Effects of closed- versus open-system intensive care units on mortality rates in patients with cancer requiring emergent surgical intervention for acute abdominal complications: a single-center retrospective study in Korea

BACKGROUND

In this study, we aimed to compare the in-hospital mortality of patients with cancer who experienced acute abdominal complications that required emergent surgery in open (treatment decisions made by the primary attending physician of the patient's admission department) versus closed (treatment decisions made by intensive care unit [ICU] intensivists) ICUs.

METHODS

This retrospective, single-center study enrolled patients with cancer admitted to the ICU before or after emergency surgery between November 2020 and September 2023. Univariate and logistic regression analyses were conducted to explore the associations between patient characteristics in the open and closed ICUs and in-hospital mortality.

RESULTS

Among the 100 patients (open ICU, 49; closed ICU, 51), 23 died during hospitalization. The closed ICU group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, vasopressor use, mechanical ventilation, and preoperative lactate levels and a shorter duration from diagnosis to ICU admission, surgery, and antibiotic administration than the open ICU group. Univariate analysis linked in-hospital mortality and APACHE II score, postoperative lactate levels, continuous renal replacement therapy (CRRT), and mechanical ventilation. Multivariate analysis revealed that in-hospital mortality rate increased with CRRT use and was lower in the closed ICU.

CONCLUSIONS

Compared to an open ICU, a closed ICU was an independent factor in reducing in-hospital mortality through prompt and appropriate treatment.

Multimodal analgesic strategies in polytraumatized patients

In recent years, the resuscitation of trauma patients has improved; however, pain related to trauma remains associated with systemic complications. In trauma patients, pain should be considered a vital sign, and its control is crucial for reducing complications, improving patient satisfaction, and enhancing the quality of life. The multimodal analgesia approach is the mainstay in pain control, and growing evidence in the literature supports a greater role of regional anesthesia in the management of trauma casualties. In this review, we offer the reader an updated general framework of the various approaches available for pain treatment in polytraumatized patients, with a focus on the opportunities presented by regional anesthesia. We will examine different types of locoregional anesthesia blocks and describe ultrasonographic execution techniques.

Consequences of a stay in the intensive care unit and outpatient follow-up care for chronic critically ill patients: A retrospective data analysis

BACKGROUND

Patients with chronic critical illness (CCI) represent a particularly vulnerable patient population with significant quality-of-life consequences and a need for follow-up care. Existing research on their quality-of-life trajectory and outpatient follow-up care is limited.

OBJECTIVES

The aim of this study was to (i) describe a quality improvement project focussing on patients with CCI in the Swiss setting; (ii) explain the consequences of an intensive care unit (ICU) stay for patients with CCI; and (iii) evaluate outpatient follow-up care for patients with CCI.

METHODS

This retrospective descriptive mixed-methods longitudinal study used routine data from outpatient follow-up care between October 2018 and June 2022. The pre-ICU data were collected retrospectively for the week before ICU admission (baseline); prospectively at 3, 6, and 12 months after ICU discharge; and during an outpatient follow-up care at 6 months. Its main outcomes were health-related quality of life (HRQOL). Patients with CCI were defined as those having a ICU stay longer than 7 days.

RESULTS

This study enrolled 227 patients with outpatient follow-up care, but only 77 were analysed at all four timepoints. Their EuroQol five-dimension five-level questionnaire-Visual Analogue Scale scores ranged from 0 to 100, with a median of 85 (interquartile range = 0-100) and a mean of 77.2 (standard deviation ± 23.52) before their ICU stay. Their scores had almost returned to the baseline 12 months after their ICU stay. While some reported existing restrictions in the individual HRQOL dimensions before their ICU stay, patients and their families appreciated the outpatient follow-up care including an ICU visit.

CONCLUSION

Patients with CCI have different HRQOL trajectories over time. Patients with CCI can have a good HRQOL despite their impairments; however, the HRQOL trajectories of many patients remain unclear. The focus must be on identifying the illness trajectories and on measuring and maintaining their long-term HRQOL.

Inferior vena cava-aortic ratio measurement as a promising modality in assessing intravascular volume in children with sepsis

BACKGROUND

Hemodynamic monitoring is crucial for the comprehensive management of children with sepsis, particularly those involving the kidneys. Sepsis-associated acute kidney injury (S-AKI) is closely linked to poor outcomes. Recently, ultrasonography modalities have been widely accepted as a non-invasive, rapid, and reliable tool for assessing volume status. We conducted research to determine intravascular volume based on ultrasound examination in S-AKI patients.

METHODS

A prospective cohort study was conducted between December 2023 and March 2024 in the Pediatric Intensive Care Unit (PICU) at Hasan Sadikin General Hospital. We divided the patients into two groups: those with sepsis without AKI and those with S-AKI. The intravascular volume was measured by the IVC/Ao (inferior vena cava/abdominal aorta) ratio using two-dimensional ultrasonography and USCOM before and 24 h after fluid treatment. The results were analyzed using SPSS 25, with a significance level of p < 0.05.

RESULTS

A total of 36 pediatric patients (aged 1 month-18 years) with sepsis were included. The IVC/Ao ratio before and after the fluid intervention demonstrated significant differences between the two groups (p < 0.001). USCOM Cardiac Index (CI) before and after the intervention also showed significant differences between the two groups (p < 0.001). Patients with S-AKI exhibited a poor hemodynamic response in the IVC/Ao ratio two-dimensional ultrasonography and USCOM examination.

CONCLUSIONS

IVC/Ao ratio measurement is as accurate as USCOM and can be used as a simple and cost-effective alternative for hemodynamic monitoring.

Neurodevelopmental outcome and quality of life in children admitted to the paediatric intensive care unit: A single-centre Australian cohort study

BACKGROUND

The development of new morbidities has become increasingly identified in paediatric critical care medicine. To date, there has been limited research of long-term outcomes following paediatric critical illness in Australia.

OBJECTIVES

The objective of this study was to quantify neurodevelopmental impairments in children following paediatric intensive care unit (PICU) discharge and their association with health-related quality of life (HRQoL).

METHODS

A single-centre ambidirectional cohort study at an Australian hospital. Parents of children admitted to the PICU between 2015 and 2017 were invited to participate. Neurodevelopmental outcome and HRQoL was prospectively evaluated, using the Ages and Stages Questionnaire (<5 years), Strengths and Difficulties Questionnaire (≥5 years), and Pediatric Quality of Life Inventory™, respectively.

RESULTS

A total of 230 parents of critically ill children participated. Children were 1.9 years old (median, interquartile range [IQR]: 0.2, 7.5), male (59.6%), and ventilated (49.1%) at PICU admission. The median time to follow-up was 24.4 months (IQR: 16.3, 36.7). Parent respondents were more likely to be female (85.5%), White (88.3%), and partnered (81.1%). The incidence of overall neurodevelopmental impairment was 30% (33% in children aged <5 years; 24% in children aged ≥5 years). The incidence of poor HRQoL was 37.9%. History of developmental delay was independently associated with overall neurodevelopmental impairment (adjusted odds ratio [aOR]: 4.21, 95% confidence interval: 2.05, 8.63) and poor HRQoL (aOR: 7.29, 95% confidence interval: 3.26, 16.27). Two or more PICU admissions (aOR: 4.10, IQR: 1.82, 9.26) was also associated with poor HRQoL.

CONCLUSIONS

This is the first contemporary view of PICU long-term outcomes conducted in Australia and significantly informs ongoing research in this area. Approximately one-third of PICU survivors demonstrate neurodevelopmental impairment and reduced quality of life. Multiple domains of post-intensive care syndrome-paediatrics must be considered to have a comprehensive understanding of child outcomes. Assessment of baseline/premorbid functioning is also essential in order to understand the true impact of illness and PICU admission.

