Dose optimization of piperacillin/tazobactam, cefepime, and ceftazidime for carbapenem-resistant Pseudomonas aeruginosa isolates in Türkiye

INTRODUCTION

Although CRPA may test susceptible to other β-lactams such as ceftazidime (CAZ), cefepime (FEP), and piperacillin/tazobactam (TZP), reduced potency has been observed. We assessed the adequacy of EUCAST Susceptible (S) or Susceptible Increased Exposure (SIE)/(I) doses for CAZ, FEP, and TZP against CRPA clinical isolates.

METHODS

CRPA isolates were collected from patients at three Turkish hospitals. CAZ, FEP, and TZP MICs were determined using broth microdilution. Monte Carlo simulations were performed to determine the probability of target attainment (PTA) for a free time above the MIC (fT > MIC) targets for various doses of each agent against isolates defined as susceptible. fT > MIC targets were 70% for CAZ or FEP and 50% for TZP. Cumulative fraction of response (CFR) was calculated. Optimal PTA and CFR was 90% target achievement.

RESULTS

The percentages of isolates SIE/I to CAZ, FEP, and TZP were 49,8%, 47%, and 31,8% respectively. Reduced potency was noted with 54,1% of CAZ-S isolates having MICs of 4 or 8 mg/L. Of the FEP and TZP-S isolates, MICs at the breakpoint (8 and 16 mg/L, respectively) were the mode with 45,2 and 53,9% of isolates for each, respectively. At an MIC of 8 mg/L for CAZ, the EUCAST standard dose was insufficient (CFR of 85%). 3 h infusions of EUCAST SIE doses were required for 90% PTA at MIC of 8 mg/L and an optimized CFR of 100%. For FEP, the SIE dose of 2 g q8h 0.5 h infusion of was effective (CFR 96%), utilization of an extended 3 h infusion further optimized the PTA at 8 mg/L (CFR 99%). For TZP, the standard dose of 4.5 q6h administered as a 0.5 h infusion was inadequate (CFR 86%). A standard TZP dose with an extended infusion (4.5 g q8h over 4 h) and the SIE dose 4.5 g q6h 3 h infusion resulted in CFRs > 95%.

CONCLUSION

These data support the EUCAST SIE breakpoints for FEP and TZP. To optimize PTA at the SIE breakpoint for CAZ, prolonged infusion is required.

Damage control surgery in non-traumatic abdominal emergencies: prognostic value of SOFA, APACHEII, and Mannheim peritonitis index

This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50%) were ASA IV. Operative findings leading to DCS included peritonitis (54; 51.9%), intestinal ischemia (39; 37.5%), inability to close the abdomen (8; 7.6%), and bleeding (3; 2.9%). The mortality rate was 75% (78/104). Thirty patients (28.8%) died after DCS; the remainder underwent one (35; 33.6%), two (21; 20.2%); three (8; 7.7%), and four or more (10;9.7%) revision procedures. The median lengths of ICU and hospital stays were 12.5 and 20.5 days, respectively. The median score values were as follows: SOFA: 12 (0-38), APACHE II: 25 (2-47), and MPI: 26 (8-43). Besides ASA classification (p = 0.03), mortality risk was influenced by: age (≤ 65 years vs. > 65 years; p = 0.04), SOFA (≤ 10 vs. > 10; p = 0.03), APACHE II (≤ 25 vs. > 25; p = 0.04), and MPI (≤ 25 vs. > 25; p = 0.003). The SOFA, APACHE II, and MPI scores proved to be valuable tools in the prognostic assessment of patients undergoing DCS in non-traumatic abdominal emergencies.

Cryoablation for the Treatment of Post-Tracheostomy Tracheal Stenosis in Neurological Patients

INTRODUCTION

Post-tracheostomy tracheal stenosis is a clinically relevant late complication of tracheostomy. To date, there is no standardized treatment strategy for post-tracheostomy tracheal stenosis. Contact cryoablation is one of the applicable methods. The aim of the present study was to explore the efficacy and safety of contact cryoablation for the treatment of post-tracheostomy tracheal stenosis.

METHODS

A total of 63 consecutive patients were included in this unicentre, combined retrospective and prospective observational study in an intensive care unit of a German neurological specialist hospital from 30 April 2020 to 21 March 2024. Post-tracheostomy tracheal stenoses were confirmed by tracheoscopy. All eligible patients were primarily treated with contact cryoablation. Primary endpoint was the rate of successful removal of the tracheostomy tube (decannulation) until hospital discharge. Technical success was defined as the absence of an endoscopically relevant residual post-tracheostomy tracheal stenosis, and clinical success was defined as the absence of symptoms, e.g., dyspnoea and stridor, both at discretion of the endoscopist and treating physician.

RESULTS

A total of 78 interventions were performed (median: 1 per patient). Cryoablation was applied in 67% of patients at least once. A total of 70% of patients could be decannulated after treatment. Technical success and clinical success were achieved in 88% and 70% of patients, and in only 5% of patients surgical treatment was performed. No complications were observed.

CONCLUSION

Contact cryoablation appears to be an effective, complication-free, simple, and non-surgical treatment option for patients with post-tracheostomy tracheal stenosis. It could be an excellent option for every patient with suitable stenosis morphology. However, other endoscopic modalities must be available or complementarily used for non-suitable stenosis morphologies.

Association Between Arterial Hyperoxia and Mortality in Pediatric and Adult Patients Undergoing Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

BACKGROUND

In patients receiving extracorporeal membrane oxygenation (ECMO) support, the association between arterial hyperoxia and outcomes is unclear. We performed a systematic review and meta-analysis to determine the association between arterial Po2 (Pao2) and mortality in patients with ECMO.

METHODS

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and registered in International Prospective Register of Systematic Reviews (PROSPERO; CRD42023467361). We systematically searched PubMed and Embase databases up to September 2023 for randomized trials or observational studies that investigated the association between Pao2 and mortality in pediatric and adult patients receiving venovenous ECMO (VV-ECMO), venoarterial ECMO (VA-ECMO), and extracorporeal cardiopulmonary resuscitation (ECPR). The predefined outcome was 28-day mortality. We synthesized the data using a random-effects model, calculating odds ratios (OR) and corresponding 95% confidence intervals (CI).

RESULTS

Thirteen cohort studies (17,766 participants) were included. All studies used categorical Pao2 cutoff, with varying thresholds ranging from ≥100 mm Hg to ≥300 mm Hg. When compared with patients with normoxia, elevated Pao2 levels at all studied thresholds were consistently associated with increased mortality (≥300 mm Hg: OR 1.56, 95% CI, 1.31-1.85, P < .01; ≥200 mm Hg: OR 1.43, 95% CI, 1.10-1.87, P < .01; ≥150 mm Hg: OR 1.51, 95% CI, 1.15-1.98, P < .01; and ≥100 mm Hg: OR 1.44, 95% CI, 1.03-2.02, P = .03). A sensitivity analysis focusing on studies reporting adjusted OR yielded similar results. We observed this association in both adult and pediatric populations.

CONCLUSIONS

In critically ill patients on VV- or VA-ECMO, increased Pao2 values were associated with increased 28-day mortality in ECMO patients. Our results should be interpreted with caution given observational nature of included studies. Further randomized trials are warranted to validate these results.

Piperacillin/Tazobactam Susceptibility Test Interpretive Criteria for Enterobacterales: Recommendations From the United States Committee on Antimicrobial Susceptibility Testing

The in vitro susceptibility testing interpretive criteria (STIC) for piperacillin/tazobactam (TZP) against Enterobacterales were recently updated by the US Food and Drug Administration, Clinical and Laboratory Standards Institute, and European Committee on Antimicrobial Susceptibility Testing. The United States Committee on Antimicrobial Susceptibility Testing (USCAST) also recently reviewed TZP STIC for Enterobacterales and arrived at different STIC for Enterobacterales. Here, we explain our recommendations and rationale behind them. Based on our review of the available data, USCAST does not recommend TZP STIC for certain Enterobacterales species that have a moderate to high likelihood of clinically significant AmpC production (Enterobacter cloacae, Citrobacter freundii, and Klebsiella aerogenes only) or for third-generation cephalosporin-nonsusceptible Enterobacterales. USCAST recommends a TZP susceptibility breakpoint of ≤ 16/4 mg/L for third-generation cephalosporin-susceptible Enterobacterales and only endorses the use of extended infusion TZP regimens for patients with infections due to these pathogens.

In vitro elimination of antimicrobials during ADVanced Organ Support hemodialysis

Background

Acute kidney injury (AKI) requiring continuous renal replacement therapy is common in critically ill patients. The ADVanced Organ Support (ADVOS) system is a novel hemodialysis machine that uses albumin enriched dialysate which allows the removal of protein-bound toxins and drugs. To date, data on antimicrobial removal under ADVOS has not yet been reported.

