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Siuba MT, Bulgarelli L, Duggal A, Cavalcanti AB, Zampieri FG, Rey DA, Lucena WDR, Maia IS, Paisani DM, Laranjeira LN, Neto AS, Deliberato RO. Differential Effect of Positive End-Expiratory Pressure Strategies in Patients With ARDS: A Bayesian Analysis of Clinical Subphenotypes. Chest 2024; 166:754-764. [PMID: 38768777 DOI: 10.1016/j.chest.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/22/2024] [Accepted: 04/06/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND ARDS is a heterogeneous condition with two subphenotypes identified by different methodologies. Our group similarly identified two ARDS subphenotypes using nine routinely available clinical variables. However, whether these are associated with differential response to treatment has yet to be explored. RESEARCH QUESTION Are there differential responses to positive end-expiratory pressure (PEEP) strategies on 28-day mortality according to subphenotypes in adult patients with ARDS? STUDY DESIGN AND METHODS We evaluated data from two prior ARDS trials (Higher vs Lower Positive End-Expiratory Pressures in Patients With the ARDS [ALVEOLI] and the Alveolar Recruitment in ARDS Trial [ART]) that compared different PEEP strategies. We classified patients into one of two subphenotypes as described previously. We assessed the differential effect of PEEP with a Bayesian hierarchical logistic model for the primary outcome of 28-day mortality. RESULTS We analyzed data from 1,559 patients with ARDS. Compared with lower PEEP, a higher PEEP strategy resulted in higher 28-day mortality in patients with subphenotype A disease in the ALVEOLI study (OR, 1.61; 95% credible interval [CrI], 0.90-2.94) and ART (OR, 1.73; 95% CrI, 1.01-2.98), with a probability of harm resulting from higher PEEP in this subphenotype of 94.3% and 97.7% in the ALVEOLI and ART studies, respectively. Higher PEEP was not associated with mortality in patients with subphenotype B disease in each trial (OR, 0.95 [95% CrI, 0.51-1.73] and 1.00 [95% CrI, 0.63-1.55], respectively), with probability of benefit of 56.4% and 50.7% in the ALVEOLI and ART studies, respectively. These effects were not modified by Pao2 to Fio2 ratio, driving pressure, or the severity of illness for the cohorts. INTERPRETATION We found evidence of differential response to PEEP strategies across two ARDS subphenotypes, suggesting possible harm with a higher PEEP strategy in one subphenotype. These observations may assist with predictive enrichment in future clinical trials.
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Affiliation(s)
- Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
| | - Lucas Bulgarelli
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | | | | | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rodrigo Octávio Deliberato
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Biostatistics, Health Informatics and Data Science (BHIDS), University of Cincinnati College of Medicine, Cincinnati, OH
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2
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Goossen RL, van Vliet R, Bos LDJ, Buiteman-Kruizinga LA, Hollman MW, Myatra SN, Neto AS, Spronk PE, van der Woude MCE, van Meenen DMP, Paulus F, Schultz MJ. High PEEP/low FiO 2 ventilation is associated with lower mortality in COVID-19. J Crit Care 2024; 83:154854. [PMID: 38996499 DOI: 10.1016/j.jcrc.2024.154854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/07/2024] [Accepted: 06/23/2024] [Indexed: 07/14/2024]
Abstract
RATIONALE The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO2 ventilation on outcomes during the second wave in the Netherlands. METHODS Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality. RESULTS This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings. CONCLUSIONS High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS.
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Affiliation(s)
- Robin L Goossen
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands.
| | - Relin van Vliet
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Laura A Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands; Department of Intensive Care, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Markus W Hollman
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands; Faculty of Health, ACHIEVE, center of applied research, University of Applied Research, Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria
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3
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van der Ven FSLIM, Blok SG, Azevedo LC, Bellani G, Botta M, Estenssoro E, Fan E, Ferreira JC, Laffey JG, Martin-Loeches I, Motos A, Pham T, Peñuelas O, Pesenti A, Pisani L, Neto AS, Schultz MJ, Torres A, Tsonas AM, Paulus F, van Meenen DMP. Epidemiology, ventilation management and outcomes of COVID-19 ARDS patients versus patients with ARDS due to pneumonia in the Pre-COVID era. Respir Res 2024; 25:312. [PMID: 39153979 PMCID: PMC11330602 DOI: 10.1186/s12931-024-02910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 07/07/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Ventilation management may differ between COVID-19 ARDS (COVID-ARDS) patients and patients with pre-COVID ARDS (CLASSIC-ARDS); it is uncertain whether associations of ventilation management with outcomes for CLASSIC-ARDS also exist in COVID-ARDS. METHODS Individual patient data analysis of COVID-ARDS and CLASSIC-ARDS patients in six observational studies of ventilation, four in the COVID-19 pandemic and two pre-pandemic. Descriptive statistics were used to compare epidemiology and ventilation characteristics. The primary endpoint were key ventilation parameters; other outcomes included mortality and ventilator-free days and alive (VFD-60) at day 60. RESULTS This analysis included 6702 COVID-ARDS patients and 1415 CLASSIC-ARDS patients. COVID-ARDS patients received lower median VT (6.6 [6.0 to 7.4] vs 7.3 [6.4 to 8.5] ml/kg PBW; p < 0.001) and higher median PEEP (12.0 [10.0 to 14.0] vs 8.0 [6.0 to 10.0] cm H2O; p < 0.001), at lower median ΔP (13.0 [10.0 to 15.0] vs 16.0 [IQR 12.0 to 20.0] cm H2O; p < 0.001) and higher median Crs (33.5 [26.6 to 42.1] vs 28.1 [21.6 to 38.4] mL/cm H2O; p < 0.001). Following multivariable adjustment, higher ΔP had an independent association with higher 60-day mortality and less VFD-60 in both groups. Higher PEEP had an association with less VFD-60, but only in COVID-ARDS patients. CONCLUSIONS Our findings show important differences in key ventilation parameters and associations thereof with outcomes between COVID-ARDS and CLASSIC-ARDS. TRIAL REGISTRATION Clinicaltrials.gov (identifier NCT05650957), December 14, 2022.