A conceptual analysis of facilitation to improve clinical outcomes in critical care units

Objectives

Effective facilitation is crucial to improve critical care outcomes in life-threatening conditions through improved teamwork, caring, decision-making, and problem-solving. The meaning of facilitation remains unprecise in a critical care context despite its frequent usage in nursing education and clinical practice. This study aimed to report a thorough concept analysis to clarify the meaning of facilitation in the critical care context by formulating attributes, antecedents, and consequences and providing model cases related to facilitation.

Methods

This analysis was performed by searching online sources published from 1999 to 2023. EBSCOhost, CINAHL, PubMed, and Google Scholar databases were searched using online search engines. The analysis also included the manual search of books, thesaurus and dictionaries that showed relevance to facilitation. Walker and Avant's eight-step approach was applied to explore and analyze the meaning of facilitation in critical care units.

Results

A total of 68 articles were included in the analysis of this study. Eleven attributes, six antecedents, and seven consequences related to facilitation were formulated. The attributes included dynamic, interactive processes, creating a positive environment, mobilizing resources, assistance, student-centered, shared goals, collaboration, engagement, participation, and feedback. Antecedents were facilitator qualities, motivation, a positive learning environment, student-facilitator relationship, time availability, and specified learning outcomes. The consequences of facilitation were identified as follows: change, professional development, competency, quality development, increased job satisfaction, staff retention, and self-confidence.

Conclusions

The findings from the analysis indicated that effective facilitation results in nurses and critical care staff developing competency, caring, critical thinking, and independence. Therefore, clinical outcomes in critical care environments are improved through teamwork, decision-making, and problem-solving in life-threatening situations.

Post-intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post-intensive-care clinic

BACKGROUND

Long-term survival data for critically ill children discharged to post-intensive care clinics are scarce, especially in Asia. The main objective of this study was to assess the prevalence of post-intensive-care morbidity among pediatric intensive care unit (PICU) survivors at 1 month and 1 year after hospital discharge and to identify the associated risk factors.

METHODS

We conducted a retrospective chart review of all children aged 1 month to 15 years who were admitted to the PICU for >48 hours from July 2019 to July 2022 and visited a post-intensive-care clinic 1 month and 1 year after hospital discharge. Post-intensive care morbidity was defined using the Pediatric Cerebral Performance Category (PCPC). Descriptive statistics, univariate, and multivariate analyses were conducted.

RESULTS

A total of 111 children visited the clinic at 1 month, and 100 of these children visited the clinic at 1 year. Only 39 of 111 children (35.2%) had normal PCPC assessments at 1 month, while 54 of 100 (54.0%) were normal at 1 year. Baseline developmental delays were significantly associated with any degree of disability and at least moderate disability at both time points. Mechanical ventilation for >7 days was associated with at least moderate disability at both time points, while PICU stay >7 days was significantly associated with moderate disability at 1 month and any degree of disability at 1 year.

CONCLUSIONS

A substantial percentage of PICU survivors had persistent disabilities even 1 year after critical illness. A structured multidisciplinary post-intensive-care follow-up plan is warranted to provide optimal care for such children.

Urinary chloride excretion in critical illness and acute kidney injury: a paediatric hypothesis-generating cohort study post cardiopulmonary bypass surgery

Renal chloride metabolism is currently poorly understood but may serve as both a diagnostic and a treatment approach for acute kidney injury. We investigated whether plasma chloride, ammonia and glutamine as well as urinary chloride, ammonium and glutamine concentrations may serve as markers for acute kidney injury in paediatric patients. We conducted a prospective observational trial in a tertiary care paediatric intensive care unit. Ninety-one patients after cardiopulmonary bypass surgery were enrolled. Plasma glutamine, creatinine, (serum) albumin, urinary electrolytes and glutamine were collected pre-cardiopulmonary bypass surgery, at paediatric intensive care unit admission, and at 6, 12, 24, 48 and 72 h after paediatric intensive care unit admission. The urinary strong ion difference was calculated. The median urinary chloride excretion decreased from 51 mmol/L pre-cardiopulmonary bypass to 25 mmol/L at paediatric intensive care unit admission, and increased from 24 h onwards. Patients with acute kidney injury had lower urinary chloride excretion than those without. The median urinary strong ion difference was 59 mmol/L pre-cardiopulmonary bypass, rose to 131 mmol/L at 24 h and fell to 20 mmol/L at 72 h. The plasma chloride rose from 105 mmol/L pre-cardiopulmonary bypass to a maximum of 109 mmol/L at 24 h. At 24 h the plasma chloride concentration was associated with the presence of acute kidney injury. There was no association between plasma or urinary amino acids and chloride excretion or kidney injury. In conclusion, renal chloride excretion decreased in all patients, although this decrease was more pronounced in patients with acute kidney injury. Our findings may reflect a response of the kidneys to critical illness, and acute kidney injury may make these changes more pronounced. Targeting chloride metabolism may offer treatment approaches to acute kidney injury.

Biomarkers and patient-related factors associated with clinical outcomes in dupilumab-treated atopic dermatitis

Background

Atopic dermatitis (AD) is a common chronic eczematous skin disease with severe pruritus. Several new therapeutic agents for AD such as dupilumab, an anti-IL-4Rα antibody, have been developed in recent years. We need to predict which agent is the best choice for each patient, but this remains difficult.

Objective

Our aim was to examine clinical background factors and baseline biomarkers that could predict the achievement of improved clinical outcomes in patients with AD treated with dupilumab.

Methods

A multicenter, prospective observational study was conducted on 110 patients with AD. The Eczema Area and Severity Index was used as an objective assessment, and the Patient-Oriented Eczema Measure and Numerical Rating Scale for Pruritus were used as patient-reported outcomes. In addition, some clinical background factors were evaluated.

Results

The achievement of an absolute Eczema Area and Severity Index of 7 or less was negatively associated with current comorbidity of food allergy and baseline serum lactate dehydrogenase (LDH) levels. There were negative associations between achievement of a Patient-Oriented Eczema Measure score of 7 or less and duration of severe AD and between achievement of an itching Numerical Rating Scale for Pruritus score of 1 or less and current comorbidity of allergic conjunctivitis or baseline serum periostin level. Furthermore, signal detection analysis showed that a baseline serum LDH level less than 328 U/L could potentially be used as a cutoff value for predicting the efficacy of dupilumab.

Conclusion

Baseline biomarkers such as LDH and periostin and clinical background factors such as current comorbidity of food allergy and a long period of severe disease may be useful indicators when choosing dupilumab for systemic treatment for AD, as they can predict the efficacy of dupilumab.

Design and validation of an In Vitro test bench for the investigation of cardiopulmonary resuscitation procedure

Despite recent clinical and technological advancements, the cardiac arrest survival rate remains as low as 10%. To enhance patient outcomes, it is crucial to deepen the understanding of cardiopulmonary resuscitation (CPR) at a fundamental level. Currently, there is a lack of knowledge on the physiological effects of CPR, in particular on the hemodynamics in the heart and the great vessels. The design and validation of a dedicated in vitro heart simulator, capable of replicating the physiological response to CPR, holds the potential to provide valuable insights into the fluid dynamics in the heart during CPR but also to be used as a platform for the development and testing of mechanical CPR machines. The main objective of this study is to design and validate the first in vitro heart simulator that can replicate the physiological response during CPR. For that, a custom-made heart simulator is designed consisting of an elastic model of the complete heart and a controllable linear actuator. The heart model is positioned in an anatomical position, and the linear actuator compresses the model at specific rates and depths. Flow and pressure waveforms are recorded on the newly developed simulator at 60 contractions per minute and results are validated against reported in vivo data in the literature. Finally, the system's capabilities are evaluated by considering several combinations of compression rates and depths.