Methods

An in vitro study was conducted using whole porcine blood and continuous infusions of different antimicrobial agents to investigate the effect of ADVOS on drug exposure. Drugs with varying protein binding, molecular weights and renal clearances, anidulafungin, cefotaxime, daptomycin, fluconazole, ganciclovir, linezolid, meropenem and piperacillin were studied.

Results

All studied drugs were removed during the in vitro ADVOS experiment. Clearance under ADVOS (CLADVOS) for low protein-bound drugs, such as cefotaxime, fluconazole, ganciclovir, linezolid, meropenem and piperacillin ranged from 2.74 to 3.4 L/h at a blood flow of 100 mL/min. With a doubling of flow rate CL for these drugs increased. Although efficiently removed, this effect was not seen for CLADVOS in high protein-bound substances such as daptomycin (1.36 L/h) and anidulafungin (0.84 L/h).

Conclusion

The ADVOS system effectively removed protein-bound and unbound antimicrobials to a significant extent indicating that dose adjustments are required. Further, clinical studies are necessary to comprehensively assess the impact of ADVOS on antimicrobial drug removal. Until clinical data are available, therapeutic drug monitoring should guide antimicrobial dosing under ADVOS.

Non-invasive point-of-care optical technique for continuous in vivo assessment of microcirculatory function: Application to a preclinical model of early sepsis

Increased amplitude of peripheral vasomotion is a potential early marker of sepsis-related microcirculatory impairment; however, previous reports relied on clinically unsuitable invasive techniques. Hyperspectral near-infrared spectroscopy (hsNIRS) and diffuse correlation spectroscopy (DCS) are non-invasive, bedside techniques that can be paired to continuously monitor tissue hemoglobin content (HbT), oxygenation (StO2), and perfusion (rBF) to detect vasomotion as low-frequency microhemodynamic oscillations. While previous studies have primarily focused on the peripheral microcirculation, cerebral injury is also a common occurrence in sepsis and hsNIRS-DCS could be used to assess cerebral microcirculatory function. This work aimed to use a hybrid hsNIRS-DCS system to continuously monitor changes in the peripheral and cerebral microcirculation in a rat model of early sepsis. It was hypothesized that the skeletal muscle would be a more sensitive early indicator of sepsis-related changes in microhemodynamics than the brain. Control animals received saline while the experimental group received fecal slurry to induce sepsis. Subsequently, hsNIRS-DCS measurements were acquired from the skeletal muscle and brain for 6 h. Peripheral rBF rapidly decreased in septic animals, but there were no significant changes in peripheral HbT or StO2, nor cerebral HbT, rBF, or StO2. The power of low-frequency peripheral oscillations in all parameters (i.e., HbT, StO2, and rBF) as well as cerebral HbT oscillations were elevated in septic animals during the final 4 h. These findings suggest that in the early stages of sepsis, while vital organs like the brain are partly protected, changes in peripheral perfusion and vasomotor activity can be detected using hsNIRS-DCS. Future work will apply the technique to ICU patients.

Predicting intra-abdominal candidiasis in elderly septic patients using machine learning based on lymphocyte subtyping: a prospective cohort study

Objective

Intra-abdominal candidiasis (IAC) is difficult to predict in elderly septic patients with intra-abdominal infection (IAI). This study aimed to develop and validate a nomogram based on lymphocyte subtyping and clinical factors for the early and rapid prediction of IAC in elderly septic patients.

Methods

A prospective cohort study of 284 consecutive elderly patients diagnosed with sepsis and IAI was performed. We assessed the clinical characteristics and parameters of lymphocyte subtyping at the onset of IAI. A machine-learning random forest model was used to select important variables, and multivariate logistic regression was used to analyze the factors influencing IAC. A nomogram model was constructed, and the discrimination, calibration, and clinical effectiveness of the model were verified.

Results

According to the results of the random forest and multivariate analyses, gastrointestinal perforation, renal replacement therapy (RRT), T-cell count, CD28+CD8+ T-cell count and CD38+CD8+ T-cell count were independent predictors of IAC. Using the above parameters to establish a nomogram, the area under the curve (AUC) values of the nomogram in the training and testing cohorts were 0.840 (95% CI 0.778-0.902) and 0.783 (95% CI 0.682-0.883), respectively. The AUC in the training cohort was greater than the Candida score [0.840 (95% CI 0.778-0.902) vs. 0.539 (95% CI 0.464-0.615), p< 0.001]. The calibration curve showed good predictive values and observed values of the nomogram; the DCA results showed that the nomogram had high clinical value.

Conclusion

We established a nomogram based on the T-cell count, CD28+CD8+ T-cell count, CD38+CD8+ T-cell count and clinical risk factors that can help clinical physicians quickly rule out IAC or identify elderly patients at greater risk for IAC at the onset of infection.

Clinical Trial Registration

[chictr.org.cn], identifier [ChiCTR2300069020].

Employing artificial intelligence for optimising antibiotic dosages in sepsis on intensive care unit: a study protocol for a prospective observational study (KI.SEP)

INTRODUCTION

In sepsis treatment, achieving and maintaining effective antibiotic therapy is crucial. However, optimal antibiotic dosing faces challenges due to significant variability among patients with sepsis. Therapeutic drug monitoring (TDM), the current gold standard, lacks initial dosage adjustments and global availability. Even with daily TDM, antibiotic serum concentrations (ASCs) often deviate from the therapeutic range. This study addresses these challenges by developing machine learning (ML)-based ASC prediction models capable of handling variable data input and encompassing diverse clinical, laboratory, microbiological and proteomic parameters without the need for daily TDM.

METHODS

This prospective observational study is conducted in a German university hospital intensive care unit. Eligible sepsis patients receive continuous antibiotic therapy with piperacillin/tazobactam (n=100) or meropenem (n=100) within 24 hours. Exclusion criteria include refusal, pregnancy, lactation and severe anaemia (haemoglobin <8 g/dL). Blood samples for TDM are collected from patients, along with clinical and laboratory parameters on days 1-8 and day 30 or on discharge. ML models predicting ASC between day 1 and day 8 serve as primary and key secondary endpoints. We will use the collected data to develop multifaceted ML-based algorithms aimed at optimising antibiotic dosing in sepsis. Our two-way approach involves creating two distinct algorithms: the first focuses on predictive accuracy and generalisability using routine clinical parameters, while the second leverages an extended dataset including a plethora of factors currently insufficiently explored and not available in standard clinical practice but may help to enhance precision. Ultimately, these models are envisioned for integration into clinical decision support systems within patient data management systems, facilitating automated, personalised treatment recommendations for sepsis.

ETHICS AND DISSEMINATION

The study received approval from the Ethics Committee of the Medical Faculty of Ruhr-University Bochum (No. 23-7905). Findings will be disseminated through open-access publication in a peer-reviewed journal and social media channels.

TRIAL REGISTRATION NUMBER

DRKS00032970.

Clinical Efficacy and Safety of Vancomycin Based on Unbound Vancomycin Concentration Monitoring

OBJECTIVE

To monitor total trough concentration (Cmin_total) and unbound trough concentration (Cmin_free) of vancomycin in clinical samples and analyze the factors influencing them, and to assess their correlation with clinical efficacy and acute kidney injury (AKI).

METHODS

Plasma samples were processed by protein precipitation, followed by hollow-fiber centrifugal ultrafiltration to separate unbound vancomycin from plasma. Thereafter, Cmin_total and Cmin_free were determined using high-performance liquid chromatography. Clinical data of patients were collected. Factors affecting vancomycin Cmin_total, Cmin_free, and their correlation with clinical efficacy and nephrotoxicity were investigated.

RESULTS

A total of 146 samples from 105 included patients were collected. Cmin_total and Cmin_free of vancomycin ranged from 0.62 to 56.08 mcg·mL-1 and 0.61-38.51 mcg·mL-1, respectively. Cmin_total and Cmin_free were correlated (r = 0.8899), influenced by basal creatinine and cystatin C. Higher level of Cmin_free (˃8.6 mcg·mL-1) and nephrotoxic drugs concomitant were risk factors of vancomycin-associated AKI (P < 0.05); Cmin_total and Cmin_free thresholds of vancomycin-associated AKI were 15.35 and 6.83 mcg·mL-1, respectively.

CONCLUSIONS

vancomycin Cmin_total and Cmin_free, higher Cmin_total and Cmin_free were correlated and higher concentrations of both may increase the risk of AKI.