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Affiliation(s)
- Fleur-Stefanie L I M van der Ven
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Intensive Care, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands.
| | - Siebe G Blok
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Luciano C Azevedo
- Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Giacomo Bellani
- Centre for Medical Sciences (CISMed), University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Elisa Estenssoro
- Department of Intensive Care, Hospital Interzonal de Agudos General San Martin La Plata, Buenos Aires, Argentina
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Juliana Carvalho Ferreira
- Department of Pulmonology, Instituto Do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
- Department of Intensive Care, AC Camargo Cancer Center, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - John G Laffey
- Department of Anaesthesiology and Intensive Care, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland
- Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ana Motos
- Departement of Pulmonology, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Institute of Health Carlos III, Madrid, Spain
- University of Barcelona, Barcelona, Spain
| | - Tai Pham
- Equipe d'Epidémiologie Respiratoire Integrative, Université Paris-Saclay, Paris, France
- Service de Médecine Intensive-Réanimation, DMU CORREVE, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Hôpital de Bicêtre, Paris, France
| | - Oscar Peñuelas
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Department of Intensive Care, Hospital Universitario de Getafe, Getafe, Spain
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva Delle Fonti, Italy
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria
- Laboratory of Experimental Intensive Care & Anaesthesiology (L·E·I·C·A), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Antoni Torres
- Departement of Pulmonology, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Institute of Health Carlos III, Madrid, Spain
- University of Barcelona, Barcelona, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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4
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Zhaoyang X, Xin Z. PEEP on postoperative complications: not to fast. J Anesth 2024; 38:573-574. [PMID: 38117328 DOI: 10.1007/s00540-023-03299-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Xiao Zhaoyang
- Department of Anesthesiology, The Second Hospital of Dalian Medical University, Dalian , Liaoning Province, China
| | - Zheng Xin
- Department of Anesthesiology, The Second Hospital of Dalian Medical University, Dalian , Liaoning Province, China.
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5
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Tran TK, Tran MC, Joseph A, Phan PA, Grau V, Farmery AD. A systematic review of machine learning models for management, prediction and classification of ARDS. Respir Res 2024; 25:232. [PMID: 38834976 DOI: 10.1186/s12931-024-02834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/04/2024] [Indexed: 06/06/2024] Open
Abstract
AIM Acute respiratory distress syndrome or ARDS is an acute, severe form of respiratory failure characterised by poor oxygenation and bilateral pulmonary infiltrates. Advancements in signal processing and machine learning have led to promising solutions for classification, event detection and predictive models in the management of ARDS. METHOD In this review, we provide systematic description of different studies in the application of Machine Learning (ML) and artificial intelligence for management, prediction, and classification of ARDS. We searched the following databases: Google Scholar, PubMed, and EBSCO from 2009 to 2023. A total of 243 studies was screened, in which, 52 studies were included for review and analysis. We integrated knowledge of previous work providing the state of art and overview of explainable decision models in machine learning and have identified areas for future research. RESULTS Gradient boosting is the most common and successful method utilised in 12 (23.1%) of the studies. Due to limitation of data size available, neural network and its variation is used by only 8 (15.4%) studies. Whilst all studies used cross validating technique or separated database for validation, only 1 study validated the model with clinician input. Explainability methods were presented in 15 (28.8%) of studies with the most common method is feature importance which used 14 times. CONCLUSION For databases of 5000 or fewer samples, extreme gradient boosting has the highest probability of success. A large, multi-region, multi centre database is required to reduce bias and take advantage of neural network method. A framework for validating with and explaining ML model to clinicians involved in the management of ARDS would be very helpful for development and deployment of the ML model.
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Affiliation(s)
- Tu K Tran
- Department of Engineering and Science, University of Oxford, Oxford, UK.