Differential Effects of Landiolol in Patients with Atrial Fibrillation and Atrial Tachycardia

Landiolol, an ultra-short-acting β1-selective blocker, is more effective in controlling heart rate compared with digoxin in patients with atrial tachyarrhythmias and left ventricular dysfunction. However, the effect of atrial tachyarrhythmia type on the effectiveness of landiolol remains unknown. Hence, this study aimed to evaluate the effectiveness of landiolol in patients with atrial fibrillation (AF) and atrial tachycardia (AT), not limited to those with heart failure with a reduced ejection fraction. To this end, we evaluated the efficacy and safety of landiolol in managing tachycardiac AF and tachycardiac atrial flutter/AT in 44 patients with reduced left ventricular function. We found that while landiolol was effective in managing patients with AF and heart failure with a preserved or mid-range ejection fraction, however, it might be more challenging to control heart rate in patients with AT using a similar dosage of landiolol.

CPAP vs HFNC in treatment of patients with COVID-19 ARDS: A retrospective propensity-matched study

Background

Previous studies exploring the application of noninvasive ventilation or high-flow nasal cannula in patients with COVID-19-related acute respiratory distress syndrome (ARDS) have yielded conflicting results on whether any method of respiratory support is superior. Our aim is to compare the efficacy and safety of respiratory therapy with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure in treatment of COVID-19-related ARDS.

Methods

This is a retrospective cohort study based on data from patients who received respiratory support as part of their treatment in the COVID intensive care unit at the University Hospital Centre Zagreb between February 2021 and February 2023. Using propensity score analysis, 42 patients treated with high-flow nasal cannula (HFNC group) were compared to 42 patients treated with noninvasive ventilation with continuous positive airway pressure (CPAP group). Primary outcome was intubation rate.

Results

Intubation rate was 71.4% (30/42) in the HFNC group and 40.5% (17/42) in the CPAP group (p = 0.004). Hazard ratio for intubation was 3.676 (95% confidence interval [CI] 1.480 to 9.232) with the HFNC versus CPAP group. Marginally significant difference in survival between the two groups was observed at 30 days (p = 0.050) but was statistically significant at 60 days (p = 0.043).

Conclusions

Respiratory support with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure yielded significantly different intubation rates in favour of continuous positive airway pressure. The same patients also had better 30-day and 60-day survival post-admission.

Airway epithelium damage in acute respiratory distress syndrome

BACKGROUND

The airway epithelium (AE) fulfils multiple functions to maintain pulmonary homeostasis, among which ensuring adequate barrier function, cell differentiation and polarization, and actively transporting immunoglobulin A (IgA), the predominant mucosal immunoglobulin in the airway lumen, via the polymeric immunoglobulin receptor (pIgR). Morphological changes of the airways have been reported in ARDS, while their detailed features, impact for mucosal immunity, and causative mechanisms remain unclear. Therefore, this study aimed to assess epithelial alterations in the distal airways of patients with ARDS.

METHODS

We retrospectively analyzed lung tissue samples from ARDS patients and controls to investigate and quantify structural and functional changes in the small airways, using multiplex fluorescence immunostaining and computer-assisted quantification on whole tissue sections. Additionally, we measured markers of mucosal immunity, IgA and pIgR, alongside with other epithelial markers, in the serum and the broncho-alveolar lavage fluid (BALF) prospectively collected from ARDS patients and controls.

RESULTS

Compared to controls, airways of ARDS were characterized by increased epithelial denudation (p = 0.0003) and diffuse epithelial infiltration by neutrophils (p = 0.0005). Quantitative evaluation of multiplex fluorescence immunostaining revealed a loss of ciliated cells (p = 0.0317) a trend towards decreased goblet cells (p = 0.056), and no change regarding cell progenitors (basal and club cells), indicating altered mucociliary differentiation. Increased epithelial permeability was also shown in ARDS with a significant decrease of tight (p < 0.0001) and adherens (p = 0.025) junctional proteins. Additionally, we observed a significant decrease of the expression of pIgR, (p < 0.0001), indicating impaired mucosal IgA immunity. Serum concentrations of secretory component (SC) and S-IgA were increased in ARDS (both p < 0.0001), along other lung-derived proteins (CC16, SP-D, sRAGE). However, their BALF concentrations remained unchanged, suggesting a spillover of airway and alveolar proteins through a damaged AE.

CONCLUSION

The airway epithelium from patients with ARDS exhibits multifaceted alterations leading to altered mucociliary differentiation, compromised defense functions and increased permeability with pneumoproteinemia.

Evaluation of the Anatomical Cross-Sectional Area of Psoas Major Muscle Using an Ultrasound Imaging System Combined With an Inertial Measurement Unit: Improved Reliability in the US Using IMU-Based Positioning Techniques

Introduction: Recently, ultrasound (US) imaging has been used to estimate the cross-sectional area of skeletal muscle, but the reliability is uncertain. To improve the reliability of the US, we investigated skeletal muscle thickness measurement using an inertial measurement unit (IMU) to determine the direction of US beam incidence based on posture angle information. In addition, we examined whether the anatomical cross-sectional area (ACSA) of muscle can be estimated from the muscle thickness measured using the US with the IMU. Methods: In Experiment 1, two examiners measured the right psoas major at the fourth lumbar vertebra level in 10 university students using the US with and without an IMU. The intraclass correlation coefficient (ICC) was used to examine intra- and inter-rater variability. In Experiment 2, the two examiners measured the muscle thickness of the right psoas major in 31 male subjects using the US with an IMU. In addition, the ACSA of this muscle was measured using MRI. Pearson's correlation coefficient was used to examine the relationship between muscle thickness and ACSA, and a single regression analysis was performed. Results: Both intrarater reliability ICC (1, 2) and inter-rater reliability ICC (2, 2) were higher when US was used with IMU compared to without IMU (Experiment 1). A significant positive correlation (r = 0.84, p < 0.01) was observed between muscle thickness and ACSA (Experiment 2). The regression equation was significant at R 2 = 0.71 (p < 0.01). Conclusion: Using an IMU during US measurement of the psoas major improves intra- and interexaminer reliability and can be used to estimate the ACSA of the muscle.

Application of zero trust model in preventing medical errors

Medical errors can occur in many areas of healthcare, including hospitals, clinics, and surgery centers. They can result in negative consequences for patients and their loved ones. Over the years, different methods have been used to reduce medical errors. Zero Trust is an information security model that denies access to applications and data by default. Other industries have successfully used Zero Trust Model (ZTM), and it has been shown to improve outcomes. This editorial analyzes how the ZTM can be introduced to prevent medical errors in healthcare settings. ZTM application in healthcare could potentially revolutionize patient safety by tightly controlling and monitoring access to sensitive patient data and critical systems. By enhancing security measures, the ZTM could address the paramount concerns of patient data privacy and safety in healthcare. The zero-trust approach offers a potential solution by identifying consistent causes of errors and providing viable solutions to prevent their recurrence. In the era of worsening ransomware attacks on healthcare systems, the ZTM could also have enormous implications in other cybersecurity aspects. With this manuscript, the authors advocate for the broader application of ZTM across other facets of healthcare cybersecurity.

The influence of sex on neuroimmune communication, pain, and physiology

With the National Institutes of Health's mandate to consider sex as a biological variable (SABV), there has been a significant increase of studies utilizing both sexes. Historically, we have known that biological sex and hormones influence immunological processes and now studies focusing on interactions between the immune, endocrine, and nervous systems are revealing sex differences that influence pain behavior and various molecular and biochemical processes. Neuroendocrine-immune interactions represent a key integrative discipline that will reveal critical processes in each field as it pertains to novel mechanisms in sex differences and necessary therapeutics. Here we appraise preclinical and clinical literature to discuss these interactions and key pathways that drive cell- and sex-specific differences in immunity, pain, and physiology.

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale

INTRODUCTION

This study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO.

METHODS

Multicenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge.

RESULTS

This study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3 years [0.1, 9.0], ECMO duration of 5 days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events.