Pharmacodynamic target attainment at infection site during treatment of post-neurosurgical ventriculitis caused by carbapenem-resistant klebsiella pneumoniae with ceftazidime-avibactam-based regimens: a case report

A patient developed a post-neurosurgical ventriculitis with carbapenem-resistant Klebsiella pneumoniae and mold, initially treated with ceftazidime/avibactam and voriconazole. A Klebsiella pneumoniae carbapenemase mutation led to therapy adjustment to ceftazidime/avibactam and polymyxin B, achieving cure. Pharmacokinetic/pharmacodynamic analysis highlights effective ceftazidime/avibactam brain penetration and bacterial clearance efficacy.

Prolonged Beta-Lactam Infusions in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess whether beta-lactam extended or continuous beta-lactam infusions (EI/CI) improve clinical outcomes in children with proven or suspected bacterial infections.

STUDY DESIGN

We included observational and interventional studies that compared beta-lactam EI or CI with standard infusions in children less than 18 years old, and reported on mortality, hospital or intensive care unit length of stay, microbiological cure, and/or clinical cure. Data sources included PubMed, Medline, EBM Reviews, EMBASE, and CINAHL and were searched from January 1, 1980, to November 3, 2023. Thirteen studies (2945 patients) were included: 5 randomized control trials and 8 observational studies. Indications for antimicrobial therapies and clinical severity varied, ranging from cystic fibrosis exacerbation to critically ill children with bacteriemia.

RESULTS

EI and CI were not associated with a reduction in mortality in randomized control trials (n = 1464; RR 0.93, 95% CI 0.71, 1.21), but were in observational studies (n = 833; RR 0.43, 95% CI 0.19, 0.96). We found no difference in hospital length of stay. Results for clinical and microbiological cures were heterogeneous and reported as narrative review. The included studies were highly heterogeneous, limiting the strength of our findings. The lack of shared definitions for clinical and microbiological cure outcomes precluded analysis.

CONCLUSIONS

EI and CI were not consistently associated with reduced mortality or length of stay in children. Results were conflicting regarding clinical and microbiological cures. More well-designed studies targeting high-risk populations are necessary to determine the efficacy of these alternative dosing strategies.

Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

A review of antimicrobial stability testing guidance for outpatient parenteral antimicrobial therapy programmes: is it time for global harmonization of testing frameworks?

Antimicrobial stability is an important consideration for treatment planning and service delivery in outpatient parenteral antimicrobial therapy (OPAT) programmes. Regulation of stability assessment varies by region, and conflicting guidance and standards exist. This leads to disparity of equity in access and limits availability of certain antimicrobials for managing infections in the outpatient setting. This review discusses the degree to which the international regulatory bodies have reached consensus on the regulation of antimicrobial stability testing, specifically for OPAT, and describes the variation in antimicrobial recommendations across regulatory bodies. The three major findings in this review are (i) variation in antimicrobial stability testing guidance, particularly in relation to temperature; (ii) lack of regulatory guidance, specifically in that some regions did not have OPAT guidelines; and (iii) only the UK's NHS has provided non-regulatory OPAT-specific advice on antimicrobial stability testing. In conclusion, harmonization of antimicrobial stability testing to form a global OPAT-specific regulatory framework, particularly considering 'areas of variation' amongst current guidance, is required. We call for the development of a global OPAT antimicrobial stability testing framework with consensus from accepted antimicrobial stability criteria, expert opinion and pharmacopoeial best practice.

A retrospective cohort analysis of factors influencing continuous antibiotic therapy with ampicillin

AIMS

There are limited data on ampicillin/sulbactam, both for continuous infusion and for use in critically ill patients. We aimed to identify factors that help predict ampicillin plasma levels during continuous antibiotic therapy in intensive care patients.

MAIN METHODS

We retrospectively reviewed and retrieved a large dataset of patients who received continuous ampicillin infusion with therapeutic drug monitoring between 2015 and 2022. Patients initially received standard dosing (single shot of 2/1 g followed by continuous infusion of 6/3 g ampicillin/sulbactam per day), which was then adjusted based on the results of regular therapeutic drug monitoring and according to a target range of 30-60 mg/l (equivalent to four to eight times the minimum inhibitory concentration of ampicillin for Enterobacterales).

MAIN RESULTS

466 measurements from 225 patients (152 male, mean age 61 years) were analyzed. Initial measurements of ampicillin plasma levels were below the predefined optimal therapeutic range in 50 %, within the range in 30 % and above the range in 20 %. Target attainment increased to 70 % by the 4th measurement. There was a significant negative correlation between ampicillin plasma levels and estimated glomerular filtration rate (eGFR) (r = -0.74; p < 0.001) and, to a lesser extent, with height (r = -0.31; p < 0.001). Based on multiple linear regression, eGFR and body weight or height were the factors accounting for 63 % of the variability in the data.

SIGNIFICANCE

To optimise target achievement, ampicillin dosing in critically ill patients requires a personalized approach based on renal function. Importantly, patients with normal or augmented eGFR require higher standard doses of ampicillin/sulbactam.

Time to positivity of Klebsiella pneumoniae in blood cultures as prognostic marker in patients with intra-abdominal infection: A retrospective study

Klebsiella pneumoniae is a common causative pathogen of intra-abdominal infection with concomitant bacteraemia, leading to a significant mortality risk. The time to positivity (TTP) of blood culture is postulated to be a prognostic factor in bacteraemia caused by other species. Therefore, this study aimed to investigate the prognostic value of TTP in these patients. The single-centred, retrospective, observational cohort study was conducted between 1 July 2016 and 30 June 2021. All adult emergency department patients with diagnosis of intra-abdominal infection and underwent blood culture collection which yield K. pneumoniae during this period were enrolled. A total of 196 patients were included in the study. The overall 30-day mortality rate was 12.2% (24/196), and the median TTP of the studied cohort was 12.3 h (10.5-15.8 h). TTP revealed a moderate 30-day mortality discriminative ability (area under the curve 0.73, p < 0.001). Compared with the late TTP group (>12 h, N = 109), patients in the early TTP (≤12 h, N = 87) group had a significantly higher risk of 30-day morality (21.8% vs. 4.6%, p < 0.01) and other adverse outcomes. Furthermore, TTP (odds ratio [OR] = 0.79, p = 0.02), Pitt bacteraemia score (OR = 1.30, p = 0.03), and implementation of source control (OR = 0.06, p < 0.01) were identified as independent factors related to 30-day mortality risk in patients with intra-abdominal infection and K. pneumoniae bacteraemia. Therefore, physicians can use TTP for prognosis stratification in these patients.

Left Atrial Strain in Omicron-Type COVID-19 Patients

Background

Information about left atrial (LA) 2-dimensional (2D) strain parameters in patients with the Omicron variant of COVID-19 is limited. The aim of this study is to evaluate LA strain (LAS) in COVID-19 patients with the Omicron variant and compare it to that of propensity-matched patients with the wild-type (WT) variant.

Methods

A total of 148 consecutive patients who were hospitalized with Omicron COVID-19 underwent an echocardiographic evaluation within the first day after hospital admission and were compared to propensity-matched patients (1:1) with the WT variant. LA 2D speckle tracking echocardiography parameters included the following: LAS, reservoir (LASr); LAS, conduit (LAScd); LAS, contraction (LASct); and LASr to the ratio between early mitral inflow velocity/mitral annular early diastolic velocity (E/e'). The values for the parameters that occurred during acute Omicron-type infection were compared with those found on historic examinations in 36 patients.

Results

Compared to the matched WT cohort, patients with acute Omicron-type infection had similar LASr (31.3% ± 13.3% vs 33.0% ± 14.2%), LAScd (-18.7% ± 9.8% vs -18.6% ± 10.8%), and LASct (-12.5% ± 8.6% vs -13.6% ± 8.2%) values (P > 0.2 for all), but a higher E/e' ratio (11.8 ± 6 vs 10.1 ± 7; P = 0.03). Surprisingly, LASr (31.9% ± 13.7% vs 22.6% ± 13.9%; P = 0.04) and LAScd (-18.7% ± 9.7% vs -10.7% ± 6.6%; P < 0.001) improved in patients during acute infection. LASr, LAScd, and LASr/(E/e') were significantly associated with an increased risk of either in-hospital mortality, need for mechanical ventilation, or the combined event.

Conclusions

In hospitalized patients with an Omicron COVID-19 infection, LAS parameters are similar to those of matched patients with WT variant and are associated with mortality and respiratory deterioration. These abnormalities were recorded previously in the 36 patients with historical echocardiograms, suggesting that they are related to background cardiac disease.

Physiologically-based pharmacokinetic modelling in sepsis: A tool to elucidate how pathophysiology affects meropenem pharmacokinetics

OBJECTIVES

Applying physiologically-based pharmacokinetic (PBPK) modelling in sepsis could help to better understand how PK changes are influenced by drug- and patient-related factors. We aimed to elucidate the influence of sepsis pathophysiology on the PK of meropenem by applying PBPK modelling.

