively observed and assigned into two groups: with and without ASF. A logistic regression model was constructed, and its predictive power and clinical utility were evaluated.

RESULTS

Of the 204 eligible patients enrolled as participants, 58 (28.43%) developed ASF. Sepsis, vasoactive drugs, and age were shown to be risk factors for ASF, whereas peripheral perfusion index ratio and albumin level were shown to be protective factors. The area under the receiver operating characteristic curve was 0.83. The maximum Youden index of the model was 0.39 (specificity: 0.87, sensitivity: 0.77). The Hosmer-Lemeshow test (p = .20) and calibration curve showed good fitness and predictive utility with respect to the model.

CONCLUSIONS

The developed model effectively predicts ASF risk, allowing for the early identification of high-risk patients. Identifying risk factors such as sepsis, vasoactive drugs, and age and considering protective factors such as peripheral perfusion index and albumin levels may help optimize care plans. Clinical staff should pay special attention to these factors and their impact on skin health in critically ill patients.

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Activity of propyl-propane-thiosulfinate and propyl-propane-thiosulfonate against carbapenem-resistant Gram-negative bacteria

Organosulfur compounds derived from plants of the Allium genus, such as propyl-propane-thiosulfinate (PTS) and propyl-propane-thiosulfonate (PTSO), have been proposed as an alternative in antibiotic resistance. The aim of this study was to compare the activity of these substances with other antibiotics against clinical isolates of carbapenem-resistant (CAR-R) and carbapenem-susceptible (CAR-S) Gram-negative bacteria. A total of 126 clinical isolates of CAR-R and 155 CAR-S bacteria were selected, including Enterobacterales, A. baumannii and P. aeruginosa. The antibiotic susceptibility of all isolates was assessed using the microdilution and Kirby-Bauer methods for PTS, PTSO, amoxicillin/clavulanate, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, imipenem, ciprofloxacin, and amikacin. Both PTS and PTSO demonstrated in vitro bactericidal activity against CAR-R Enterobacteriaceae and A. baumannii, with no significant difference in activity compared to their response against CAR-S isolates. However, both compounds were less active against P. aeruginosa than against any of the other bacteria, regardless of their resistance to carbapenems. In all cases, the minimum inhibitory concentration values of PTSO were significantly lower than those of PTS. These findings offer valuable information about the potential antibacterial use of these substances, particularly against infections that currently have limited therapeutic options.

Ultrasound monitoring to detect embolic phenomena in the inferior vena cava during hip arthroplasty

INTRODUCTION AND OBJECTIVES

Embolic phenomena frequently occur during hip joint replacement surgery, and may lead to haemodynamic instability in frail patients. Transoesophageal ultrasound monitoring is rarely available in non-cardiac operating theatres, and cannot be performed in awake patients under spinal anaesthesia. The main objectives of this prospective exploratory study were to determine the feasibility of using an alternative ultrasound approach to monitor the inferior vena cava during hip replacement surgery, and to determine the intra and interobserver reliability of the ultrasound findings.

METHOD

We conducted a prospective exploratory study in 20 patients undergoing cemented hip arthroplasty in the supine position under spinal anaesthesia and sedation. The inferior vena cava was assessed through a subcostal window at 10 intraoperative time points, and the findings were rated on a qualitative embolism severity scale. The ultrasound images were evaluated by 2 independent observers.

RESULTS

An adequate subcostal window was obtained in 90% of cases. Intra- and inter-observer reliability was high (kappa index >0.80, p < 0.001). Nearly all (95%) patients presented some degree of embolism, which was severe in 50% of cases.

CONCLUSIONS

Our study suggests that ultrasound assessment of embolic phenomena in the inferior vena cava through a subcostal window is feasible in 90% of cases. The qualitative embolic severity rating scale is highly reproducible and has high intra- and inter-observer reliability.

The medical treatment of cardiogenic shock

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

CTC-177, a novel drug-Fc conjugate, shows promise as an immunoprophylactic agent against multidrug-resistant Gram-negative bacterial infections

Background

The widespread emergence of antibiotic resistance including MDR in Gram-negative bacterial pathogens poses a critical challenge to the current antimicrobial armamentarium.

Objectives

To create a novel drug-Fc conjugate (DFC) that can be delivered at sustained and prolonged levels while simultaneously activating the host immune response to combat MDR Gram-negative infections.

Methods

The Cloudbreak™ platform was used to develop DFCs consisting of a targeting moiety (TM) (a polymyxin-derived dimer) attached via a non-cleavable linker to an effector moiety (EM) (the Fc domain of human IgG1). In vitro activities of the DFCs were assessed by MIC testing. Neutropenic mouse models of thigh infection, septicaemia and pneumonia were used to evaluate in vivo efficacy. Pharmacokinetics were evaluated in mice and cynomolgus monkeys.