- Nuffield Department of Clinical Neurosciences, Oxford Institute of Biomedical Engineering, University of Oxford, Oxford, UK.
| | - Minh C Tran
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | - Arun Joseph
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | - Phi A Phan
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | - Vicente Grau
- Department of Engineering and Science, University of Oxford, Oxford, UK
| | - Andrew D Farmery
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
- Nuffield Department of Clinical Neurosciences, Oxford Institute of Biomedical Engineering, University of Oxford, Oxford, UK
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6
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Maia IS, Medrado FA, Tramujas L, Tomazini BM, Oliveira JS, Sady ERR, Barbante LG, Nicola ML, Gurgel RM, Damiani LP, Negrelli KL, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Fernandes RP, Zandonai CL, Pincelli MP, Figueiredo RC, Bustamante CLS, Norbin LF, Boschi E, Lessa R, Romano MP, Miura MC, de Alencar MS, Dantas VCDS, Barreto PA, Hernandes ME, Grion CMC, Laranjeira AS, Mezzaroba AL, Bahl M, Starke AC, Biondi RS, Dal-Pizzol F, Caser EB, Thompson MM, Padial AA, Veiga VC, Leite RT, Araújo G, Guimarães M, Martins PDA, Lacerda FH, Hoffmann CR, Melro L, Pacheco E, Ospina-Táscon GA, Ferreira JC, Freires FJC, Machado FR, Cavalcanti AB, Zampieri FG. Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan. CRITICAL CARE SCIENCE 2024; 36:e20240210en. [PMID: 38775567 PMCID: PMC11098077 DOI: 10.62675/2965-2774.20240210-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear. OBJECTIVE To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia. METHODS The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance. OUTCOMES The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide. CONCLUSION STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.
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Affiliation(s)
- STAMINA Study Group Investigators
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
- Hospital Nereu RamosFlorianópolisSCBrazilHospital Nereu Ramos - Florianópolis (SC), Brazil.
- Hospital e Maternidade São JoséColatinaESBrazilHospital e Maternidade São José - Colatina (ES), Brazil.
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
- Hospital São Vicente de PauloBarbalhaCEBrazilHospital São Vicente de Paulo - Barbalha (CE), Brazil.
- Hospital Marcílio DiasRio de JaneiroRJBrazilHospital Marcílio Dias - Rio de Janeiro (RJ), Brazil.
- Santa Casa de VotuporangaVotuporangaSPBrazilSanta Casa de Votuporanga - Votuporanga (SP), Brazil.
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
- Hospital BrasíliaBrasíliaDFBrazilHospital Brasília - Brasília (DF), Brazil.
- Hospital São JoséCriciúmaSCBrazilHospital São José - Criciúma (SC), Brazil.
- Hospital Unimed VitóriaVitóriaSCBrazilHospital Unimed Vitória - Vitória (SC), Brazil.
- Hospital Evangélico de Cachoeiro de ItapemirimCachoeiro de ItapemirimESBrazilHospital Evangélico de Cachoeiro de Itapemirim - Cachoeiro de Itapemirim (ES), Brazil.
- Instituto Baía SulFlorianópolisSCBrazilInstituto Baía Sul - Florianópolis (SC), Brazil.
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
- Imperial Hospital de CaridadeFlorianópolisSCBrazilImperial Hospital de Caridade - Florianópolis (SC), Brazil.
- Santa Casa de Misericórdia de BarretosBarretosSPBrazilSanta Casa de Misericórdia de Barretos - Barretos (SP), Brazil.
- Hospital Estadual Dr. Jayme Santos NevesSerraESBrazilHospital Estadual Dr. Jayme Santos Neves - Serra (ES), Brazil.
- Hospital OtoclínicaFortalezaCEBrazilHospital Otoclínica - Fortaleza (CE), Brazil.
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazilHospital Regional Hans Dieter Schmidt - Joinville (SC), Brazil.
- Hospital SamaritanoSão PauloSPBrazilHospital Samaritano, São Paulo (SP), Brazil.
- Hospital SepacoSão PauloSPBrazilHospital Sepaco - São Paulo (SP), Brazil.
- Universidad ICESIFundación Valle del LiliColombiaCOFundación Valle del Lili - Universidad ICESI - Colombia, CO.
- Universidade de São PauloHospital das ClínicasDepartment of PneumologySão PauloSPBrazilDepartment of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
- University of Alberta and Alberta Health Services - EdmontonFaculty of Medicine and DentistryDepartment of Critical Care MedicineAlbertaCanadaDepartment of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services - Edmonton, Alberta, Canada.
| | - Israel Silva Maia
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Fernando Azevedo Medrado
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Lucas Tramujas
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Bruno Martins Tomazini
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Júlia Souza Oliveira
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Erica Regina Ribeiro Sady
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Letícia Galvão Barbante
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Marina Lazzari Nicola
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Rodrigo Magalhães Gurgel
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Lucas Petri Damiani
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Karina Leal Negrelli
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Tamiris Abait Miranda
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Eliana Santucci
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Nanci Valeis
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Ligia Nasi Laranjeira
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Glauco Adrieno Westphal
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
| | - Ruthy Perotto Fernandes
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
| | - Cássio Luis Zandonai
- Hospital Nereu RamosFlorianópolisSCBrazilHospital Nereu Ramos - Florianópolis (SC), Brazil.
| | | | - Rodrigo Cruvinel Figueiredo
- Hospital e Maternidade São JoséColatinaESBrazilHospital e Maternidade São José - Colatina (ES), Brazil.