METHODS

A whole-body meropenem PBPK model was developed and evaluated in healthy individuals, and renally impaired non-septic patients. Sepsis-induced physiological changes in body composition, organ blood flow, kidney function, albumin, and haematocrit were implemented according to a previously proposed PBPK sepsis model. Model performance was evaluated, and a local sensitivity analysis was conducted.

RESULTS

The model-predicted PK metrics (AUC, Cmax, CL, Vss) were within 1.33-fold-error margin of published data for 87.5% of the simulated profiles in healthy individuals. In sepsis, the model provided good predictions for literature-digitised average plasma and tissue exposure data, where the model-predicted AUC was within 1.33-fold-error margin for 9 out 11 simulated study profiles. Furthermore, the model was applied to individual plasma concentration data from 52 septic patients, where the model-predicted AUC, Cmax, and CL had a fold-error ratio range of 0.98-1.12, with alignment of the predicted and observed variability. For Vss, the fold-error ratio was 0.81, and the model underpredicted the population variability. CL was sensitive to renal plasma clearance, and kidney volume, whereas Vss was sensitive to the unbound fraction, organ volume fraction of the interstitial compartment, and the organ volume.

CONCLUSIONS

These findings may be extended to more diverse drug types and support a more mechanistic understanding of the effect of sepsis on drug exposure.

Pharmacokinetic Factors Associated With Early Meropenem Target Attainment in Pediatric Severe Sepsis

OBJECTIVES

To determine the frequency of early meropenem concentration target attainment (TA) in critically ill children with severe sepsis; to explore clinical, therapeutic, and pharmacokinetic factors associated with TA; and to assess how fluid resuscitation and volume status relate to early TA.

DESIGN

Retrospective analysis of prospective observational cohort study.

SETTING

PICU in a single academic quaternary care children's hospital.

PATIENTS

Twenty-nine patients starting meropenem for severe sepsis (characterized as need for positive pressure ventilation, vasopressors, or ≥ 40 mL/kg bolused fluid), of which 17 were newly escalated to PICU level care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Concentration-time profiles were analyzed using modeling software employing opportunistic sampling, Bayesian estimation, and a population pharmacokinetic model. Time above four times minimum inhibitory concentration (T > 4×MIC), using the susceptibility breakpoint of 1 µg/mL, was determined for each patient over the first 24 hours of meropenem therapy, as well as individual clearance and volume of distribution (Vd) estimates. Twenty-one of 29 patients met a target of 40%T > MIC 4 μg/mL. Reaching TA, vs. not, was associated with lower meropenem clearance. We failed to identify a difference in Vd or an association between the TA group and age, weight, creatinine-based estimated glomerular filtration rate (eGFR), or the amount of fluid administered. eGFR was, however, negatively correlated with overall T > MIC.

CONCLUSIONS

Eight of 29 pediatric patients with early severe sepsis did not meet the selected TA threshold within the first 24 hours of meropenem therapy. Higher clearance was associated with failure to meet targets. Identifying patients likely to have higher meropenem clearance could help with dosing regimens.

Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association

Cardiac arrhythmias are commonly noted in patients during infections with and recovery from COVID-19. Arrhythmic manifestations span the spectrum of innocuous and benign to life-threatening and deadly. Various pathophysiological mechanisms have been proposed. Debate continues on the impact of incident and exacerbated arrhythmias on the acute and chronic (recovery) phase of the illness. COVID-19 and COVID-19 vaccine-associated myocardial inflammation and autonomic disruption remain concerns. As the pandemic has transformed to an endemic, with discovery of new SARS-CoV-2 variants, updated vaccines, and potent antiviral drugs, vigilance for COVID-19-associated arrhythmic and dysautonomic manifestations remains. The objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology, pathophysiology, clinical presentation, and management of cardiac arrhythmias and autonomic dysfunction in patients infected with and recovering from COVID-19 and to provide evidence-based guidance. The writing committee's consensus on implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.

Treatment of Invasive Pulmonary Aspergillosis and Preventive and Empirical Therapy for Invasive Candidiasis in Adult Pulmonary and Critical Care Patients. An Official American Thoracic Society Clinical Practice Guideline

BACKGROUND

The incidence of invasive fungal infections is increasing in immune-competent and immune-compromised patients. An examination of the recent literature related to the treatment of fungal infections was performed to address two clinical questions. First, in patients with proven or probable invasive pulmonary aspergillosis, should combination therapy with a mold-active triazole plus echinocandin be administered vs. mold-active triazole monotherapy? Second, in critically ill patients at risk for invasive candidiasis who are non-neutropenic and are not transplant recipients, should systemic antifungal agents be administered either as prophylaxis or as empiric therapy?

METHODS

A multidisciplinary panel reviewed the available data concerning the two questions. The evidence was evaluated, and recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

A conditional recommendation was made for patients with proven or probable invasive pulmonary aspergillosis to receive either initial combination therapy with a mold-active triazole plus an echinocandin or initial mold-active triazole monotherapy based on low-quality evidence. Further, a conditional weak recommendation was made against routine administration of prophylactic or empiric antifungal agents targeting Candida species for critically ill patients without neutropenia or a history of transplant based on low-quality evidence.

CONCLUSIONS

The recommendations presented in these Guidelines are the result of an analysis of currently available evidence. Additional research and new clinical data will prompt an update in the future.

A nomogram prediction model for the risk of intra-abdominal infection after endoscopic full-thick resection of gastric submucosal tumors

Background

This study aimed to investigate the risk factors for complication of intra-abdominal infection (IAI) after endoscopic full-thickness resection of gastric submucosal tumors (GSMT) and to establish a nomogram prediction model for the occurrence of IAI.

Methods

Clinical data of patients with GSMT who underwent endoscopic full-thick resection (EFR) from January 2018 to July 2023 were retrospectively analyzed. The patients were divided into IAI and non-IAI groups according to whether IAI occurred during postoperative hospitalization. Univariate and multivariate logistic regression analyses were performed on the relevant clinical data of patients in the two groups to screen the independent influencing factors for the occurrence of IAI. The nomogram model was constructed based on the independent influencing factors. Model discrimination was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The consistency of model-predicted risk with actual risk was evaluated using the Hosmer-Lemeshow goodness-of-fit test. The clinical performance of the nomogram model was evaluated using decision curve analysis.

Results

A total of 240 GSMT patients who underwent EFR procedures were finally included in this study, including 14 patients (5.83 %) in the IAI group and 226 patients in the non-IAI group. Univariate and multivariate logistic regression analyses showed that age (OR = 1.283, 95 % CI = 1.029-1.600), preoperative albumin (OR = 0.575, 95 % CI = 0.395-0.837), duration of operation (OR = 1.222, 95 % CI = 1.060-1.409), and hospitalization time (OR = 4.089, 95 % CI = 1.190-14.043) were independent influencing factors for the incidence of IAI in GSMT patients undergoing EFR surgery (P < 0.05). A Nomogram model was established based on the above factors. The Hosmer ⁃ Lemeshow test value of this model was 4.230 (P = 0.836). The AUC value of the predictive model was 0.992 (95 % CI: 0.983 to 1.000), with a C-index of 0.992 (95 % CI: 0.983-1.000), indicating that the nomogram model had good accuracy and discrimination. Decision curve analysis showed that the nomogram model had a good predictive performance.

Conclusions

Age, preoperative albumin, duration of operation, and hospitalization time were independent influences on the occurrence of IAI in GSMT patients undergoing EFR surgery. A nomogram model based on these factors had a high predictive efficacy and may provide a guiding intervention for the prevention of postoperative IAI in GSMT patients.

Microcirculation: Current Perspective in Diagnostics, Imaging, and Clinical Applications

This review discusses the pivotal role of microcirculation in maintaining tissue oxygenation and waste removal and highlights its significance in various pathological conditions. It delves into the cellular mechanisms underlying hemodynamic coherence, elucidating the roles of the endothelium, glycocalyx, and erythrocytes in sustaining microcirculatory integrity. Furthermore, the review gives comprehensive information about microcirculatory changes observed in cardiac surgery, sepsis, shock, and COVID-19 disease. Through comprehensive exploration, the review underscores the intricate relationship between microcirculation, disease states, and clinical outcomes, emphasizing the importance of understanding and monitoring microvascular dynamics in critical care settings.

Changes in central venous-to-arterial PCO2 difference and central venous oxygen saturation as markers to define fluid responsiveness in critically ill patients: a pot-hoc analysis of a multi-center prospective study

BACKGROUND

The main aim of the study whether changes in central venous-to-arterial CO2 difference (ΔP(v-a)CO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness (FR) in sedated and mechanically ventilated septic patients. We also sought to determine whether the degree of FR was related to baseline ScvO2 and P(v-a)CO2 levels.