Results

A single prophylactic dose of our lead DFC, CTC-177, resulted in significantly decreased bacterial burdens and reduced inflammation comparable to daily treatment with colistin in septicaemia and pneumonia mouse models. Furthermore, CTC-177 prophylaxis was able to restore colistin efficacy in colistin-resistant septicaemia, reducing bacterial burdens beyond the limit of detection. Finally, CTC-177 displayed a long terminal half-life of over 24 and 65 h in mice and cynomolgus monkeys, respectively.

Conclusions

These data support the continued development of Cloudbreak™ DFCs as broad-spectrum prophylactic agents against Gram-negative infections.

Evaluation of the degree of implementation of zero projects in critical care units of Galicia (Spain) through internal audits

OBJECTIVE

The objective of this study was to assess the implementation of Zero Projects in Critical Care Units (CCUs) through Internal Audits (IA).

MATERIALS AND METHODS

Design: Real-time observational safety analysis. A questionnaire was developed with defined items to ensure objectivity. After IAs, a survey was conducted with the auditors.

SCOPE

11 CCUs in hospitals of the Servizo Galego de Saúde and Ribera-POVISA.

PATIENTS OR PARTICIPANTS

24 auditors in 9 teams composed of medical, nursing, and quality personnel from health areas and 34 patients were assessed.

MAIN VARIABLES OF INTEREST

Compliance with the quality standard (≥60% of items), strengths, areas for improvement, auditor's interest in IA, conformity with the organization and items.

RESULTS

100% CCUs met the quality standard. 18.03% of items were fulfilled by all CCUs. Strengths: staff motivation, positive reception of auditors, and use of computer tools in some CCUs. Areas for improvement: deficit of automatic systems for controlling endotracheal tube cuff pressure (compliance rate in 9.1% of CCUs), training needs, communication issues, and not using checklists (45.5% of the reports). Auditors found IA very interesting, and 19% suggested improving organization and items.

CONCLUSIONS

All CCUs met the previously agreed-upon quality standard. Numerous improvement opportunities were identified and communicated to the audited CCUs. For greater homogeneity and objectivity, a review of previously agreed items and definitions is required.

Outcome of Intravenous and Inhaled Polymyxin B treatment in Patients with Multidrug-Resistant Gram-Negative Bacterial Pneumonia

PURPOSE

The incidence of pneumonia caused by multidrug-resistant gram-negative bacteria (MDR GNB) is increasing, which imposes significant burden on public health. Inhalation combined with intravenous polymyxins has emerged as a viable treatment option. However, pharmacokinetic studies focusing on intravenous and inhaled polymyxin B (PMB) are limited.

METHODS

This study included seven patients with MDR GNB-induced pneumonia who were treated with intravenous plus inhaled PMB from March 1 to November 30, 2022, in the intensive care unit of the First Affiliated Hospital of Zhejiang University School of Medicine. Clinical outcomes and therapeutic drug monitoring data of PMB in both plasma and epithelial lining fluid (ELF) were retrospectively reviewed.

RESULTS

Median PMB concentrations in the ELF were 7.83 (0.72-66.5), 116.72 (17.37-571.26), 41.1 (3.69-133.78), and 33.82 (0.83-126.68) mg/L at 0, 2, 6, and 12 h, respectively, and were much higher than those detected in the serum. ELF concentrations of PMB at 0, 2, 6, and 12 h were higher than the minimum inhibitory concentrations of pathogens isolated from the patients. Steady-state concentrations of PMB in the plasma were > 2 mg/L in most patients. Of the patients, 57.14 % were cured and 71.43 % showed a favorable microbiological response. The incidence of side effects with PMB was low.

CONCLUSIONS

Inhaled plus intravenous PMB can achieve high ELF concentrations and favorable clinical outcomes without an increased adverse effect profile. This treatment approach appears promising for the treatment of patients with pneumonia caused by MDR-GNB.