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
| | | | - Luiz Fernando Norbin
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
| | - Emerson Boschi
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
| | - Rafael Lessa
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
| | - Marcelo Pereira Romano
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Mieko Cláudia Miura
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Meton Soares de Alencar
- Hospital São Vicente de PauloBarbalhaCEBrazilHospital São Vicente de Paulo - Barbalha (CE), Brazil.
| | | | - Priscilla Alves Barreto
- Hospital Marcílio DiasRio de JaneiroRJBrazilHospital Marcílio Dias - Rio de Janeiro (RJ), Brazil.
| | - Mauro Esteves Hernandes
- Santa Casa de VotuporangaVotuporangaSPBrazilSanta Casa de Votuporanga - Votuporanga (SP), Brazil.
| | - Cintia Magalhães Carvalho Grion
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
| | - Alexandre Sanches Laranjeira
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
| | - Ana Luiza Mezzaroba
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
| | - Marina Bahl
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
| | - Ana Carolina Starke
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
| | - Rodrigo Santos Biondi
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Hospital BrasíliaBrasíliaDFBrazilHospital Brasília - Brasília (DF), Brazil.
| | - Felipe Dal-Pizzol
- Hospital São JoséCriciúmaSCBrazilHospital São José - Criciúma (SC), Brazil.
| | | | - Marlus Muri Thompson
- Hospital Evangélico de Cachoeiro de ItapemirimCachoeiro de ItapemirimESBrazilHospital Evangélico de Cachoeiro de Itapemirim - Cachoeiro de Itapemirim (ES), Brazil.
| | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
| | - Rodrigo Thot Leite
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
| | - Gustavo Araújo
- Imperial Hospital de CaridadeFlorianópolisSCBrazilImperial Hospital de Caridade - Florianópolis (SC), Brazil.
| | - Mário Guimarães
- Santa Casa de Misericórdia de BarretosBarretosSPBrazilSanta Casa de Misericórdia de Barretos - Barretos (SP), Brazil.
| | - Priscilla de Aquino Martins
- Hospital Estadual Dr. Jayme Santos NevesSerraESBrazilHospital Estadual Dr. Jayme Santos Neves - Serra (ES), Brazil.
| | | | - Conrado Roberto Hoffmann
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazilHospital Regional Hans Dieter Schmidt - Joinville (SC), Brazil.
| | - Livia Melro
- Hospital SamaritanoSão PauloSPBrazilHospital Samaritano, São Paulo (SP), Brazil.
| | - Eduardo Pacheco
- Hospital SepacoSão PauloSPBrazilHospital Sepaco - São Paulo (SP), Brazil.
| | | | - Juliana Carvalho Ferreira
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Universidade de São PauloHospital das ClínicasDepartment of PneumologySão PauloSPBrazilDepartment of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Fabricio Jocundo Calado Freires
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Alexandre Biasi Cavalcanti
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Fernando Godinho Zampieri
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- University of Alberta and Alberta Health Services - EdmontonFaculty of Medicine and DentistryDepartment of Critical Care MedicineAlbertaCanadaDepartment of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services - Edmonton, Alberta, Canada.