METHODS

This was a post-hoc analysis of a multicenter prospective study. We included 205 mechanically ventilated patients with acute circulatory failure. Cardiac index (CI), P(v-a)CO2, ScvO2, and other hemodynamic variables were measured before and after VE. A VE-induced increase in CI > 15% defined fluid responders. Areas under the receiver operating characteristic curves (AUCs) and the gray zones were determined for ΔP(v-a)CO2 and ΔScvO2.

RESULTS

One hundred fifteen patients (56.1%) were classified as fluid responders. The AUCs for ΔP(v-a)CO2 and ΔScvO2 to define FR were 0.831 (95% CI 0.772-0.880) (p < 0.001) and 0.801 (95% CI 0.739-0.853) (p < 0.001), respectively. ΔP(v-a)CO2 ≤ 2.1 mmHg and ΔScvO2 ≥ 3.4% after VE allowed the categorization between responders and non-responders with positive predictive values of 90% and 86% and negative predictive values of 58% and 64%, respectively. The gray zones for ΔP(v-a)CO2 (- 2 to 0 mmHg) and ΔScvO2 (- 1 to 5%) included 22% and 40.5% of patients, respectively. ΔP(v-a)CO2 and ΔScvO2 were independently associated with FR in multivariable analysis. No significant relationships were found between pre-infusion ScvO2 and P(v-a)CO2 levels and FR.

CONCLUSION

In mechanically critically ill patients, ΔP(v-a)CO2 and ΔScvO2 are reliable parameters to define FR and can be used in the absence of CI measurement. The response to VE was independent of baseline ScvO2 and P(v-a)CO2 levels. Clinical trial registration The study was registered in the ClinicalTrials.gov registry: NCT03225378, date: July 20, 2017.

Left Atrial Strain: State of the Art and Clinical Implications

The assessment of left atrial strain (LAS) has emerged as an essential component in the evaluation of cardiac function, especially in pathologies such as heart failure and atrial fibrillation. This narrative review aims to outline the available methods for assessing LAS with a major emphasis on speckle-tracking echocardiography techniques. Other imaging modalities, including cardiac magnetic resonance and cardiac computed tomography, also provide important information on LA dynamics but have disadvantages with respect to cost and availability. The current narrative review underlines basic concepts such as the accurate assessment of LAS and discusses the clinical relevance of LAS by pointing out its significant diagnostic and prognostic role in several cardiovascular conditions. The aim of this article is to discuss the current integration of LAS into clinical practice with a view to further improving patient management and treatment strategies.

Changes in portal pulsatility index induced by a fluid challenge in patients with haemodynamic instability and systemic venous congestion: a prospective cohort study

BACKGROUND

It is uncertain whether fluid administration can improve patients with systemic venous congestion and haemodynamic instability. This study aimed to describe the changes in systemic venous congestion and peripheral perfusion parameters induced by a fluid challenge in these patients, and to analyse the influence of the fluid responsiveness status on these changes.

METHODS

The study is a single-centre prospective cohort study of 36 critically ill ICU patients with haemodynamic instability and a maximum vena cava diameter ≥ 20 mm. Changes in cardiac index during a fluid challenge (4 mL/kg of lactated Ringer's solution during 5 min) assessed by pulse contour analysis, central venous pressure, ultrasound systemic congestion parameters (portal venous flow pulsatility index, supra hepatic and intrarenal venous Doppler), and peripheral perfusion parameters (capillary refill time and peripheral perfusion index) were assessed in the overall population. All these data were compared between patients presenting a cardiac index increase > 10% during the fluid challenge (fluid responders) and the others (fluid non-responders).

RESULTS

Twenty-eight (78%) patients were admitted for postoperative care following cardiac surgery; their mean ± SD left ventricular ejection fraction was 42 ± 9% and right ventricular dysfunction was found in at least 61% of the patients. The mean ± SD SOFA score was 9 ± 3. Thirteen (36%) patients were fluid responders. The fluid challenge administration induced a significant increase in portal pulsatility index, VExUS score, and central venous pressure without significant difference of these changes between fluid responders and non-responders. No significant change in perfusion parameters was observed.

CONCLUSION

Fluid administration in patients with haemodynamic instability and systemic venous congestion worsens venous congestion regardless of the fluid responsiveness status, without improving perfusion parameters.

SIL-IS LC-ESI-MS/MS method for simultaneous quick detection of amoxicillin and clavulanic acid in human plasma: Development, validation and its application to a pharmacokinetics study

A liquid chromatography electrospray ionization tandem mass spectrometry method with amoxicillin-d4 as the stable isotope-labeled internal standard for simultaneous quick detection of amoxicillin and clavulanic acid in human plasma was developed and validated. Chromatographic separations were performed on a Hedera ODS-2 column (2.1 × 150 mm, 5 μm). The mobile phases for gradient elution were aqueous solution containing 0.2% acetic acid (AA) (mobile phase A) together with organic phase solution (acetonitrile and methanol mixed solution, mobile phase B). Mass spectrometry was performed using negative electrospray ionization in multiple reaction monitoring mode. The target fragment ion pairs of amoxicillin, clavulanic acid and amoxicillin-d4 were m/z 364.1 → 223.1, 198.1 → 135.9 and 368.1 → 227.1, respectively. The linear ranges of this method were 40-5,000 ng/ml for amoxicillin and 30-2,500 ng/ml for clavulanic acid, with coefficient of determination > 0.9900. This method validation included selectivity, standard curve, lower limit of quantitation, accuracy, precision, recovery, matrix effect (hemolytic matrix and hyperlipidemic matrix), carryover, stability, dilution reliability and incurred sample reanalysis study. A successful application of this method was realized in a pharmacokinetic study after administration of amoxicillin-clavulanic acid potassium granules.

Examining efficacy and safety of ethyl acetate extract from Allium hirtifolium as complementary therapy in COVID-19: A randomized, multicenter, controlled clinical trial

Objective

Given the apparent life-threatening nature of COVID-19, finding an effective treatment is under investigation.

Materials and Methods

We assessed effect of shallomin oral syrup (co IranAmin®) as a complementary treatment to improve the clinical outcomes in COVID-19 patients. Patients in the control group received the approved treatment protocol (lopinavir/ritonavir), while those in the intervention group were treated with the oral syrup shallomin in addition to the approved treatment. Clinical status of treated patients was recorded and compared.

Results

There were meaningful differences between the two groups regarding shortened length of hospital stay and the recovery time for cough, myalgia, sore throat, and shortness of breath. No side effect occurred in the intervention group compared to the control group in terms of biochemical and hematological factors.

Conclusion

It seems that the treatment with shallomin syrup showed remarkable contribution to the recovery of COVID-19 induced symptoms in the patients under lopinavir/ritonavir therapy.

Intra-abdominal infection and sepsis in immunocompromised intensive care unit patients: Disease expression, microbial aetiology, and clinical outcomes

We compared epidemiology of intra-abdominal infection (IAI) between immunocompromised and non-immunocompromised ICU patients and identified risk factors for mortality. We performed a secondary analysis on the "AbSeS" database, a prospective, observational study with IAI patients from 309 ICUs in 42 countries. Immunocompromised status was defined as either neutropenia or prolonged corticosteroids use, chemotherapy or radiotherapy in the past year, bone marrow or solid organ transplantation, congenital immunodeficiency, or immunosuppressive drugs use. Mortality was defined as ICU mortality at any time or 28-day mortality for those discharged earlier. Associations with mortality were assessed by logistic regression. The cohort included 2589 patients of which 239 immunocompromised (9.2 %), most with secondary peritonitis. Among immunocompromised patients, biliary tract infections were less frequent, typhlitis more frequent, and IAIs were more frequently healthcare-associated or early-onset hospital-acquired compared with immunocompetent patients. No difference existed in grade of anatomical disruption, disease severity, organ failure, pathogens, and resistance patterns. Septic shock was significantly more frequent in the immunocompromised population. Mortality was similar in both groups (31.1% vs. 28.9 %; p = 0.468). Immunocompromise was not a risk factor for mortality (OR 0.98, 95 % CI 0.66-1.43). Independent risk factors for mortality among immunocompromised patients included septic shock at presentation (OR 6.64, 95 % CI 1.27-55.72), and unsuccessful source control with persistent inflammation (OR 5.48, 95 % CI 2.29-12.57). In immunocompromised ICU patients with IAI, short-term mortality was similar to immunocompetent patients, despite the former presented more frequently with septic shock, and septic shock and persistent inflammation after source control were independent risk factors for death.