Attitudes and Skills in Basic Life Support after Two Types of Training: Traditional vs. Gamification, of Compulsory Secondary Education Students: A Simulation Study

It is recommended to implement the teaching of Basic Life Support (BLS) in schools; however, studies on the best training method are limited and have been a priority in recent years. The objective of this study was to analyze the attitudes and practical skills learned during BLS training using a gamified proposal. A comparative study was carried out, consisting of Compulsory Secondary Education students [control group (CG; classical teaching) and experimental group (EG; gamified proposal)]. The instruments used were the CPR and AED action sequence observation sheet, data from the Laerdal Resusci Anne manikin and AED and Attitude Questionnaire towards Basic Life Support and the Use of the Automated External Defibrillator. Sixty-eight students (33 girls) with a mean age of 13.91 ± 0.70 years were recruited. Results were significantly better in the EG (n = 37) [i.e., breathing control (p = 0.037); call to emergency services (p = 0.049); mean compression depth (p = 0.001); self-confidence (p = 0.006); intention to perform BLS and AED (p = 0.002)]; and significantly better in the CG (n = 31) [Total percentage of CPR (p < 0.001); percentage of correct compression (p < 0.001); time to apply effective shock with AED (p < 0.001); demotivation (p = 0.005). We can conclude that the group that was trained with the training method through the gamified proposal presents better intentions and attitudes to act in the event of cardiac arrest than those of the classic method. This training method allows for similar results in terms of CPR and AED skills to classical teaching, so it should be taken into account as a method for teaching BLS to secondary education students.

Prognosis of major trauma in patients older than 85 years admitted to the ICU, a registry-based study

BACKGROUND

The aging population in France and Western Europe is on the rise, particularly among individuals aged 65 years and older. Although older adults are susceptible to traumatic injuries, they constitute a minority of trauma center admissions especially those aged 85 and above. The aim of our study was to investigate the prognostic factors for mortality among the older old population (aged 85 years and above) managed in ICU of Traumabase group trauma centers.

METHODS

This retrospective observational cohort study, conducted from 2013 to 2022, analyzed all severely injured older patients (aged ≥ 85 years) managed in 14 ICU trauma centers enrolled in the Traumabase registry. The study examined sociodemographic, clinical, and outcome variables. Frailty was assessed using the Clinical Frailty Scale.

RESULTS

Among the 365 older trauma patients, 190 (52.1%) were classified as non-frail (CFS 1-3), 80 (21.9%) as pre-frail (CFS 4,5), and 95 (26%) as frail (CFS 6-9). Falls were the most common mechanism of injury. High mortality rates were observed, with 43.5% ICU mortality and 45.5% mortality at day 30. Factors most associated with ICU mortality included traumatic brain injury (CGS < 13), pre-hospital micromethod hemoglobin < 13 and severity of injury (ISS > 16).

CONCLUSION

Factors such as traumatic brain injury and severe hemorrhage (micromethod hemoglobin < 13) and ISS > 16 are associated with ICU mortality in in patients older than 85 years trauma patient. Early geriatric intervention is crucial for optimizing outcomes in this vulnerable population.

Impact of the COVID-19 pandemic on the incidence and the epidemiology of catheter-related bloodstream infection two years later

Introduction

The COVID-19 pandemic increased catheter-related bloodstream infections (C-RBSI), but its subsequent impact has not been adequately described. Our hospital has already depicted the effects of the COVID-19 pandemic in the first wave. However, we still do not know whether C-RBSI rates and aetiology are similar to those described before the COVID-19 pandemic. We aimed to evaluate the impact of the COVID-19 pandemic on the evolution of C-RBSI in a large tertiary teaching hospital two years later.

Material and methods

We prospectively collected all confirmed C-RBSI episodes in a clinical microbiology laboratory database by matching blood cultures and catheter tip cultures with the isolation of the same microorganism (s). We compared our C-RBSI incidence rates and aetiology from 2018 to 2023. C-RBSI was defined as bacteremia or fungemia in a patient with clinical manifestations of infection and no other apparent source except the catheter.

Results

During the study period, we collected 556 C-RBSI episodes. C-RBSI incidence rate per 1000 admissions each year was as follows: 2018: 2.2; 2019: 1.7; 2020: 3.29; 2021: 2.92; 2022: 2.69. and 2023: 2.01. Mainly, C-RBSI episodes occurring in critical care units each year were, respectively: 2018: 57 (54.8 %), 2019: 38 (45.2 %), 2020: 89 (63.6 %), 2021: 69 (60.5 %), 2022: 58 (50.9 %) and 2023 (61.4 %). The distribution of microorganisms showed an increase in Gram-negative episodes after the pandemic.

Conclusion

Our study shows an increase in the incidence rate of C-RBSI during the COVID-19 pandemic, with a discrete decrease after that. C-RBSI episodes were mainly caused by coagulase-negative Staphylococci but with a rise in Gram-negative bacilli.

Application of a novel nested ensemble algorithm in predicting motor function recovery in patients with traumatic cervical spinal cord injury

Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary

AIM

Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group.

RESULTS

The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice.