CONCLUSION

Short-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

Cold Pressor Test Induces Significant Changes in Internal Jugular Vein Flow Dynamics in Healthy Young Adults

BACKGROUND The cold pressor test (CPT), which has long been used to test autonomic functions by causing sympathetic excitation, increases systolic and diastolic blood pressure and heart rate and causes coronary vasodilation within physiological limits in healthy individuals. This study aimed to evaluate internal jugular vein (IJV) flow parameters using the CPT with systolic and diastolic blood pressure and heart rate in 40 healthy volunteers aged 18-40 years. MATERIAL AND METHODS The volunteers' IJV diameter, blood flow peak velocity, and volumetric flow values were recorded. Then, their right hands were immersed in a bucket of cold water maintained at 1°C up to the wrist level. At the end of the first minute (CPT-1), systolic and diastolic blood pressure, heart rhythm, IJV diameter, peak velocity, and volumetric flow measurements were performed again. RESULTS Systolic and diastolic blood pressure values were significantly higher at CPT-1 compared to baseline values (P<0.001, P<0.001). Heart rate and peak velocity values also showed a significant increase at CPT-1 compared to baseline values (P<0.001, P=0.001). While diameter values showed a significant decrease compared to baseline, volumetric flow rate values showed a significant increase at CPT-1 (P=0.003, P<0.001). CONCLUSIONS Sympathetic nervous system activation triggered by CPT increases IJV volumetric flow and flow velocity in healthy young individuals, and sympathetic nervous system activation causes a venoconstrictive effect in the IJV.

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.

Inflammation, immunity and biomarkers in procoagulant responses of critically ill patients

Understanding the pathobiology of critical illness is essential for patients' prognosis. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. As part of the host response, procoagulant responses, one of the most primitive reactions in biology, start at the very beginning of diseases and can be monitored throughout the process. Currently, we can achieve near-complete monitoring of the coagulation process, and procoagulant responses serve as indicators of the severity of host response in critically ill patients. However, the rapid interpretation of the complex results of various biomarkers remains a challenge for many clinicians. The indicators commonly used for coagulation assessment are complex, typically divided into three categories for clarity: process index, functional index, and outcome index. Monitoring and understanding these indicators can help manage procoagulant responses. The intervention of procoagulant response should be part of the bundle therapy, alongside the treatment for primary disease, management for hemodynamics, and controlling for host response. Early intervention for procoagulant response mainly includes anti-inflammation, antiplatelet and anticoagulant therapy, as well as management of primary disease. In this review, we systemically introduce the onset, assessment and intervention of procoagulant response.

Association of COVID-19 with acute and post-acute risk of multiple different complications and mortality in patients infected with omicron variant stratified by initial disease severity: a cohort study in Hong Kong

BACKGROUND

Few studies have attempted to use clinical and laboratory parameters to stratify COVID-19 patients with severe versus non-severe initial disease and evaluate age-specific differences in developing multiple different COVID-19-associated disease outcomes.

METHODS

A retrospective cohort included patients from the electronic health database of Hong Kong Hospital Authority between 1 January 2022 and 15 August 2022 until 15 November 2022. The cohort was divided into three cohorts by age (≤ 40, 41-64, and ≥ 65 years old). Each age cohort was stratified into four groups: (1) COVID-19 critically exposed group (ICU admission, mechanical ventilation support, CRP > 80 mg/L, or D-dimer > 2 g/mL), (2) severely exposed group (CRP 30-80 mg/L, D-dimer 0.5-2 g/mL, or CT value < 20), (3) mildly-moderately exposed group (COVID-19 positive-tested but not fulfilling the criteria for the aforementioned critically and severely exposed groups), and (4) unexposed group (without COVID-19). The characteristics between groups were adjusted with propensity score-based marginal mean weighting through stratification. Cox regression was conducted to determine the association of COVID-19 disease severity with disease outcomes and mortality in the acute and post-acute phase (< 30 and ≥ 30 days from COVID-19 infection) in each age group.

RESULTS

A total of 286,114, 320,304 and 194,227 patients with mild-moderate COVID-19 infection; 18,419, 23,678 and 31,505 patients with severe COVID-19 infection; 1,168, 2,261 and 10,178 patients with critical COVID-19 infection, and 1,143,510, 1,369,365 and 1,012,177 uninfected people were identified in aged ≤ 40, 40-64, and ≥ 65 groups, respectively. Compared to the unexposed group, a general trend tending towards an increase in risks of multiple different disease outcomes as COVID-19 disease severity increases, with advancing age, was identified in both the acute and post-acute phases. Notably, the mildly-moderately exposed group were associated with either insignificant risks (aged ≤ 40) or the lowest risks (aged > 40) for the disease outcomes in the acute phase of infection (e.g., mortality risk HR (aged ≤ 40): 1.0 (95%CI: 0.5,2.0), HR (aged 41-64): 2.1 (95%CI: 1.8, 2.6), HR (aged > 65): 4.8 (95%CI: 4.6, 5.1)); while in the post-acute phase, these risks were largely insignificant in those aged < 65, remaining significant only in the elderly (age ≥ 65) (e.g., mortality risk HR (aged ≤ 40): 0.8 (95%CI: (0.5, 1.0)), HR (aged 41-64): 1.1 (95%CI: 1.0,1.2), HR (aged > 65): 1.5 (95%CI: 1.5,1.6)). Fully vaccinated patients were associated with lower risks of disease outcomes than those receiving less than two doses of vaccination.

CONCLUSIONS

The risk of multiple different disease outcomes in both acute and post-acute phases increased significantly with the increasing severity of acute COVID-19 illness, specifically among the elderly. Moreover, future studies could improve by risk-stratifying patients based on universally accepted thresholds for clinical parameters, particularly biomarkers, using biological evidence from immunological studies.

Potential protective efficacy of biogenic silver nanoparticles synthesised from earthworm extract in a septic mice model

Sepsis is an inevitable stage of bacterial invasion characterized by an uncontrolled inflammatory response resulting in a syndrome of multiorgan dysfunction. Most conventional antibiotics used to treat sepsis are efficacious, but they have undesirable side effects. The green synthesised Ag NPs were synthesized by 5 g of the earthworm extract dissolved in a volume of 500mL of distilled water and then added to 2,500 mL aqueous solution of 1mM silver nitrate at 40 °C. After 4 h, the mixture was then allowed to dry overnight at 60 °C. Later, Ag NPs were washed and collected. They were characterized by X-ray diffraction, ultraviolet-visible spectroscopy, and transmission electron microscopy. Sepsis model as induced by feces-intraperitoneal injection method. Eighteen male mice were assigned into three main groups: the control group, the sepsis-model group, and the Ag NPs-treated group. The control group received a single oral dose of distilled water and, after two days, intraperitoneally injected with 30% glycerol in phosphate buffer saline. The Sepsis-model group received a single oral dose of distilled water. Ag NPs - The treated group received a single oral dose of 5.5 mg/kg of Ag NPs. After two days, the sepsis-model group and Ag NPs-treated group were intraperitoneally injected with 200 µL of faecal slurry. Ag NPs treatment in septic mice significantly decreased liver enzyme activities, total protein, and serum albumin. Moreover, Ag NPs significantly enhanced kidney function, as indicated by a significant decrease in the levels of creatinine, urea, and uric acid. In addition, Ag NPs showed a powerful antioxidant effect via the considerable reduction of malondialdehyde and nitric oxide levels and the increase in antioxidant content. The histopathological investigation showed clear improvement in hepatic and kidney architecture. Our findings demonstrate the protective efficacy of biogenic Ag NPs against sepsis-induced liver and kidney damage.