[Bedside imaging]

Sonography, in particular echocardiography, is essential in the assessment of volume status and hemodynamics in critically ill patients. Examination of the left ventricle, in addition to assessing ventricular function, provides valuable information, including the "kissing papillary muscle sign," which may indicate fluid responsiveness. Examination of the right ventricle is also important because it is sensitive to both volume and pressure overload. Assessment of diastolic function and measurement of inferior vena cava width and variability provide clues to left and right ventricular preload, respectively. Measurement of stroke volume and cardiac output allows further assessment of hemodynamics and also permits determination of stroke volume variability.

Challenging management dogma where evidence is non-existent, weak, or outdated: part II

Many dogmas influence daily clinical practice, and critical care medicine is no exception. We previously highlighted the weak, questionable, and often contrary evidence base underpinning four established medical managements-loop diuretics for acute heart failure, routine use of heparin thromboprophylaxis, rate of sodium correction for hyponatremia, and 'every hour counts' for treating bacterial meningitis. We now provide four further examples in this "Dogma II" piece (a week's course of antibiotics, diabetic ketoacidosis algorithms, sodium bicarbonate to improve ventricular contractility during severe metabolic acidosis, and phosphate replacement for hypophosphatemia) where routine practice warrants re-appraisal.

Development and clinical utility of an ultra performance liquid chromatography - tandem mass spectrometry assay for monitoring omadacycline and tigecycline in severe bacterial infections

Objective

We aimed to develop a rapid, simple, and precise ultra performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) technique for simultaneous measurement of omadacycline (OMA) and tigecycline (TGC) in the bloodstream of individuals suffering from serious bacterial infections.

Methods

All analytes were extracted using a 0.2 % formic acid-water dilution and acetonitrile plasma protein precipitation. The quantification was performed by electrospray ionization-triple quadrupole mass spectrometry with selected reaction monitoring and positive ion mode detection. Tetracycline was used as an internal standard in this experiment, with the mobile phase composed of water (with 0.1 % formic acid) and acetonitrile (using gradient elution) flowing at a rate of 0.35 ml/min, and the column temperature set at 30 °C. Each individual analysis was completed in under 3.5 min.

Results

The method was validated based on FDA recommendations, including the assessment of extraction recovery (92.65-101.72 %) and matrix effects (86.22-91.12 %). The standard curve ranges for both OMA and TGC are 0.025 µg/mL to 2.5 µg/mL. The plasma samples were found to be consistent after undergoing three rounds of freezing and thawing at room temperature for 24 h, being placed in an automated sample injector for 24 h, and then frozen for 45 days. Clinical cases were used to demonstrate the application of the therapeutic drug monitoring (TDM) assay, showing how an analytical test can quickly provide information on antibiotic levels in patients and impact their treatment.

Conclusion

Multiplex UPLC-MS/MS assays for the simultaneous measurement of plasma OMA and TGC concentrations are the ideal choice for clinically TDM applications.

Tele-education in point-of-care ultrasound training

BACKGROUND

Traditionally, ultrasound skills have been taught through a one-on-one approach, where instructors physically guide learners' hands at the bedside or in the workshop. However, this method is frequently challenged by scheduling and cost limitations. Our objective was to create a tele-education model for point-of-care ultrasound training and evaluate its effectiveness and its impact on learners' perceived workload compared to conventional education and self-directed learning methods.

METHODS

We conducted a 3-arm randomized trial, comparing tele-education (TE), conventional education (CE) and self-directed learning (SL) methods. All subjects underwent online didactic lectures prior to a hands-on ultrasound workshop. The TE group utilized an ultrasound machine equipped with a speakerphone, a webcam for direct visualization of learner's hand maneuvers, and an analog-to-video converter for the real-time streaming of ultrasound images. This configuration enabled remote instructors to provide immediate verbal feedback to learners. In contrast, the CE group received in-person coaching, while the SL group had no instructors present. Following the coaching session, subjects completed a scenario-based skill test and a survey on the National Aeronautics and Space Administration task load index (NASA-TLX) to measure their ultrasound competency and perceived workload, respectively.

RESULTS

Twenty-seven ultrasound novices were randomly allocated into 3 groups. The median skill test score of TE, CE, and SL was 22 [interquartile range (IQR): 18-28], 24 [IQR: 21-31], and 16 [IQR: 15-18], respectively (p < 0.01). Pairwise comparisons of median test scores of 3 groups demonstrated a statistical significance in comparisons of TE vs. SL (22 vs. 16, p = 0.01) and CE vs. SL (24 vs. 16, p < 0.01), but not in TE vs. CE (22 vs. 24, p = 0.56). There was no statistical significance observed in the median NASA-TLX scores among the 3 groups; 54 [IQR:47-61] in TE, 57 [IQR:22-64] in CE, and 66 [IQR: 66-72] in SL (p = 0.05).

CONCLUSIONS

Our tele-education model was more effective than self-directed learning. There was no statistically significant difference in effectiveness between the tele-education and the conventional education groups. Importantly, tele-education did not impose a significantly higher workload on learners compared to conventional education or self-directed learning. Tele-education has a substantial potential as an alternative to conventional ultrasound training.

Hemodynamic monitoring during weaning from mechanical ventilation in critically ill pediatric patients: a prospective observational study

BACKGROUND

Cardiovascular dysfunction is a significant factor contributing to weaning failure in mechanically ventilated children. Understanding the cardiopulmonary pathophysiological changes that occur during weaning is a prerequisite for the early recognition of weaning failure of cardiovascular origin. This study aimed to assess the effect of weaning trials on central hemodynamics and to identify the indices predictive of cardiac-related weaning failure.

METHODS

This prospective observational study was conducted in the Pediatric Intensive Care Unit (PICU) and included mechanically ventilated patients aged between 2 and 30 months who were on minimal ventilatory settings and ready for weaning. Patients who were hemodynamically unstable, diagnosed with neuromuscular diseases, or diagnosed with cardiac diseases were excluded. Hemodynamic parameters were evaluated during weaning from ventilation via echocardiography and noninvasive cardiometry during pressure support (PS) ventilation and at the end of the spontaneous breathing trial (SBT).

RESULTS

The study included 50 patients, comprising 30 males (60%) and 20 females (40%) with ages ranging from 2 to 30 months. Echocardiography revealed a significant increase in the cardiac index (CI), tricuspid annular plane systolic excursion (TAPSE), and the E/A ratio at the end of SBT. Moreover, right ventricular systolic pressure (RVSP) significantly decreased. Noninvasive cardiometry revealed a significant increase in the index of contractility (ICON) and CI at the end of SBT (p-value = 0.023 and < 0.001, respectively). Of the 12 (25%) patients who failed their first extubation trial, they exhibited a significantly lower CI and TAPSE (p values = 0.001 and 0.001, respectively).

CONCLUSION

This study identified that weaning from mechanical ventilation in children is associated with hemodynamic changes, which can impact weaning success and reveal potential ventricular dysfunction. Bedside echocardiography was found to detect cardiac dysfunctions during weaning, and noninvasive cardiometry was considered a reliable tool that supports echocardiography for detecting changing trends in CI in PICUs. However, accurate values should be confirmed by echocardiography.

Effect of clustered nursing on liver function indexes, nutrition, and emotional status of patients with severe liver failure

Liver failure is a metabolic disorder caused by a variety of mixed factors. For such diseases, adopting cluster care can effectively improve the relevant symptoms of patients. To explore the nursing effect of nutritional nursing combined with clustered nursing for patients with severe liver failure. A total of 129 patients with severe liver failure were selected as retrospective study subjects. Nine cases were due to an end event, such as death. The other patients were divided into control group and observation group according to different nursing methods. Among them, the control group adopted nutrition nursing, and the observation group implemented cluster nursing on this basis. The differences of liver function, anxiety and depression score, gastrointestinal recovery, nutritional status, and sleep quality were compared between the 2 groups before and after nursing. After nursing, the total bilirubin, albumin, and aspartate aminotransferase of the observation group were significantly higher than those of the control group (P < .05). The nursing staff used Self-Rating Anxiety Scale and Self-Rating Depression Scale of the observation group, which were slightly lower than those of the control group. The difference was statistically significant after testing (P < .05). After nursing, the observation group's upper arm circumference, brachial tri-scalp fold thickness, and hemoglobin were better than those of the control group. Statistics showed that the difference was statistically significant (P < .05). The depth of sleep, time to fall asleep, number of awakenings, time to fall asleep after awakening, overall sleep quality, and intensive care unit environmental noise intensity in the Richards-Campbell Sleep Questionnaire sleep scale after nursing in the 2 groups were significantly higher than those before nursing, and the scores of the observation group were significantly lower than those in the observation group. In the control group, this difference was statistically significant (P < .05). Nutritional nursing combined with clustered nursing can effectively promote the recovery of gastrointestinal function in patients with severe liver failure.