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7
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Slim MA, Lim EHT, van Vught LA, Boer AMTD, Rademaker E, Mulier JLGH, Engel JJ, Pickkers P, van de Veerdonk FL, Vlaar APJ, Derde LPG, Juffermans NP. The effect of immunosuppressive therapies on the endothelial host response in critically ill COVID-19 patients. Sci Rep 2024; 14:9113. [PMID: 38643179 PMCID: PMC11032323 DOI: 10.1038/s41598-024-59385-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2024] [Indexed: 04/22/2024] Open
Abstract
While several effective therapies for critically ill patients with COVID-19 have been identified in large, well-conducted trials, the mechanisms underlying these therapies have not been investigated in depth. Our aim is to investigate the association between various immunosuppressive therapies (corticosteroids, tocilizumab and anakinra) and the change in endothelial host response over time in critically ill COVID-19 patients. We conducted a pre-specified multicenter post-hoc analysis in a Dutch cohort of COVID-19 patients admitted to the ICU between March 2020 and September 2021 due to hypoxemic respiratory failure. A panel of 18 immune response biomarkers in the complement, coagulation and endothelial function domains were measured using ELISA or Luminex. Biomarkers were measured on day 0-1, day 2-4 and day 6-8 after start of COVID-19 treatment. Patients were categorized into four treatment groups: no immunomodulatory treatment, corticosteroids, anakinra plus corticosteroids, or tocilizumab plus corticosteroids. The association between treatment group and the change in concentrations of biomarkers was estimated with linear mixed-effects models, using no immunomodulatory treatment as reference group. 109 patients with a median age of 62 years [IQR 54-70] of whom 72% (n = 78) was male, were included in this analysis. Both anakinra plus corticosteroids (n = 22) and tocilizumab plus corticosteroids (n = 38) were associated with an increase in angiopoietin-1 compared to no immune modulator (n = 23) (beta of 0.033 [0.002-0.064] and 0.041 [0.013-0.070] per day, respectively). These treatments, as well as corticosteroids alone (n = 26), were further associated with a decrease in the ratio of angiopoietin-2/angiopoietin-1 (beta of 0.071 [0.034-0.107], 0.060 [0.030-0.091] and 0.043 [0.001-0.085] per day, respectively). Anakinra plus corticosteroids and tocilizumab plus corticosteroids were associated with a decrease in concentrations of complement complex 5b-9 compared to no immunomodulatory treatment (0.038 [0.006-0.071] and 0.023 [0.000-0.047], respectively). Currently established treatments for critically ill COVID-19 patients are associated with a change in biomarkers of the angiopoietin and complement pathways, possibly indicating a role for stability of the endothelium. These results increase the understanding of the mechanisms of interventions and are possibly useful for stratification of patients with other inflammatory conditions which may potentially benefit from these treatments.
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Affiliation(s)
- M A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, the Netherlands.
| | - E H T Lim
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - E Rademaker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J L G Haitsma Mulier
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J Engel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L P G Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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8
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Pennati F, Aliverti A, Pozzi T, Gattarello S, Lombardo F, Coppola S, Chiumello D. Machine learning predicts lung recruitment in acute respiratory distress syndrome using single lung CT scan. Ann Intensive Care 2023; 13:60. [PMID: 37405546 PMCID: PMC10322807 DOI: 10.1186/s13613-023-01154-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/11/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND To develop and validate classifier models that could be used to identify patients with a high percentage of potentially recruitable lung from readily available clinical data and from single CT scan quantitative analysis at intensive care unit admission. 221 retrospectively enrolled mechanically ventilated, sedated and paralyzed patients with acute respiratory distress syndrome (ARDS) underwent a PEEP trial at 5 and 15 cmH2O of PEEP and two lung CT scans performed at 5 and 45 cmH2O of airway pressure. Lung recruitability was defined at first as percent change in not aerated tissue between 5 and 45 cmH2O (radiologically defined; recruiters: Δ45-5non-aerated tissue > 15%) and secondly as change in PaO2 between 5 and 15 cmH2O (gas exchange-defined; recruiters: Δ15-5PaO2 > 24 mmHg). Four machine learning (ML) algorithms were evaluated as classifiers of radiologically defined and gas exchange-defined lung recruiters using different models including different variables, separately or combined, of lung mechanics, gas exchange and CT data. RESULTS ML algorithms based on CT scan data at 5 cmH2O classified radiologically defined lung recruiters with similar AUC as ML based on the combination of lung mechanics, gas exchange and CT data. ML algorithm based on CT scan data classified gas exchange-defined lung recruiters with the highest AUC. CONCLUSIONS ML based on a single CT data at 5 cmH2O represented an easy-to-apply tool to classify ARDS patients in recruiters and non-recruiters according to both radiologically defined and gas exchange-defined lung recruitment within the first 48 h from the start of mechanical ventilation.
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Affiliation(s)
- Francesca Pennati
- Ipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Andrea Aliverti
- Ipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - Davide Chiumello
- Department of Health Sciences, University of Milan, Milan, Italy.
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy.
- Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
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9
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Mazzinari G, Zampieri FG, Ball L, Campos NS, Bluth T, Hemmes SN, Ferrando C, Librero J, Soro M, Pelosi P, Gama de Abreu M, Schultz MJ, Serpa Neto A. Effect of intraoperative PEEP with recruitment maneuvers on the occurrence of postoperative pulmonary complications during general anesthesia--protocol for Bayesian analysis of three randomized clinical trials of intraoperative ventilation. F1000Res 2023; 11:1090. [PMID: 37234075 PMCID: PMC10207960 DOI: 10.12688/f1000research.125861.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 10/22/2023] Open
Abstract
Background: Using the frequentist approach, a recent meta-analysis of three randomized clinical trials in patients undergoing intraoperative ventilation during general anesthesia for major surgery failed to show the benefit of ventilation that uses high positive end-expiratory pressure with recruitment maneuvers when compared to ventilation that uses low positive end-expiratory pressure without recruitment maneuvers. Methods: We designed a protocol for a Bayesian analysis using the pooled dataset. The multilevel Bayesian logistic model will use the individual patient data. Prior distributions will be prespecified to represent a varying level of skepticism for the effect estimate. The primary endpoint will be a composite of postoperative pulmonary complications (PPC) within the first seven postoperative days, which reflects the primary endpoint of the original studies. We preset a range of practical equivalence to assess the futility of the intervention with an interval of odds ratio (OR) between 0.9 and 1.1 and assess how much of the 95% of highest density interval (HDI) falls between the region of practical equivalence. Ethics and dissemination: The used data derive from approved studies that were published in recent years. The findings of this current analysis will be reported in a new manuscript, drafted by the writing committee on behalf of the three research groups. All investigators listed in the original trials will serve as collaborative authors.