Angiotensin-converting enzyme 2 activation attenuates inflammation and oxidative stress in brain death donor followed by rat lung transplantation

Brain death (BD) provides most of the donor organs destined for lung transplantation (LTx). However, the organs may be affected by inflammatory and oxidative processes. Based on this, we hypothesize that the angiotensin-converting enzyme 2 (ACE2) activation can reduce the lung injury associated with LTx. 3 h after BD induction, rats were injected with saline (BD group) or an ACE2 activator (ACE2a group; 15 mg/kg-1) and kept on mechanical ventilation for additional 3 h. A third group included a control ventilation (Control group) prior to transplant. After BD protocol, left LTx were performed, followed by 2 h-reperfusion. ACE2 activation was associated with better oxygenation after BD management (p = 0.01), attenuating edema (p = 0.05) followed by the reduction in tissue resistance (p = 0.01) and increase of respiratory compliance (p = 0.02). Nrf2 expression was also upregulated in the ACE2a group (p = 0.03). After transplantation, ACE2a group showed lower levels of TNF-α (p = 0.02), IL-6 (p = 0.001), IL-1β (p = 0.01), ROS (p = 0.004) and MDA (p = 0.002), in addition to higher CAT activity (p = 0.04). In conclusion, our study suggests that ACE2 activation improves anti-inflammatory and antioxidant activity in a model of LTx.

Acute Ischemic Stroke during Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review of the Literature

Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO.

Glycemic Management in Patients with COVID-19 Admitted to the Intensive Care Unit: Evaluation of Glycemic Control and Drug Therapy

Background

Emerging evidence describes the high incidence and strong impact of hyperglycemia on the outcomes of critically ill patients with a diagnosis of COVID-19. Given resource limitations during the COVID-19 pandemic, clinicians moved away from using continuous IV infusions of insulin to manage hyperglycemia.

Objective

To evaluate glycemic control in critically ill patients receiving various medication regimens to manage their hyperglycemia.

Methods

This retrospective cohort study involved 120 mechanically ventilated adult patients (> 18 years) with COVID-19 who were admitted to the intensive care unit (ICU) between February 2020 and December 2021. The following data were collected for the first 14 days of the ICU admission: blood glucose values (up to 4 times daily), hypoglycemia events, and antihyperglycemic medication regimens.

Results

The use of IV insulin infusions maintained glucose measurements within the target range of 4 to 10 mmol/L more often than any other medication regimen, with 60% of measured values falling within the target range. The use of a sliding-scale insulin regimen maintained 52% of glucose measurements within the target range. Oral hypoglycemic agents performed relatively poorly, with only 12% to 29% of glucose measurements within range. The coadministration of corticosteroids led to worse glycemic control across all medication regimens.

Conclusions

This study confirmed that ICUs should continue using the standard protocol of IV insulin infusion to achieve recommended blood glucose targets in critically ill patients with COVID-19, particularly those receiving corticosteroids.

Effectiveness of ulinastatin in critical care patients in real world: a retrospective multi-center study

OBJECTIVES

Ulinastatin has been applied in various diseases associated with inflammation, but its effectiveness lacks real-world evidence. We aimed to evaluate the effectiveness of ulinastatin based on a real-world database in the intensive care unit (ICU) patients.

METHODS

This was a retrospective cohort study. ICU patient data from multi-centers in China were collected. Propensity score matching (PSM) was applied. The effectiveness of ulinastatin was evaluated by mortality, length of stay in the ICU and mechanical ventilation duration. Kaplan-Meier method was used to estimate the hazard ratio and plot the survival curve.

RESULTS

A total of 2036 patients were analyzed after PSM. Mortality was significantly lower in the ulinastatin group than in the non-ulinastatin group (hazard ratio for death: 0.77; 95% confidence interval: 0.62-0.96; p = 0.018). Ulinastatin significantly reduced mortality at 28 days (10.0% vs. 13.6%), 60 days (13.9% vs. 18.2%) and 90 days (14.7% vs. 18.5%), length of stay in the ICU (median 8.0 d vs. 13.0 d), and mechanical ventilation duration (median 24.0 h vs. 25.0 h; p < 0.05).

CONCLUSIONS

Ulinastatin was beneficial for patients in the ICU, mainly by reducing mortality, length of ICU stay, and mechanical ventilation duration. This study provides evidence of the clinical effectiveness of ulinastatin.

Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review

Millions of critically ill patients are discharged from intensive care units (ICUs) every year. These ICU survivors may suffer from a condition known as post-intensive care syndrome (PICS) which includes a wide range of cognitive, psychological, and physical impairments. This article will provide an extensive review of PICS. ICU survivors may experience cognitive deficits in memory and attention, with a slow-down of mental processing and problem-solving. From psychological perspectives, depression, anxiety, and post-traumatic stress disorder are the most common issues suffered after ICU discharge. These psycho-cognitive impairments might be coupled with ICU-acquired weakness (polyneuropathy and/or myopathy), further reducing the quality of life, the ability to return to work, and other daily activities. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. The development of PICS (and PICS-F) is likely multifactorial, and both patient- and ICU-related factors may influence it. Whilst the prevention of PICS is complex, it is important to identify the patients at higher risk of PICS, and clinicians should be aware of the tools available for diagnosis. Stakeholders should implement strategies to achieve PICS prevention and to support its effective treatment during the recovery phase with dedicated pathways and supporting care.

Barriers to reporting adverse events from the perspective of ICU nurses: A mixed-method study

INTRODUCTION

Nurses represent the largest group of healthcare professionals and are responsible for improving patient safety, including reporting adverse events. However, adverse events are underreported due to the many barriers that compromise patient safety in the hospital setting.

AIM

The study aimed to investigate the barriers to reporting adverse events as perceived by nurses working in intensive care units (ICUs).

METHODS

The exploratory sequential mixed-method study design was used. Data were collected between January 2022 and March 2023 in intensive care units of one selected university hospital in the Slovak Republic. The quantitative phase was carried out using a specific instrument to explore barriers to reporting adverse events and included 111 nurses from the ICU. The qualitative phase was conducted using semi-structured face-to-face interviews and consisted of 10 nurses from the ICU.

RESULTS

In terms of quantitative aspect, fear of liability, lawsuits, or sanctions was the most significant barrier to reporting adverse events among ICU nurses. As a result of qualitative thematic analysis, four significant barriers to reporting adverse events were identified: negative attitude toward reporting adverse events; lack of knowledge and experience in reporting adverse events; time scarcity; fear.

CONCLUSION

Based on the results of the study, it is evident that only effective and regular reporting of adverse events leads to the minimization of adverse events. To improve patient safety in hospitals, education and management practices must be implemented to overcome barriers to reporting adverse events. The most important approach to overcoming barriers to reporting adverse events is to implement a culture of no blame and a positive culture of patient safety.

Hypoactive Delirium: A Rare Manifestation of Scrub Typhus

Scrub typhus continues to pose a significant threat to life, manifesting in a spectrum that ranges from mild, non-specific febrile illness to severe multi-organ dysfunction. Although neuropsychiatric symptoms are rare in cases of scrub typhus, we present a unique case involving a 60-year-old male who initially exhibited fever and headache, subsequently developing neuropsychiatric symptoms on the third day of hospitalization. Following the exclusion of prevalent metabolic, autoimmune, and infectious conditions, he was diagnosed with hypoactive delirium associated with scrub typhus. This case highlights the complex nature of hypoactive delirium, which may manifest with nonspecific symptoms that are frequently overlooked. Consequently, the recognition of delirium can be particularly difficult, potentially resulting in underdiagnosis in clinical settings.

Postoperative Intravenous Fluids and Electrolytes Management After Gastrointestinal Surgery in a Sudanese Teaching Hospital: A Prospective Audit

BACKGROUND

Postoperative fluid and electrolyte management is crucial for adequate patients' recovery and healing. This audit aimed to assess the current practice of postoperative intravenous fluids (IV) and electrolyte administration and investigate postoperative electrolyte disturbances.

METHOD

This study was conducted at Soba Teaching Hospital and comprised two cycles, it examined adult patients who underwent abdominal surgery and were exclusively on postoperative intravenous fluid therapy for at least one day. Exclusions were made for certain conditions (Heart or renal failure, ICU admissions, day surgeries). Data collected from medical records including intravenous fluid types and amounts, electrolytes, and daily serum sodium and potassium levels, were compared to British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). Following cycle one, regular educational sessions were conducted for medical staff, emphasizing the need for improved practices in postoperative care.