Incidence, predictability, and outcomes of systemic venous congestion following a fluid challenge in initially fluid-tolerant preload-responders after cardiac surgery: a pilot trial

BACKGROUND

Fluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes.

METHODS

This single-center, prospective, observational study (May 2023-July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer's Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS).

RESULTS

45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001).

CONCLUSION

Post-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications.

TRIAL REGISTRATION

NCT06440772. Registered 30 May 2024. Retrospectively registered.

Echocardiographic Assessment of Left Atrial Mechanics in Patients with Atrial Fibrillation Undergoing Electrical Cardioversion: A Systematic Review

Background: To date, only a few studies have evaluated left atrial (LA) mechanics in patients with atrial fibrillation (AF) scheduled for electrical cardioversion (ECV). The present systematic review has been primarily designed to summarize the main findings of these studies and to examine the overall effect of AF on left atrial reservoir strain (LASr) in patients undergoing ECV. Methods: All the echocardiographic studies evaluating the effect of AF on LA mechanics in patients scheduled for ECV, selected from the PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full texts of 12 studies with 880 AF patients were analyzed. The pooled ECV success rate was 91.5% (range 65.8-100%). Over a median follow-up of 5.4 months (range 0.3-12 months), 35.2% of the patients (range 5-68.8%) experienced AF recurrence. At baseline, the average LASr was 11.4% (range 6.2-17.7%). A reduced LASr before ECV was strongly correlated with reduced left atrial appendage (LAA) flow velocities and/or thrombosis. The main independent predictors of cardioversion failure were impaired LASr and previous AF history. A severe LASr deterioration was independently correlated with AF recurrence after ECV. The other independent predictors of AR relapses were LA asynchrony, reduced difference between post- and pre-ECV LASr, and reduced right atrial reservoir strain. Conclusions: LASr assessment before ECV may provide useful prognostic information about AF relapses and improve the refinement of the thromboembolic risk of AF patients scheduled for ECV.

Advances in the application of ultrasonographic parameters for fluid management in obstetric anesthesia

Ultrasound provides a valuable non-invasive approach for fluid management in obstetric anesthesia. Ultrasonographic parameters assist anesthesiologists to effectively assess the fluid status of parturients and reduce related complications. In addition to conventional parameters, which have been widely validated in clinical practice, we provide new insights into arterial parameters such as peak velocity, velocity-time integral, corrected flow time, and vein-related parameters, including the internal jugular vein and its collapsibility index, the inferior vena cava and its collapsibility index, as well as subclavian vein and its collapsibility index. These parameters can potentially enhance fluid management in obstetric anesthesia.

Quantitative Evaluation of Microcirculatory Alterations in Patients with COVID-19 and Bacterial Septic Shock through Remote Photoplethysmography and Automated Capillary Refill Time Analysis

Background and Objectives: Sepsis, a leading global health challenge, accounts for around 20% of deaths worldwide. The complexity of sepsis, especially the difference between bacterial and viral etiologies, requires an effective assessment of microcirculation during resuscitation. This study aimed to evaluate the impact of infusion therapy on microcirculation in patients with sepsis, focusing on bacterial- and COVID-19-associated sepsis using remote photoplethysmography (rPPG) and the automated capillary refill time (aCRT). Materials and Methods: This single-center prospective study was conducted in the ICU of Pauls Stradins Clinical University Hospital, including 20 patients with sepsis/septic shock. The patients were selected based on hemodynamic instability and divided into COVID-19 and Bacterial Septic Shock groups. Fluid responsiveness was assessed using the Passive Leg Raising Test (PLRT). Systemic hemodynamics and microcirculation were monitored through MAP CRT, rPPG, and serum lactate levels. Statistical analyses compared responses within and between the groups across different stages of the protocol. Results: The Bacterial group exhibited higher initial serum lactate levels and more pronounced microcirculatory dysfunction than the COVID-19 group. rPPG was more sensitive in detecting perfusion changes, showing significant differences between the groups. The automated CRT demonstrated greater sensitivity compared to the manual CRT, revealing significant differences during PLRT stages between bacterial- and COVID-19-associated sepsis. Both groups had a transient hemodynamic response to PLRT, with subsequent stabilization upon fluid infusion. Conclusions: When managing patients with sepsis in intensive care, monitoring microcirculation is of paramount importance in infusion therapy. Our study highlights the potential of rPPG and aCRT as tools for this purpose. These techniques can be used in conjunction with routine parameters, such as lactate levels and systemic hemodynamic parameters, to provide a comprehensive assessment of a patient's condition.

Enhancing Stability and Investigating Target Attainment of Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Insights from In Vitro and In Vivo Evaluations

Background/Objective: Narrow-spectrum beta-lactam antibiotics such as benzylpenicillin and flucloxacillin are increasingly used in outpatient parenteral antimicrobial therapy (OPAT) programs to mitigate the adverse effects associated with broad-spectrum antibiotics. These beta-lactams require continuous administration via portable infusion devices during OPAT. However, the use of benzylpenicillin in OPAT requires special consideration because of its limited stability at elevated temperatures. Methods: We tested the benzylpenicillin stability, pH, and degradation of products in elastomeric pumps at different concentrations in saline and in buffered solution containing sodium citrate during a prolonged storage and at high temperatures (seven days at 2-8 °C followed by 24 h at 37 °C). Additionally, drug concentrations during intermittent bolus infusion and during OPAT were determined in five patients. The concentrations and degradation products of benzylpenicillin were measured using liquid chromatography mass spectrometry (LC-MS/MS). Results: Unbuffered benzylpenicillin solutions that were already degraded during refrigerator storage and analyte concentration were not measurable after 8 days. The stability of the buffered solutions was acceptable at all three of the tested concentrations (97.6 ± 1.3%, 96.3 ± 0.8%, and 94.9 ± 1.1% for 10 Mio IU, 20 Mio IU, and 40 Mio IU of benzylpenicillin). The stability was influenced by benzylpenicillin concentration, and several breakdown products were identified. Benzylpenicillin concentrations were measured in five patients during OPAT and ranged from 7.2 to 60 mg/L. Conclusions: Benzylpenicillin buffered with sodium citrate is a safe and convenient option for use in continuous infusions during OPAT and should be favored over broad-spectrum antibiotics. Therapeutic drug monitoring data indicate sufficient to high plasma levels when patients received benzylpenicillin as continuous infusions.

Cardiac Function and Structure before and after Mild SARS-CoV-2 Infection in Elite Athletes Using Biventricular and Left Atrial Strain

BACKGROUND/OBJECTIVES

Myocardial involvement has been observed in athletes following SARS-CoV-2 infection. It is unclear if these changes are due to myocardial damage per se or to an interruption in training. The aim of this study was to assess cardiac function and structure in elite athletes before and after infection (INFAt) and compare them to a group of healthy controls (CON).

METHODS

Transthoracic echocardiography was performed in 32 elite athletes, including 16 INFAt (median 21.0 (19.3-21.5) years, 10 male) before (t0) and 52 days after (t1) mild SARS-CoV-2 infection and 16 sex-, age- and sports type-matched CON. Left and right ventricular global longitudinal strain (LV/RV GLS), RV free wall longitudinal strain (RV FWS) and left atrial strain (LAS) were assessed by an investigator blinded to patient history.

RESULTS

INFAt showed no significant changes in echocardiographic parameters between t0 and t1, including LV GLS (-21.8% vs. -21.7%, p = 0.649) and RV GLS (-29.1% vs. -28.7%, p = 0.626). A significant increase was observed in LA reservoir strain (LASr) (35.7% vs. 47.8%, p = 0.012). Compared to CON, INFAt at t1 had significantly higher RV FWS (-33.0% vs. -28.2%, p = 0.011), LASr (47.8% vs. 30.5%, p < 0.001) and LA contraction strain (-12.8% vs. -4.9%, p = 0.050) values.

CONCLUSIONS

In elite athletes, mild SARS-CoV-2 infection does not significantly impact LV function when compared to their pre-SARS-CoV-2 status and to healthy controls. However, subtle changes in RV and LA strain may indicate temporary or training-related adaptions. Further research is needed, particularly focusing on athletes with more severe infections or prolonged symptoms.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment in Adults and Children

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides a recommendation for risk stratification according to severity of illness score. The panel's recommendation is based on evidence derived from systematic literature reviews and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Utility of Intra-abdominal Fluid Cultures in Adults, Children, and Pregnant People

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides recommendations for obtaining cultures of intra-abdominal fluid in patients with known or suspected intra-abdominal infection. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Patient flow management in biological events: a scoping review

INTRODUCTION

Biological Events affect large populations depending on transmission potential and propagation. A recent example of a biological event spreading globally is the COVID-19 pandemic, which has had severe effects on the economy, society, and even politics,in addition to its broad occurrence and fatalities. The aim of this scoping review was to look into patient flow management techniques and approaches used globally in biological incidents.