CONCLUSIONS

The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

Risk factors for COVID-19 and their association with mortality in Ecuadorian patients admitted to the ICU: A retrospective cohort multicentric study

Several risk factors were associated with mortality in patients with coronavirus disease 2019 (COVID-19) infection in intensive care units (ICU). We assessed the effect of risk factors related to the characteristics and clinical history of the population, laboratory test results, drug management, and type of ventilation on the probability of survival/discharge from the ICU. A retrospective cohort multicentric study of adults with COVID-19 admitted to the ICU between March 2020 and December 2021. Data were collected from 6 hospitals in 5 cities in Ecuador. The primary outcome was ICU survival/discharge. Survival analysis was conducted using semi-parametric Cox proportional hazards models. Of those admitted to the ICU with COVID-19, (n = 991), mean age was 56.76 ± 13.14, and 65.9% were male. Regarding the primary outcome, 51.1% (n = 506) died and 48.9% (n = 485) survived. Of the group that died, their mean age was higher than the survivors (60.7 vs 52.60 years, respectively), and they had a higher prevalence of comorbidities such as arterial hypertension (37.2% vs 20.4%, respectively) and diabetes mellitus (26.9% vs 15.7%, respectively), with P < .001. In ventilatory management, 32.7% of patients used noninvasive ventilation and high-flow nasal cannula, and 67.3% required invasive ventilatory support. After adjusting for confounders, Cox regression analysis showed that patients were less likely to be discharged alive from the ICU if they met the following conditions: arterial hypertension (hazard ratio [HR] = 0.83 95% CI 0.723-0.964), diabetes mellitus (HR = 0.80 95% CI 0.696-0.938), older than 62 years (HR = 0.86 95% CI 0.790-0.956), obese (body mass index ≥ 30) (HR = 0.78 95% CI 0.697-0.887), 1 unit increase in SOFA score (HR = 0.94 95% CI 0.937-0.961), PaO2/FiO2 ratio <100 mm Hg (HR = 0.84 95% CI 0.786-0.914), and the use of invasive mechanical ventilation (HR = 0.68 95% CI 0.614-0.769). Risk factors associated with increased mortality were older age, obesity, arterial hypertension, and diabetes. Factors such as male gender, chronic obstructive pulmonary disease, acute kidney injury, and cancer reported in other investigations did not have the same effect on mortality in our study.

Ultrasonography for confirmation of gastric tube placement

BACKGROUND

Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.

OBJECTIVES

To assess the diagnostic accuracy of ultrasound alone or in combination with other methods for gastric tube placement confirmation in children and adults.

SEARCH METHODS

This systematic review is an update of a previously published Cochrane review. For this update, we searched the Cochrane Library (2021, Issue 6), MEDLINE (to April 2023), Embase (to April 2023), five other databases (to July 2021), and reference lists of articles, and contacted study authors.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies and case-control studies. We excluded case series or case reports. We excluded studies if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. There were sparse data for specificity. Therefore, we performed a meta-analysis of only sensitivity using a univariate random-effects logistic regression model to combine data from studies that used the same method and echo window.

MAIN RESULTS

We identified 12 new studies in addition to 10 studies included in the earlier version of this review, totalling 1939 participants and 1944 tube insertions. Overall, we judged the risk of bias in the included studies as low or unclear. No study was at low risk of bias or low concern for applicability in every QUADAS-2 domain. There were limited data (152 participants) for misplacement detection (specificity) due to the low incidence of misplacement. The summary sensitivity of ultrasound on neck and abdomen echo windows were 0.96 (95% confidence interval (CI) 0.92 to 0.98; moderate-certainty evidence) for air injection and 0.98 (95% CI 0.83 to 1.00; moderate-certainty evidence) for saline injection. The summary sensitivity of ultrasound on abdomen echo window was 0.96 (95% CI 0.65 to 1.00; very low-certainty evidence) for air injection and 0.97 (95% CI 0.95 to 0.99; moderate-certainty evidence) for procedures without injection. The certainty of evidence for specificity across all methods was very low due to the very small sample size. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (8 studies, 552 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide CIs. For studies of ultrasound alone (9 studies, 782 participants), sensitivity estimates ranged from 0.77 to 0.98 and specificity estimates were 1.00 with wide CIs or not estimable due to no occurrence of misplacement.

AUTHORS' CONCLUSIONS

Of 22 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Impacts of COVID-19 pandemic prevention measures to the palliative care in Taiwan

Background

Prevention measures for palliative care and the provision of discharge planning services for inpatients in Taiwan before and during the COVID-19 pandemic had not been investigated. This study was aimed to investigate the factors associated with heightened palliative care needs and increased mortality rates.