RESULTS

A total of 14 patients in cycle one and 15 patients in cycle two were included. The data analysis unit was the patient-day. Patient-days refers to the total number of days patients were on IV fluids after surgery, starting from the day after the operation and excluding the day of surgery. It is calculated by adding up the number of days each patient remained exclusively on IV fluids. A total of 33 and 30 patient-days were analyzed in cycle one and cycle two respectively. The recommended daily amount of IV fluids for maintenance was given in 0.00% of patient-days in cycle one as compared to 76.7% in cycle two. Sodium and potassium doses were given within the recommended range of 0.00% and 24% patient-days respectively in cycle one. In cycle two, sodium and potassium were given according to the guidelines in 46.7% and 60% of patient-days respectively. Electrolyte disturbances occurred in 69.7% of patient-days in cycle one, decreasing to 46.7% in cycle two, primarily in the form of hyponatremia and hypokalemia.

CONCLUSION

This study highlighted the need for continued monitoring and emphasized the importance of adequate medical staff training about postoperative IV fluids and electrolytes.

Pyogenic Liver Abscess and the Important Role of Point-of-Care Ultrasound (POCUS) in Daily Practice: A Report of Two Cases

A pyogenic liver abscess (PLA) is uncommon and a potentially life-threatening condition. Clinical manifestations and laboratory investigations can be non-specific and the detection of PLAs requires imaging, which can often be delayed. Point-of-care ultrasound (POCUS) is now becoming more widely adopted and plays an important role in clinical practice. We report two cases of PLA, one of which was a gas-forming PLA that we encountered in a district general hospital where POCUS played an important role in the diagnosis and management. The diagnoses of PLAs were initially unsuspected due to a combination of non-specific symptom manifestations, initial negative imaging, and a subtle radiological clue that was missed due to a lack of awareness. Bedside POCUS examinations were done due to clinical deterioration in one patient and lack of inflammatory marker improvement in both patients. These cases highlight the important role of POCUS in the management of patients with liver abscesses.

Quantification of Metabolic Acidosis at Bedside by S.A.L.T Approach

Introduction

Traditionally, metabolic acidosis is analyzed using an anion gap (AG). The aim of the study was to compare the utility of quantitative David Story's simplified Stewart approach against traditional approach to analyze metabolic acidosis. ICU setting. Analytical, cross-sectional observational study.

Methods

Blood gas reports of 50 adult critically ill patients with primary metabolic acidosis at admission were analyzed using both approaches. With traditional approach, acidosis was classified simply as high or normal AG acidosis. With S.A.L.T approach, the components of base deficit were further quantified into sodium chloride, albumin, lactate, and other ions effects. A contribution of sodium chloride or albumin effect of > 30% to the base deficit was considered significant. The proportion of patients with such abnormalities was determined. Descriptive statistics was used.

Results

The mean ± standard deviation (SD) age of patients was 54.52 ± 19.71 years, 52% were males, and 72% were medical admissions. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 10 (5-13). The mean ± SD pH, bicarbonate, base excess, and albumin were 7.198 ± 0.13, 11.73 ± 4.2 mmol/L, -15.13 ± 5.6 mmol/L, and 2.9 ± 0.77 g%, respectively. The median (IQR) of serum lactate was 6.77 (1.53, 16.32) mmol/L. Hyponatremia and hypochloremia were seen in 68% and 46% of patients, respectively. Eighty-eight percent of patients had acidosis due to other ions, 52% due to lactates. Twenty-eight percent had a significant sodium chloride effect and 32% had significant hypoalbuminemia.

Conclusion

Quantification of base deficit of metabolic acidosis using S.A.L.T approach showed changes in sodium chloride levels and hypoalbuminemia affecting base deficit in nearly 30% of the patients. Quantification of metabolic acidosis using S.A.L.T approach is likely to help treat metabolic acidosis more appropriately, with clinical implications.

Candidemia Following Severe COVID-19 in Hospitalised and Critical Ill Patients: A Systematic Review and Meta-Analysis

RATIONALE

The epidemiology and clinical impact of COVID-19-associated candidemia (CAC) remained uncertain, leaving gaps in understanding its prevalence, risk factors and outcomes.

METHODS

A systematic review and meta-analysis were conducted by searching PubMed, Embase and Scopus for reports of CAC prevalence, risk factors and clinical outcomes up to June 18, 2024. The generalised linear mixed model was employed to determine the prevalence and 95% confidence intervals (CIs). The risk factors and clinical outcomes were compared between patients with and without CAC using the inverse variance method.

RESULTS

From 81 studies encompassing 29 countries and involving 351,268 patients, the global prevalence of CAC was 4.33% (95% Cl, 3.16%-5.90%) in intensive care unit (ICU) patients. In ICUs, the pooled prevalence of CAC in high-income countries was significantly higher than that of lower-middle-income countries (5.99% [95% Cl, 4.24%-8.40%] vs. 2.23% [95% Cl, 1.06%-4.61%], p = 0.02). Resistant Candida species, including C. auris, C. glabrata (Nakaseomyces glabratus) and C. krusei (Pichia kudriavzveii), constituted 2% of ICU cases. The mortality rate for CAC was 68.40% (95% Cl, 61.86%-74.28%) among ICU patients. Several risk factors were associated with CAC, including antibiotic use, central venous catheter placement, dialysis, mechanical ventilation, tocilizumab, extracorporeal membrane oxygenation and total parenteral nutrition. Notably, the pooled odds ratio of tocilizumab was 2.59 (95% CI, 1.44-4.65).

CONCLUSIONS

The prevalence of CAC is substantial in the ICU setting, particularly in high-income countries. Several risk factors associated with CAC were identified, including several that are modifiable, offering the opportunity to mitigate the risk of CAC.

Association Between Neurological Status and Outcomes in Cardiac Arrest Patients Undergoing PCI in Contemporary Practice: Insights From BMC2

BACKGROUND

Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre-percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI.

METHODS

The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury.

RESULTS

Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P<0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67-8.04]; P<0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97-19.51]; P<0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34-34.23]; P<0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients.

CONCLUSIONS

Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient's pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI.

Proton Pump Inhibitor Usage in Urban vs. Rural Intensive Care Units: A Narrative Review of Implications for Standardization of Care

Intensive care unit (ICU) patients frequently require and benefit from stress ulcer prophylaxis (SUP) using proton pump inhibitors (PPIs). Despite recognized benefits, PPIs are overutilized in patients who do not have high-risk factors predisposing them to clinically significant gastrointestinal bleeding (CSGIB), including mechanical ventilation and coagulopathy. This overuse increases the risk of adverse effects associated with PPIs. Several urban healthcare systems have created educational initiatives aimed at reducing PPI usage in patients who do not meet recommendations or who are outside the period for serious risk of CSGIB. However, there was no available literature exploring PPI use or educational trends in rural hospitals. This situation presents an opportunity to investigate the disparities in PPI use between rural and urban healthcare settings. This narrative review aimed to assess current data on PPI usage in both urban and rural critical care environments, and to appraise existing practices, ultimately identifying gaps in current literature and informing future guidelines. With these evaluations, this review intended to provide a comprehensive overview of current PPI prescribing practices in the ICU and improve patient care across diverse healthcare settings.

Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries

INTRODUCTION

The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs).

METHODS

This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR.

RESULTS

Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001).

CONCLUSIONS

Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations.

Effect of the Levels and Sources of Noise on the Sleep Quality of Conscious Patients in Emergency Intensive Care Unit

PURPOSE

This study aimed to assess the levels and sources of noise in the emergency intensive care unit (EICU) of an emergency department and investigate their effects on the sleep quality of conscious patients.