METHODS

The current investigation was conducted based on PRISMA-ScR: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. All articles released until March 31, 2023, about research question were examined, regardless of the year of publication. The authors searched in databases including Scopus, Web of Science, PubMed, Google scholar search engine, Grey Literature and did hand searching. Papers with lack of the required information and all non-English language publications including those with only English abstracts were excluded. Data extraction checklist has been developed Based on the consensus of authors.the content of the papers based on data extraction, analyzed using content analysis.

RESULTS

A total of 19,231 articles were retrieved in this study and after screening, 36 articles were eventually entered for final analysis. Eighty-four subcategories were identified,To facilitate more precise analysis and understanding, factors were categorised into seven categories: patient flow simulation models, risk communication management, integrated ICT system establishment, collaborative interdisciplinary and intersectoral approach, systematic patient management, promotion of health information technology models, modification of triage strategies, and optimal resource and capacity management.

CONCLUSION

Patient flow management during biological Events plays a crucial role in maintaining the performance of the healthcare system. When public health-threatening biological incidents occur, due to the high number of patients, it is essential to implement a holistic,and integrated approach from rapid identification to treatment and discharge of patients.

Antibiotic dose optimisation in the critically ill: targets, evidence and future strategies

PURPOSE OF REVIEW

To highlight the recent evidence for antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in enhancing patient outcomes in sepsis and septic shock. We also summarise the limitations of available data and describe future directions for research to support translation of antibiotic dose optimisation to the clinical setting.

RECENT FINDINGS

Sepsis and septic shock are associated with poor outcomes and require antibiotic dose optimisation, mostly due to significantly altered pharmacokinetics. Many studies, including some randomised controlled trials have been conducted to measure the clinical outcome effects of antibiotic dose optimisation interventions including use of therapeutic drug monitoring. Current data support antibiotic dose optimisation for the critically ill. Further investigation is required to evolve more timely and robust precision antibiotic dose optimisation approaches, and to clearly quantify whether any clinical and health-economic benefits support expanded use of this treatment intervention.

SUMMARY

Antibiotic dose optimisation appears to improve outcomes in critically ill patients with sepsis and septic shock, however further research is required to quantify the level of benefit and develop a stronger knowledge of the role of new technologies to facilitate optimised dosing.

Tracheal tube introducer-associated airway trauma: a systematic review

BACKGROUND

Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma.

METHODS

PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments.

RESULTS

We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome.

CONCLUSIONS

Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Arterial hyperoxia and mortality in the cardiac intensive care unit

BACKGROUND

Arterial hyperoxia (hyperoxemia), defined as a high arterial partial pressure of oxygen (PaO2), has been associated with adverse outcomes in critically ill populations, but has not been examined in the cardiac intensive care unit (CICU). We evaluated the association between exposure to hyperoxia on admission with in-hospital mortality in a mixed CICU cohort.

METHODS

We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 with admission PaO2 data (defined as the PaO2 value closest to CICU admission) and no hypoxia (PaO2 < 60mmHg). The admission PaO2 was evaluated as a continuous variable and categorized (60-100 mmHg, 101-150 mmHg, 151-200 mmHg, 201-300 mmHg, >300 mmHg). Logistic regression was used to evaluate predictors of in-hospital mortality before and after multivariable adjustment.

RESULTS

We included 3,368 patients with a median age of 70.3 years; 70.3% received positive-pressure ventilation. The median PaO2 was 99 mmHg, with a distribution as follows: 60-100 mmHg, 51.9%; 101-150 mmHg, 28.6%; 151-200 mmHg, 10.6%; 201-300 mmHg, 6.4%; >300 mmHg, 2.5%. A J-shaped association between admission PaO2 and in-hospital mortality was observed, with a nadir around 100 mmHg. A higher PaO2 was associated with increased in-hospital mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, p = 0.03). Patients with PaO2 >300 mmHg had higher in-hospital mortality versus PaO2 60-100 mmHg (adjusted OR 2.37, 95% CI 1.41-3.94, p < 0.001).

CONCLUSIONS

Hyperoxia at the time of CICU admission is associated with higher in-hospital mortality, primarily in those with severely elevated PaO2 >300 mmHg.

Dose Individualisation of Antimicrobials from a Pharmacometric Standpoint: The Current Landscape

Successful antimicrobial therapy depends on achieving optimal drug concentrations within individual patients. Inter-patient variability in pharmacokinetics (PK) and differences in pathogen susceptibility (reflected in the minimum inhibitory concentration, [MIC]) necessitate personalised approaches. Dose individualisation strategies aim to address this challenge, improving treatment outcomes and minimising the risk of toxicity and antimicrobial resistance. Therapeutic drug monitoring (TDM), with the application of population pharmacokinetic (popPK) models, enables model-informed precision dosing (MIPD). PopPK models mathematically describe drug behaviour across populations and can be combined with patient-specific TDM data to optimise dosing regimens. The integration of machine learning (ML) techniques promises to further enhance dose individualisation by identifying complex patterns within extensive datasets. Implementing these approaches involves challenges, including rigorous model selection and validation to ensure suitability for target populations. Understanding the relationship between drug exposure and clinical outcomes is crucial, as is striking a balance between model complexity and clinical usability. Additionally, regulatory compliance, outcome measurement, and practical considerations for software implementation will be addressed. Emerging technologies, such as real-time biosensors, hold the potential for revolutionising TDM by enabling continuous monitoring, immediate and frequent dose adjustments, and near patient testing. The ongoing integration of TDM, advanced modelling techniques, and ML within the evolving digital health care landscape offers a potential for enhancing antimicrobial therapy. Careful attention to model development, validation, and ethical considerations of the applied techniques is paramount for successfully optimising antimicrobial treatment for the individual patient.

Role of mitochondria in reno-cardiac diseases: A study of bioenergetics, biogenesis, and GSH signaling in disease transition

Acute kidney injury (AKI) and chronic kidney disease (CKD) are global health burdens with rising prevalence. Their bidirectional relationship with cardiovascular dysfunction, manifesting as cardio-renal syndromes (CRS) types 3 and 4, underscores the interconnectedness and interdependence of these vital organ systems. Both the kidney and the heart are critically reliant on mitochondrial function. This organelle is currently recognized as a hub in signaling pathways, with emphasis on the redox regulation mediated by glutathione (GSH). Mitochondrial dysfunction, including impaired bioenergetics, redox, and biogenesis pathways, are central to the progression of AKI to CKD and the development of CRS type 3 and 4. This review delves into the metabolic reprogramming and mitochondrial redox signaling and biogenesis alterations in AKI, CKD, and CRS. We examine the pathophysiological mechanisms involving GSH redox signaling and the AMP-activated protein kinase (AMPK)-sirtuin (SIRT)1/3-peroxisome proliferator-activated receptor-gamma coactivator (PGC-1α) axis in these conditions. Additionally, we explore the therapeutic potential of GSH synthesis inducers in mitigating these mitochondrial dysfunctions, as well as their effects on inflammation and the progression of CKD and CRS types 3 and 4.

Multiorgan Congestion Assessment by Venous Excess Ultrasound Score in Acute Heart Failure

BACKGROUND

This study sought to explore the prevalence and clinical utility of different patterns of multiorgan venous congestion as assessed by the venous excess ultrasound (VExUS) score in hospitalized patients with acute heart failure (HF).

METHODS

Consecutive patients admitted for acute HF were prospectively enrolled. Inferior vena cava diameter, hepatic vein, portal vein, and renal vein Doppler waveforms were assessed at admission, and patients were stratified based on VExUS score from 0 to 3, with higher values indicating worse congestion. The clinical score Get with the Guidelines (GWTG)-HF for predicting in-hospital mortality in HF was evaluated. In-hospital mortality was recorded.

RESULTS

Two hundred ninety patients admitted with acute HF were included, and 114 (39%) of them were classified as VExUS score 3, which was the most prevalent group. Patients with VExUS score 3 suffered more frequently from chronic atrial fibrillation, chronic kidney disease, and anemia. Parameters independently associated with VExUS score 3 were higher mean E/e' ratio, larger right ventricular size, severe tricuspid regurgitation, and impaired right atrial function. A VExUS score of 3 was associated with in-hospital mortality (odds ratio, 8.03; 95% CI [2.25-28.61], P = .001). The addition of VExUS score on top of the GWTG-HF score improved the predictability of the model (Δx2 = +8.44, P = .03) for in-hospital mortality, whereas other indices of venous congestion (right atrial function, inferior vena cava size) did not.

CONCLUSIONS

Patients admitted with acute HF commonly had severe venous congestion based on the VExUS score. The VExUS score improved the prediction of in-hospital mortality compared with other indices of venous congestion.