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Affiliation(s)
- Guido Mazzinari
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
| | | | - Lorenzo Ball
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Niklas S. Campos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
| | - Thomas Bluth
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sabrine N.T. Hemmes
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
| | - Carlos Ferrando
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Julian Librero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
| | - Marina Soro
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Paolo Pelosi
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J. Schultz
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROVHILO investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - iPROVE investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROBESE investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROVE network investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
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10
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Granholm A, Munch MW, Andersen‐Ranberg N, Myatra SN, Vijayaraghavan BKT, Venkatesh B, Jha V, Wahlin RR, Jakob SM, Cioccari L, Møller MH, Perner A. Heterogeneous treatment effects of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia-Post hoc exploratory analyses of the COVID STEROID 2 trial. Acta Anaesthesiol Scand 2023; 67:195-205. [PMID: 36314057 PMCID: PMC9874464 DOI: 10.1111/aas.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/12/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Corticosteroids improve outcomes in patients with severe COVID-19. In the COVID STEROID 2 randomised clinical trial, we found high probabilities of benefit with dexamethasone 12 versus 6 mg daily. While no statistically significant heterogeneity in treatment effects (HTE) was found in the conventional, dichotomous subgroup analyses, these analyses have limitations, and HTE could still exist. METHODS We assessed whether HTE was present for days alive without life support and mortality at Day 90 in the trial according to baseline age, weight, number of comorbidities, category of respiratory failure (type of respiratory support system and oxygen requirements) and predicted risk of mortality using an internal prediction model. We used flexible models for continuous variables and logistic regressions for categorical variables without dichotomisation of the baseline variables of interest. HTE was assessed both visually and with p and S values from likelihood ratio tests. RESULTS There was no strong evidence for substantial HTE on either outcome according to any of the baseline variables assessed with all p values >.37 (and all S values <1.43) in the planned analyses and no convincingly strong visual indications of HTE. CONCLUSIONS We found no strong evidence for HTE with 12 versus 6 mg dexamethasone daily on days alive without life support or mortality at Day 90 in patients with COVID-19 and severe hypoxaemia, although these results cannot rule out HTE either.
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Affiliation(s)
- Anders Granholm
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Marie Warrer Munch
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Nina Andersen‐Ranberg
- Collaboration for Research in Intensive CareCopenhagenDenmark,Department of Anaesthesiology and Intensive Care MedicineZealand University HospitalKøgeDenmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and PainTata Memorial Hospital, Homi Bhabha National InstituteMumbaiIndia
| | | | | | - Vivekanand Jha
- Chennai Critical Care ConsultantsChennaiIndia,Prasanna School of Public HealthManipal Academy of Higher EducationManipalIndia,School of Public HealthImperial College LondonLondonUK
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland,Department of Intensive Care MedicineKantonsspital AarauAarauSwitzerland
| | - Morten Hylander Møller
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Anders Perner
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
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11
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Schultz MJ, van Meenen DM, Bos LD. COVID-19-related acute respiratory distress syndrome: lessons learned during the pandemic. THE LANCET. RESPIRATORY MEDICINE 2022; 10:1108-1110. [PMID: 36335954 PMCID: PMC9633071 DOI: 10.1016/s2213-2600(22)00401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - David M van Meenen
- Department of Intensive Care, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lieuwe D Bos
- Department of Intensive Care, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands,Department of Pulmonology, Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, Netherlands
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12
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Yueyi J, Jing T, Lianbing G. A structured narrative review of clinical and experimental studies of the use of different positive end-expiratory pressure levels during thoracic surgery. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:717-731. [PMID: 36181340 PMCID: PMC9629996 DOI: 10.1111/crj.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present a review on the general effects of different positive end-expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. DATA SOURCE Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one-lung ventilation, PEEP, and thoracic surgery. RESULTS We divide the non-individualized PEEP value into five grades, that is, less than 5, 5, 5-10, 10, and more than 10 cmH2 O, among which 5 cmH2 O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. CONCLUSIONS Available data suggest that PEEP might play an important role in one-lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.