METHODS

A study was conducted on patients admitted to the EICU from December 2020 to December 2023. They were categorised according to their sleep quality with the Pittsburgh Sleep Quality Index. Environmental noise levels were measured using precision sound level metres and environmental noise automatic monitoring instruments. Data analysis was performed using SPSS version 25.0, and Chi-square test, Fisher's exact probability and t-tests were conducted when applicable. The significance threshold was set at P < 0.05. Regression analysis was carried out for indicators with significant differences.

RESULTS

A total of 200 patients were included in the study. Of them 96 in the ideal sleep group and 104 in the non-ideal sleep group. Patients with non-ideal sleep experienced significantly higher noise levels across various measures (P < 0.05). Additionally, patients with non-ideal sleep reported significantly higher occurrences of noise-related awakening, difficulty in falling asleep, nightmares or vivid dreams and sleepwalking episodes (P < 0.05). Significant differences in staff activities, including staff conversations, equipment noise exposure, cleaning activities, patient interventions and overhead pages, were observed between the groups (P < 0.05). Multivariate logistic regression analysis indicating that the average noise level, conversational speech, equipment alarms, ambient noise, peak noise levels, staff conversations, cleaning activities, patient interventions and overhead pages were significant contributors to poor sleep.

CONCLUSION

The study suggested that high noise levels and staff-related activities affected the sleep quality of conscious patients in the EICU. Targeted measures could improve the prognoses of patients.

Comparative Side-Effects of Neurosurgical Treatment of Treatment-Resistant Depression

INTRODUCTION

Treatment-resistant depression (TRD) is a condition in which patients suffering from depression no longer respond to common methods of treatment, such as anti-depressant medication. Neurosurgical procedures such as ablative surgery, deep brain stimulation, and vagus nerve stimulation have been used in efforts to overcome TRD.

OBJECTIVES

This review aims to provide an overview of the side effects of neurosurgery performed in clinical studies related to depression.

METHODS

A literature search was conducted through PubMed, MEDLINE, EMBASE, Ovid, and ClinicalTrials.gov databases.

RESULTS

This review selected 10 studies for ablative surgery, 12 for deep brain stimulation, and 10 for vagus nerve stimulation, analyzing their side effect profiles of neurosurgery for TRD. The major side effects of each type of neurosurgery were identified, such as incontinence and confusion for ablative surgery, headaches and increased suicide ideation for deep brain stimulation, and voice hoarseness and dyspnea for vagus nerve stimulation.

CONCLUSION

The review discusses the merits and demerits of neurosurgery as a treatment option for TRD. It also suggests new insights into decreasing the burden of these neurosurgical side effects so that they can be a viable, high-efficacy treatment method for TRD.

Relation Between Multiplication of Venous Carbon Dioxide Partial Pressure (PvCO2) and the Ratio of Gas Flow to Pump Flow (Ve/Q) with Hyperlactatemia During Cardiopulmonary Bypass

BACKGROUND

The incidence of hyperlactatemia due to hypoperfusion during cardiopulmonary bypass (CPB) increases morbidity. Carbon dioxide production during CPB is one of the lactate production markers, in addition to other markers such as delivery oxygen (DO2), oxygen consumption (VO2), mixed vein oxygen saturation (SvO2), and oxygen extraction ratio (O2ER).

METHOD

This observational analytic study was conducted on 40 adult cardiac surgery patients using a CPB machine. Initial lactate is taken when entering CPB and final lactate is examined 15 min after coming off bypass. The values of DO2, VO2, SvO2, VCO2, respiratory quotient (RQ), DO2/VCO2, PvCO2 × Ve/Q were calculated from the results of blood and venous gas analysis 1 h after entering CPB in the nadir of core temperature and lowest pump flow.

RESULT

The multivariate test showed that the value of PvCO2 × Ve/Q was more effective than other oxygenation and carbon dioxide parameters in predicting an increase in the percentage of lactate. Each increase of 1 mmHg PvCO2 ×× Ve/Q can predict a final lactate increase of 29% from the initial lactate. The high PvCO2 × Ve/Q value is also the strongest correlation factor for the incidence of hyperlactatemia after CPB (final lactate >3 mmol/L). The cutoff value of this marker is >19.3 mmHg, which has a sensitivity of 100% and a specificity of 55.6% with a strong correlation value.

CONCLUSION

The PvCO2 × Ve/Q value proved to be one of the significant markers in predicting hyperlactatemia during cardiac surgery using CPB.

The Prospective Analysis of Biomarkers in Sepsis: Correlation With Clinical Outcomes

Background Sepsis is a medical emergency and necessitates immediate diagnosis and treatment to prevent the progression to severe sepsis, septic shock, and potentially mortality. Aim This study aims to study the diagnostic significance of conventional and new markers, interleukin-10 (IL-10), in predicting the severity of sepsis. Methodology A prospective observational study was conducted in the department of surgery in a tertiary care hospital in Pune, India. The study included 100 patients diagnosed with a quick Sequential Organ Failure Assessment (qSOFA) score of ≥2. Serum C-reactive protein (CRP), procalcitonin (PCT), and interleukin-10 (IL-10) levels were measured. Receiver operating characteristic (ROC) curves were plotted to assess the diagnostic performance of these biomarkers. Results The mean serum CRP level on day 7 was significantly higher than the baseline, day 1, and day 3 groups (p=0.0001). On analysis by repeated measure, the ANOVA test revealed that the mean CRP levels on day 7 were significantly higher. The mean PCT levels on day 7, day 3, and day 1 groups were significantly lower than those on day 1, day 2, and day 2, respectively (p=0.0001). The mean p-value of 3.3 g/L CRP was significantly lower on day 1 than that on day 3. IL-10 levels showed a significant upward trend, rising from 5.21 pg/mL at baseline to 7.57 pg/mL by day 7, with a p-value of <0.0001. Our cohort population showed elevated IL-10 values on the day of admission in a total of 15 patients. In our study, we observed that 11 patients with elevated IL-10 levels progressed toward multiple organ dysfunction syndrome (MODS) and four mortalities. IL-10 is a crucial marker for identifying patients with worsening surgical sepsis. Conclusion IL-10, CRP, and PCT have potential as prognostic markers in assessing and predicting disease severity. The dynamic changes in these biomarkers correlate strongly with clinical outcomes, suggesting their role in guiding treatment decisions.

Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery.

METHODS

In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively.

RESULTS

A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype.

CONCLUSIONS

A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.

Effects of volume management on free flap perfusion and metabolism in a large animal model study

Free flap failure represents a substantial clinical burden. The role of intraoperative volume management remains controversial, with valid studies lacking. Here, using a large animal model, we investigated the influence of volume management on free flap perfusion and metabolism. Autotransfer of a musculocutaneous gracilis flap was performed on 31 German domestic pigs, with arterial anastomosis and catheterization of the pedicle vein for sequential blood sampling. Flap reperfusion was followed by induction of a hemorrhagic shock with maintenance for 30 min and subsequent circulation stabilization with crystalloid solution, crystalloid solution and catecholamine, autotransfusion or colloidal solution. Flap perfusion and oxygenation were periodically assessed using hyperspectral imaging. Flap metabolism was assessed via periodic blood gas analyses. Hyperspectral imaging revealed no difference in either superficial or deep tissue oxygen saturation, tissue hemoglobin or tissue water content between the test groups at any time point. Blood gas analyses showed that lactate levels were significantly increased in the group that received crystalloid solution and catecholamine, after circulatory stabilization and up to 2 h after. We conclude that, in hemorrhagic shock, volume management impacts acid-base balance in free flaps. Crystalloid solutions with norepinephrine increase lactate levels, yet short-term effects on flap perfusion seem minimal, suggesting that vasopressors are not detrimental.