Methods

This research adopts a retrospective case-control study design. The investigation encompasses patients admitted before the pandemic (from January 1, 2019, to May 31, 2019) and during the COVID-19 pandemic (from January 1, 2020, to May 31, 2020). The case group consisted of 231 end-of-life inpatients during the pandemic, control group was composed of the pool of inpatients with pre-pandemic and matched with cases by sex and age in a 1:1 ratio.

Results

The results showed that the prevalence of respiratory failure symptoms (p = 0.004), residing in long-term care facilities (p = 0.017), palliative care needs assessment scores (p = 0.010), as well as the provision of guidance for nasogastric tube feeding (p = 0.002), steam inhalation (p = 0.003), turning and positioning (p < 0.001), percussion (p < 0.001), passive range of motion (p < 0.001), and blood pressure measurement (p < 0.001). Furthermore, the assessment of the necessity for assistive devices, including hospital beds, also exhibited statistically significant variations (p < 0.001). Further investigation of the factors associated with high palliative care needs and the risk of mortality for both the case and control groups. Risk factors for high palliative care needs encompassed assessments of daily activities of living, the presence of pressure ulcers, and the receipt of guidance for ambulation. Risk factors for mortality encompassed age, a diagnosis of cancer, palliative care needs assessment scores, and the provision of guidance for disease awareness.

Conclusion

This research highlights the heightened risk of COVID-19 infection among end-of-life inpatients during the COVID-19 pandemic. The findings of this study may advance care planning to alleviate avoidable suffering. To meet the needs of inpatients during pandemic, healthcare professionals should undergo comprehensive palliative care training and receive policy support.

Machine learning for predicting mortality in adult critically ill patients with Sepsis: A systematic review

INTRODUCTION

Various Machine Learning (ML) models have been used to predict sepsis-associated mortality. We conducted a systematic review to evaluate the methodologies employed in studies to predict mortality among patients with sepsis.

METHODS

Following a pre-established protocol registered at the International Prospective Register of Systematic Reviews, we performed a comprehensive search of databases from inception to February 2024. We included peer-reviewed articles reporting predicting mortality in critically ill adult patients with sepsis.

RESULTS

Among the 1822 articles, 31 were included, involving 1,477,200 adult patients with sepsis. Nineteen studies had a high risk of bias. Among the diverse ML models, Logistic regression and eXtreme Gradient Boosting were the most frequently used, in 22 and 16 studies, respectively. Nine studies performed internal and external validation. Compared with conventional scoring systems such as SOFA, the ML models showed slightly higher performance in predicting mortality (AUROC ranges: 0.62-0.90 vs. 0.47-0.86).

CONCLUSIONS

ML models demonstrate a modest improvement in predicting sepsis-associated mortality. The certainty of these findings remains low due to the high risk of bias and significant heterogeneity. Studies should include comprehensive methodological details on calibration and hyperparameter selection, adopt a standardized definition of sepsis, and conduct multicenter prospective designs along with external validations.

Anti-Xa activity below range is related to thrombosis in patients with severe COVID-19

OBJECTIVE

We aimed to anlayse the relationship between anti-Xa activity below range and thomboembolic events.

DESIGN

Single center prospective observational longitudinal cohort study (February-November 2021).

SETTING

Patients admitted to the ICU of a University Hospital.

PARTICIPANTS

Patients with severe COVID-19 pneumoniae.

INTERVENTIONS

Enoxaparin was used for prophylactic and therapeutic anticoagulation. Enoxaparin dosing and dose adjustment were based on anti-Xa activity according to the hospital protocol.

MAIN VARIABLES OF INTEREST

Target: thomboembolic events.

PREDICTORS

demographics, pharmacotherapy, anti-Xa measurements, clinical data, and laboratory results. Logistic regression was used to identify independent risk factors for thomboembolic events.

RESULTS

Data were available for 896 serum anti-Xa measurements from 228 subjects. Overall, 71.9% were male, with a median age of 62. Most patients needed invasive mechanical ventilation (87.7%) and mortality was 24.1%. A total of 28.9% new thomboembolic events were diagnosed. There were 27.1% anti-Xa measesurements below range. When multivariable logistic regression analysis was performed anti-Xa activity below range (RR, 4.2; p = 0.000), C-reactive protein (25 mg/L increase) (RR, 1.14; p = 0.005) and D-dimer (1000 ng/L increase) (RR, 1.06; p = 0.002) were the independent factors related to new thomboembolic events in patients with severe COVID-19.

CONCLUSIONS

Anti-Xa activity below range, C-reactive protein and D-dimer were the independent factors related to thomboembolic events in patients with severe COVID-19. Purposely designed clinical trials should be carried out to confirm the benefit of an anti-Xa monitoring.