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Affiliation(s)
- Jiang Yueyi
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina
| | - Tan Jing
- Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
| | - Gu Lianbing
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina,Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
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13
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Rashid M, Ramakrishnan M, Chandran VP, Nandish S, Nair S, Shanbhag V, Thunga G. Artificial intelligence in acute respiratory distress syndrome: A systematic review. Artif Intell Med 2022; 131:102361. [DOI: 10.1016/j.artmed.2022.102361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/01/2022] [Accepted: 07/11/2022] [Indexed: 11/02/2022]
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14
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Phenotypes of sickle cell intensive care admissions: an unsupervised machine learning approach in a single-center retrospective cohort. Ann Hematol 2022; 101:1951-1957. [PMID: 35836008 DOI: 10.1007/s00277-022-04918-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/27/2022] [Indexed: 11/01/2022]
Abstract
Sickle cell disease (SCD) is associated with multiple known complications and increased mortality. This study aims to further understand the profile of intensive care unit (ICU) admissions of SCD patients. In this single-center retrospective cohort (approval number 0926-11), we evaluated SCD-related ICU admissions at our hospital in São Paulo, Brazil. Admissions were clustered using clinical data and organ dysfunction at ICU admission. A hierarchical clustering method was used to distinguish phenotypes. From 140 admissions obtained, 125 were included. The mean age was 30 years, 48% were male, and SS genotype was predominant (71.2%). Non-surgical causes of admissions accounted for 85.6% (n = 107). The mean Sequential Organ Failure Assessment score (SOFA) was 4 (IQR 2-7). Vasopressors were required by 12% and mechanical ventilation by 17.6%. After analysis of the average silhouette width, the optimal number of clusters was 3: cluster 1 (n = 69), cluster 2 (n = 25), cluster 3 (n = 31). Cluster 1 had a mean age of 29 years, 87% of SS genotype, and mean SOFA of 4. Cluster 2 had a mean age of 37 years, 80% of SS genotype, and mean SOFA of 8. Cluster 3 had a mean age of 26 years, 29% of SS genotype, and mean SOFA of 3. The need for mechanical ventilation was 11.6%, 44%, and 9.7%, respectively. Mortality was significantly higher in cluster 2 (44%, p = 0.012). This cohort of critical SCD admissions suggested the presence of three different profiles. This can be informative in the ICU setting to identify SCD patients at higher risk of worse outcomes.
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15
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Shah FA, Meyer N, Angus DC, Yende S. Reply to Goligher et al.: Physiology Is Vital to Precision Medicine in Acute Respiratory Distress Syndrome and Sepsis. Am J Respir Crit Care Med 2022; 206:121-122. [PMID: 35533404 PMCID: PMC9954328 DOI: 10.1164/rccm.202203-0534le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Faraaz Ali Shah
- University of PittsburghPittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Healthcare SystemPittsburgh, Pennsylvania
| | - Nuala Meyer
- University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Sachin Yende
- University of PittsburghPittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Healthcare SystemPittsburgh, Pennsylvania,Corresponding author (e-mail: )
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16
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Okada Y, Komukai S, Kitamura T, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Inoue T, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Matsuyama T, Nishioka N, Kobayashi D, Matsui S, Hirayama A, Yoshimura S, Kimata S, Shimazu T, Ohtsuru S, Iwami T. Clinical Phenotyping of Out-of-Hospital Cardiac Arrest Patients With Shockable Rhythm - Machine Learning-Based Unsupervised Cluster Analysis. Circ J 2022; 86:668-676. [PMID: 34732587 DOI: 10.1253/circj.cj-21-0675] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The hypothesis of this study is that latent class analysis could identify the subphenotypes of out-of-hospital cardiac arrest (OHCA) patients associated with the outcomes and allow us to explore heterogeneity in the effects of extracorporeal cardiopulmonary resuscitation (ECPR). METHODS AND RESULTS This study was a retrospective analysis of a multicenter prospective observational study (CRITICAL study) of OHCA patients. It included adult OHCA patients with initial shockable rhythm. Patients from 2012 to 2016 (development dataset) were included in the latent class analysis, and those from 2017 (validation dataset) were included for evaluation. The association between subphenotypes and outcomes was investigated. Further, the heterogeneity of the association between ECPR implementation and outcomes was explored. In the study results, a total of 920 patients were included for latent class analysis. Three subphenotypes (Groups 1, 2, and 3) were identified, mainly characterized by the distribution of partial pressure of O2(PO2), partial pressure of CO2(PCO2) value of blood gas assessment, cardiac rhythm on hospital arrival, and estimated glomerular filtration rate. The 30-day survival outcomes were varied across the groups: 15.7% in Group 1; 30.7% in Group 2; and 85.9% in Group 3. Further, the association between ECPR and 30-day survival outcomes by subphenotype groups in the development dataset was as varied. These results were validated using the validation dataset. CONCLUSIONS The latent class analysis identified 3 subphenotypes with different survival outcomes and potential heterogeneity in the effects of ECPR.