Reimagining Undergraduate Critical Care Medical Education: A Path for the Next Decade

Foundational training in critical care medicine is an integral part of both undergraduate and graduate medical education. Yet, many medical school graduates enter residency underprepared to care for critically ill patients because of a lack of ubiquity of undergraduate critical care education and the heterogeneity of existing didactic and clinical experiences. This Perspective explores the importance of undergraduate critical care education, the current national and international landscape, innovative educational strategies and exemplar curricula, and recent advances in assessment that may better reflect learner-centered educational outcomes. As broad curricular reforms push medical education toward a more innovative, interactive, and collaborative future, now is the time to rethink and reimagine undergraduate critical care education.

Performance and safety of PowerPICC catheters and accessories: a prospective observational study

OBJECTIVE

This study aimed to evaluate the safety and performance of PowerPICC catheters in a real-world setting.

DESIGN

Prospective, observational, multicentre study.

SETTING

Nine European countries, involving 14 centres.

PARTICIPANTS

General patient population.

INTERVENTION

PowerPICC catheter inserted by the clinician as standard of care with routinely collected outcomes followed through device removal or 180 days postinsertion.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Safety and performance outcomes were assessed for PowerPICC, PowerPICC SOLO 2 and PowerGroshong PICC. The primary safety endpoint was the incidence of symptomatic venous thrombosis (VT), and secondary safety endpoints included phlebitis, extravasation, vessel laceration, vessel perforation local infection, accidental dislodgment and catheter-related bloodstream infection (CRBSI). The primary performance endpoint was the percentage of patients whose PowerPICC device remained in place through the completion of therapy. The secondary performance endpoints included catheter patency, placement success in a single attempt and usability.

RESULTS

The enrolled patients (N=451) received either PowerPICC, PowerPICC SOLO 2 or PowerGroshong PICC catheters. Across all devices, 1.6% of patients developed symptomatic VT, and CRBSI occurred in 1.6% of patients. There were no cases of phlebitis or extravasation and only three cases of vein laceration or vein perforation. The catheters showed high success rates in completing therapy (81.8%), maintaining patency (93.9%) and achieving successful placement in a single attempt (90.4%). Clinicians overwhelmingly agreed that both the guidewire and stylet (93.3% and 94.4%, respectively) were easy or very easy to use.

CONCLUSIONS

This study demonstrates the safety and performance of PowerPICC catheters across diverse settings and patient cohorts in real-world hospital settings across Europe. The findings indicate that these catheters are safe and can be effectively used in the general patient setting and when inserted by a variety of clinicians. The low incidence of complications and high success rates further support the clinical utility of these catheters.

TRIAL REGISTRATION NUMBER

NCT04263649.

Receptor and metabolic insights on the ability of caffeine to prevent alcohol-induced stimulation of mesolimbic dopamine transmission

The consumption of alcohol and caffeine affects the lives of billions of individuals worldwide. Although recent evidence indicates that caffeine impairs the reinforcing properties of alcohol, a characterization of its effects on alcohol-stimulated mesolimbic dopamine (DA) function was lacking. Acting as the pro-drug of salsolinol, alcohol excites DA neurons in the posterior ventral tegmental area (pVTA) and increases DA release in the nucleus accumbens shell (AcbSh). Here we show that caffeine, via antagonistic activity on A2A adenosine receptors (A2AR), prevents alcohol-dependent activation of mesolimbic DA function as assessed, in-vivo, by brain microdialysis of AcbSh DA and, in-vitro, by electrophysiological recordings of pVTA DA neuronal firing. Accordingly, while the A1R antagonist DPCPX fails to prevent the effects of alcohol on DA function, both caffeine and the A2AR antagonist SCH 58261 prevent alcohol-dependent pVTA generation of salsolinol and increase in AcbSh DA in-vivo, as well as alcohol-dependent excitation of pVTA DA neurons in-vitro. However, caffeine also prevents direct salsolinol- and morphine-stimulated DA function, suggesting that it can exert these inhibitory effects also independently from affecting alcohol-induced salsolinol formation or bioavailability. Finally, untargeted metabolomics of the pVTA showcases that caffeine antagonizes alcohol-mediated effects on molecules (e.g. phosphatidylcholines, fatty amides, carnitines) involved in lipid signaling and energy metabolism, which could represent an additional salsolinol-independent mechanism of caffeine in impairing alcohol-mediated stimulation of mesolimbic DA transmission. In conclusion, the outcomes of this study strengthen the potential of caffeine, as well as of A2AR antagonists, for future development of preventive/therapeutic strategies for alcohol use disorder.

Numerical Study of the Effect of the Port Angle of the Superior Vena Cava Supplying Cannula on Hemodynamics in the Right Atrium in VV-ECMO

Objective: To elucidate the pattern of the influence of the port angle of the superior vena cava supplying cannula (SVCS) on hemodynamics within the right atrium in VV-ECMO. Methods: A three-dimensional model of the right atrium was established based on CT images of a real patient. The 3D models of the SVCS and inferior vena cava draining cannula (IVCD) were established based on the Edwards 18Fr and Medos 22Fr real intubation models, respectively. Based on these models, three-dimensional models of the SVCS ports with bending angles of -90°, -60°, -30°, 0°, 30°, 60°, and 90° in the plane formed by the centerline of the SVCS and the center point of the tricuspid valve (TV) were established. Transient-state computational fluid dynamics (CFD) was performed to clarify the right atrium blood flow pattern and hemodynamic states at different SVCS port orientation angles. The velocity clouds, wall pressure, wall shear stress (WSS), relative residence time (RRT), and recirculation fraction (RF) were calculated to assess hemodynamic changes in the right atrium at different angles of the port of the SVCS. Results: As the angle of the port of the superior chamber cannula changed, the location of the high-velocity blood impingement from the SVCS changed, and the pattern of blood flow within the right atrium was dramatically altered. The results for the maximum right atrial wall pressure were 13,472 pa, 13,424 pa, 10,915 pa, 7680.2 pa, 5890.3 pa, 5597.6 pa, and 7883.5 pa (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the mean right atrial wall pressure were 6788.9 pa, 8615.1 pa, 8684.9 pa, 6717.2 pa, 5429.2 pa, 5455.6 pa, and 7117.8 pa ( -90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°). The results of the maximum right atrial wall WSS in the seven cases were 63.572 pa, 55.839 pa, 31.705 pa, 39.531 pa, 40.11 pa, 28.474 pa, and 35.424 (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively, and the results of the mean right atrial wall WSS results were 3.8589 pa, 3.6706 pa, 3.3013 pa, 3.2487 pa, 2.3995 pa, 1.3304 pa, and 2.0747 pa (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively. The results for the area percentage of high RRT in the seven cases were 3.44%, 2.23%, 4.24%, 1.83%, 3.69%, 7.73%, and 3.68% (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the RF were 21.57%, 23.24%, 19.78%, 12.57%, 10.24%, 5.07%, and 8.05% (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°). Conclusions: The more the port of the SVCS is oriented toward the TV, the more favorable it is for reducing RF and the impingement of blood flow in the right atrial wall, but there may be an increased risk of RRT. The opposite orientation of the SVCS port to the TV is not conducive to reducing flow impingement on the right atrial wall and RF.

Struggling to Understand the NEC Spectrum-Could the Integration of Metabolomics, Clinical-Laboratory Data, and Other Emerging Technologies Help Diagnosis?

Necrotizing enterocolitis (NEC) is the most prevalent and potentially fatal intestinal injury mainly affecting premature infants, with significant long-term consequences for those who survive. This review explores the scale of the problem, highlighting advancements in epidemiology, the understanding of pathophysiology, and improvements in the prediction and diagnosis of this complex, multifactorial, and multifaced disease. Additionally, we focus on the potential role of metabolomics in distinguishing NEC from other conditions, which could allow for an earlier and more accurate classification of intestinal injuries in infants. By integrating metabolomic data with other diagnostic approaches, it is hoped to enhance our ability to predict outcomes and tailor treatments, ultimately improving care for affected infants.