Assessment of the shock index in septic shock: A systematic review

OBJECTIVE

To identify published research on the Shock Index (SI) in patients with septic shock or severe sepsis and to describe its main findings and conclusions.

DESIGN

Systematic review of the literature following the recommendations of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

SETTINGS

The following databases were consulted: Pubmed, Embase, Library Cochrane and Lilacs.

PATIENTS

Patients older than 14 years with septic shock. Pregnant women and population with COVID-19 were excluded.

INTERVENTIONS

Studies reporting measurement of the shock index or its modified variants.

MAIN VARIABLES OF INTEREST

Absolute frequencies and relative frequencies were assessed with measures of central tendency and dispersion. Effect estimators (OR, RR and HR) were extracted according to the context of each study.

RESULTS

Seventeen articles were included, of which 11 investigated the SI as a predictor of mortality. Seven of them found significant differences in the SI when comparing survivors to non-survivors and observed a relationship between the SI evolution and clinical outcomes. Additional research evidenced a relation between the Modified Shock Index and myocardial depression, as well as mortality. Furthermore, they identified a relationship between the Diastolic Shock Index, the dose of administered dobutamine, and mortality.

CONCLUSIONS

The results suggest that both the SI and its modified versions, particularly in serial assessments, can be considered for evaluating patient prognosis. The SI can also aid in determining fluid management for patients.

Corticosteroid Treatment for Leptospirosis: A Systematic Review and Meta-Analysis

Background: Leptospirosis, a zoonotic disease prevalent in tropical regions, often leads to severe complications such as Weil's disease and acute respiratory distress syndrome (ARDS). This pioneering meta-analysis investigated the role of corticosteroids in treating severe leptospirosis, addressing a critical gap in the current clinical knowledge. Methods: We systematically reviewed studies from PubMed and Scopus, focusing on randomized controlled trials and observational cohort studies involving adult patients diagnosed with leptospirosis. Five studies comprising 279 participants met the inclusion criteria. Results: Although some studies suggest potential benefits, particularly for pulmonary complications, the evidence remains inconclusive due to the limited number of studies and their methodological limitations. Notably, while four of the five reviewed studies indicated a possible positive role of corticosteroids, the single randomized controlled trial showed no significant benefit, highlighting the need for more robust research. Conclusions: While the current evidence provides a basis for potential benefits, it is not sufficient to make definitive clinical recommendations. Further research is essential to clarify the role of corticosteroids in the treatment of severe leptospirosis, with the aim of improving patient outcomes and guiding clinical practices effectively.

Effect of Fu Zheng Jie Du Formula on outcomes in patients with severe pneumonia receiving prone ventilation: a retrospective cohort study

Background

The effect of combining prone ventilation with traditional Chinese medicine on severe pneumonia remains unclear.

Objective

To evaluate the effect of Fu Zheng Jie Du Formula (FZJDF) combined with prone ventilation on clinical outcomes in patients with severe pneumonia.

Methods

This single-center retrospective cohort study included 188 severe pneumonia patients admitted to the ICU from January 2022 to December 2023. Patients were divided into an FZJD group (receiving FZJDF for 7 days plus prone ventilation) and a non-FZJD group (prone ventilation only). Propensity score matching (PSM) was performed to balance baseline characteristics. The primary outcome was the change in PaO2/FiO2 ratio after treatment. Secondary outcomes included 28-day mortality, duration of mechanical ventilation, length of ICU stay, PaCO2, lactic acid levels, APACHE II score, SOFA score, Chinese Medicine Score, inflammatory markers, and time to symptom resolution.

Results

After PSM, 32 patients were included in each group. Compared to the non-FZJD group, the FZJD group showed significantly higher PaO2/FiO2 ratios, lower PaCO2, and lower lactic acid levels after treatment (p < 0.05 for all). The FZJD group also had significantly lower APACHE II scores, SOFA scores, Chinese Medicine Scores, and levels of WBC, PCT, hs-CRP, and IL-6 (p < 0.05 for all). Time to symptom resolution, including duration of mechanical ventilation, length of ICU stay, time to fever resolution, time to cough resolution, and time to resolution of pulmonary rales, was significantly shorter in the FZJD group (p < 0.05 for all). There was no significant difference in 28-day mortality between the two groups.

Conclusion

FZJDF as an adjuvant therapy to prone ventilation can improve oxygenation and other clinical outcomes in severe pneumonia patients. Prospective studies are warranted to validate these findings.

Impact of high-flow oxygen therapy via high velocity nasal insufflation on diaphragmatic thickening fraction in healthy subjects

OBJECTIVE

The primary objective of this study was to evaluate the impact of high-flow nasal cannula oxygen therapy [HFNC] on the diaphragm thickening fraction.

DESIGN

Prospective, descriptive, cohort study SETTING: The study was conducted in the Physiology and Respiratory Care Laboratory, Intensive Care Unit, Hospital Británico de Buenos Aires.

PARTICIPANTS

Thirteen healthy subjects >18 years old INTERVENTIONS: High-flow nasal cannula oxygen therapy MAIN VARIABLES OF INTEREST: Demographic data (age and gender), anthropometric data (weight, height, and body mass index), and clinical and respiratory variables (Diaphragm thickening fraction [DTf], esophageal pressure swing, respiratory rate [RR], esophageal pressure-time product per minute [PTPes/min]).

RESULTS

Median DTf decreased significantly as flow increased (p < 0.05). The baseline DTf measurement was 21.4 %, 18.3 % with 20 L/m, and 16.4 % with 40 L/m. We also observed a significant decrease in RR as flow increased in HFNC (p < 0.05). In the 8 subjects with recordings, the PTPes/min was 81.3 (±30.8) cmH2O/sec/min and 64.4 (±25.3) cmH2O/sec/min at baseline and 40 L/m respectively (p = 0.044).

CONCLUSIONS

The use of high-flow oxygen therapy through nasal cannula of HFNC in healthy subjects decreases the DTf and RR in association with increased flow. In addition, the use of 40 L/m flow may reduce the muscular work associated with respiration.

Effect of occupational therapy on the occurrence of delirium in critically ill patients: a systematic review and meta-analysis

Aim

Delirium poses a major challenge to global health care, yet there is currently a dearth of single effective interventions or medications. Particularly, addressing delirium induced by critical illness is a complex process. Occupational therapy is considered to have a high potential for use in the prevention of delirium, as it involves both cognitive training and training in ADL. To comprehensively analyze the effect of occupational therapy on delirium prevention, we evaluated the effects of occupational therapy vs. standard non-pharmacological prevention on incidence and duration of delirium, clinical outcomes and rehabilitation outcomes in critically ill patients.

Methods

The data sources, including PubMed/Medline, Web of Science, EMBASE, and Cochrane Library, were comprehensively searched from their inception until 15 October 2023. Following the PICOS principle, a systematic screening of literature was conducted to identify relevant studies. Subsequently, the quality assessment was performed to evaluate the risk of bias in the included literature. Finally, outcome measures from each study were extracted and comprehensive analysis was conducted using Review Manager 5.4.

Results

A total of four clinical trials met the selection criteria. The pooled analysis indicated no significant difference in the incidence and duration of delirium between the OT group and standard non-pharmacological interventions. A comprehensive analysis of clinical outcomes revealed that OT did not significantly reduce the length of hospital stay or ICU stay. Meanwhile, there was no significant difference in mortality rates between the two groups. It is noteworthy that although grip strength levels did not exhibit significant improvement following OT intervention, there were obvious enhancements observed in ADL and MMSE scores.

Conclusion

Although occupational therapy may not be the most effective in preventing delirium, it has been shown to significantly improve ADL and cognitive function among critically ill patients. Therefore, we contend that occupational therapy is a valuable component of a comprehensive multidisciplinary approach to managing delirium. In the future, high-quality researches are warranted to optimize the implementation of occupational therapy interventions for delirium prevention and further enhance their benefits for patients.

Identification and validation of potential genes for the diagnosis of sepsis by bioinformatics and 2-sample Mendelian randomization study

This integrated study combines bioinformatics, machine learning, and Mendelian randomization (MR) to discover and validate molecular biomarkers for sepsis diagnosis. Methods include differential expression analysis, weighted gene co-expression network analysis (WGCNA) for identifying sepsis-related modules and hub genes, and functional enrichment analyses to explore the roles of hub genes. Machine learning algorithms identify 3 diagnostic genes - CD177, LDHA, and MCEMP1 - consistently highly expressed in sepsis patients. The nomogram model effectively predicts sepsis risk, supported by receiver operator characteristic (ROC) curves. Correlations between diagnostic genes and immune cell infiltration are observed. MR analysis reveals a positive causal relationship between MCEMP1 and sepsis risk. In conclusion, this study presents potential sepsis diagnostic biomarkers, highlighting the genetic association of MCEMP1 with sepsis for insights into early diagnosis.

Innovation through Artificial Intelligence in Triage Systems for Resource Optimization in Future Pandemics

Artificial intelligence (AI) systems are already being used in various healthcare areas. Similarly, they can offer many advantages in hospital emergency services. The objective of this work is to demonstrate that through the novel use of AI, a trained system can be developed to detect patients at potential risk of infection in a new pandemic more quickly than standardized triage systems. This identification would occur in the emergency department, thus allowing for the early implementation of organizational preventive measures to block the chain of transmission.

MATERIALS AND METHODS

In this study, we propose the use of a machine learning system in emergency department triage during pandemics to detect patients at the highest risk of death and infection using the COVID-19 era as an example, where rapid decision making and comprehensive support have becoming increasingly crucial. All patients who consecutively presented to the emergency department were included, and more than 89 variables were automatically analyzed using the extreme gradient boosting (XGB) algorithm.

RESULTS

The XGB system demonstrated the highest balanced accuracy at 91.61%. Additionally, it obtained results more quickly than traditional triage systems. The variables that most influenced mortality prediction were procalcitonin level, age, and oxygen saturation, followed by lactate dehydrogenase (LDH) level, C-reactive protein, the presence of interstitial infiltrates on chest X-ray, and D-dimer. Our system also identified the importance of oxygen therapy in these patients.

CONCLUSIONS

These results highlight that XGB is a useful and novel tool in triage systems for guiding the care pathway in future pandemics, thus following the example set by the well-known COVID-19 pandemic.

Comparative Efficacy of Inhaled and Intravenous Corticosteroids in Managing COVID-19-Related Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a life-threatening condition in which the lungs fail to provide sufficient oxygen to the body's vital organs. It is commonly associated with COVID-19 patients. Severe cases of COVID-19 can lead to lung damage and organ failure due to an immune response in the body. To mitigate these effects, corticosteroids, which are known for their anti-inflammatory properties, have been suggested as a potential treatment option. The primary focus of this study was to assess the impact of various corticosteroid administration methods on the outcomes of patients with COVID-19. Methods: The current study was conducted on COVID-19 patients divided into three groups. The first group was administered 6 mg of intravenous (IV) dexamethasone; the second group received 1 mg/kg of IV methylprednisolone (methylprednisolone); and the third group received budesonide respirable solution at a dosage of 1mg twice daily. The neubilizer used was a vibrating mesh nebulizer (VMN). All patients received standard care. We found that dexamethasone administered intravenously led to a significant reduction in C-reactive protein levels, surpassing the effectiveness of both IV methylprednisolone and inhaled budesonide. Oxygen saturation without mask change over time showed statistically significant differences (p = 0.004) in favor of the budesonide and dexamethasone groups for all days. Individuals who received methylprednisolone showed a significant decrease in mortality rate and an extended survival duration, with statistical significance observed at p = 0.024. The rest of the parameters, including ferritin, lymphocytes, total leukocyte count, platelets, hemoglobin, urea, serum potassium, serum sodium, serum creatinine, serum glutamic-pyruvic transaminase, serum glutamic-oxaloacetic transaminase, uric acid, albumin, globulin, erythrocyte sedimentation rate, international normalized ratio, oxygen saturation with flow, and oxygen flow, showed no statistically significant differences between the three drugs. In conclusion, treatment with IV methylprednisolone (1 mg/kg) resulted in a shorter hospital stay, decreased reliance on ventilation, and improved health outcomes for COVID-19 patients compared to using dexamethasone at a daily dosage of 6 mg or budesonide respirable solution at a dosage of 1mg twice daily.

Is It Feasible to Perform Infant CPR during Transfer on a Stretcher until Cannulation for Extracorporeal CPR? A Randomization Simulation Study

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) improves infant survival outcomes after cardiac arrest. If not feasible at the place of arrest, victims must be transported to a suitable room to perform ECMO while effective, sustained resuscitation maneuvers are performed. The objective of this simulation study was to compare the quality of resuscitation maneuvers on an infant manikin during simulated transfer on a stretcher (stretcher test) within a hospital versus standard stationary resuscitation maneuvers (control test).

METHODS

A total of 26 nursing students participated in a randomized crossover study. In pairs, the rescuers performed two 2 min tests, consisting of five rescue breaths followed by cycles of 15 compressions and two breaths. The analysis focused on CPR variables (chest compression and ventilation), CPR quality, the rate of perceived exertion and the distance covered.

RESULTS

No differences were observed in the chest compression quality variable (82 ± 10% versus 84 ± 11%, p = 0.15). However, significantly worse values were observed in the test for ventilation quality on the stretcher (18 ± 14%) compared to the control test (28 ± 21%), with a value of p = 0.030. Therefore, the overall CPR quality was worse in the stretcher test (50 ± 9%) than in the control test (56 ± 13%) (p = 0.025).

CONCLUSIONS

Infant CPR performed by nursing students while walking alongside a moving stretcher is possible. However, in this model, the global CPR quality is less due to the low ventilation quality.