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Affiliation(s)
- Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine, Osaka University
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | | | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center, Osaka Police Hospital
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital
| | - Changhwi Park
- Department of Emergency Medicine, Tane General Hospital
| | | | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kindai University Faculty of Medicine
| | | | | | | | | | - Taku Sogabe
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital
| | - Takaya Morooka
- Emergency and Critical Care Medical Center, Osaka City General Hospital
| | | | - Keitaro Suzuki
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
| | - Norihiro Nishioka
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Daisuke Kobayashi
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | - Satoshi Yoshimura
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Shunsuke Kimata
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University
| | - Taku Iwami
- Department of Preventive Services, School of Public Health, Kyoto University
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17
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Patel B, Mumby S, Johnson N, Falaschetti E, Hansen J, Adcock I, McAuley D, Takata M, Karbing DS, Jabaudon M, Schellengowski P, Rees SE. Decision support system to evaluate ventilation in the acute respiratory distress syndrome (DeVENT study)-trial protocol. Trials 2022; 23:47. [PMID: 35039050 PMCID: PMC8762446 DOI: 10.1186/s13063-021-05967-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/23/2021] [Indexed: 12/16/2022] Open
Abstract
Background The acute respiratory distress syndrome (ARDS) occurs in response to a variety of insults, and mechanical ventilation is life-saving in this setting, but ventilator-induced lung injury can also contribute to the morbidity and mortality in the condition. The Beacon Caresystem is a model-based bedside decision support system using mathematical models tuned to the individual patient’s physiology to advise on appropriate ventilator settings. Personalised approaches using individual patient description may be particularly advantageous in complex patients, including those who are difficult to mechanically ventilate and wean, in particular ARDS. Methods We will conduct a multi-centre international randomised, controlled, allocation concealed, open, pragmatic clinical trial to compare mechanical ventilation in ARDS patients following application of the Beacon Caresystem to that of standard routine care to investigate whether use of the system results in a reduction in driving pressure across all severities and phases of ARDS. Discussion Despite 20 years of clinical trial data showing significant improvements in ARDS mortality through mitigation of ventilator-induced lung injury, there remains a gap in its personalised application at the bedside. Importantly, the protective effects of higher positive end-expiratory pressure (PEEP) were noted only when there were associated decreases in driving pressure. Hence, the pressures set on the ventilator should be determined by the diseased lungs’ pressure-volume relationship which is often unknown or difficult to determine. Knowledge of extent of recruitable lung could improve the ventilator driving pressure. Hence, personalised management demands the application of mechanical ventilation according to the physiological state of the diseased lung at that time. Hence, there is significant rationale for the development of point-of-care clinical decision support systems which help personalise ventilatory strategy according to the current physiology. Furthermore, the potential for the application of the Beacon Caresystem to facilitate local and remote management of large numbers of ventilated patients (as seen during this COVID-19 pandemic) could change the outcome of mechanically ventilated patients during the course of this and future pandemics. Trial registration ClinicalTrials.gov identifier NCT04115709. Registered on 4 October 2019, version 4.0 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05967-2.
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Affiliation(s)
- Brijesh Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK.
| | - Sharon Mumby
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Nicholas Johnson
- Imperial Clinical Trials Unit, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | | | | | - Ian Adcock
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Masao Takata
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
| | - Dan S Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Peter Schellengowski
- Medical University of Vienna, Department of Medicine I, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Stephen E Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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18
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Klitgaard TL, Schjørring OL, Lange T, Møller MH, Perner A, Rasmussen BS, Granholm A. Lower versus higher oxygenation targets in critically ill patients with severe hypoxaemia: secondary Bayesian analysis to explore heterogeneous treatment effects in the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) trial. Br J Anaesth 2022; 128:55-64. [PMID: 34674834 PMCID: PMC8787771 DOI: 10.1016/j.bja.2021.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) trial, a lower (8 kPa) vs a higher (12 kPa) PaO2 target did not affect mortality amongst critically ill adult patients. We used Bayesian statistics to evaluate any heterogeneity in the effect of oxygenation targets on mortality between different patient groups within the HOT-ICU trial. METHODS We analysed 90-day all-cause mortality using adjusted Bayesian logistic regression models, and assessed heterogeneous treatment effects according to four selected baseline variables using both hierarchical models of subgroups and models with interactions on the continuous scales. Results are presented as mortality probability (%) and relative risk (RR) with 95% credibility intervals (CrI). RESULTS All 2888 patients in the intention-to-treat cohort of the HOT-ICU trial were included. The adjusted 90-day mortality rates were 43.0% (CrI: 38.3-47.8%) and 42.3% (CrI: 37.7-47.1%) in the lower and higher oxygenation groups, respectively (RR 1.02 [CrI: 0.93-1.11]), with 36.5% probability of an RR <1.00. Analyses of heterogeneous treatment effects suggested a dose-response relationship between baseline norepinephrine dose and increased mortality with the lower oxygenation target, with 95% probability of increased mortality associated with the lower oxygenation target as norepinephrine doses increased. CONCLUSIONS A lower oxygenation target was unlikely to affect overall mortality amongst critically ill adult patients with acute hypoxaemic respiratory failure. However, our results suggest an increasing mortality risk for patients with a lower oxygen target as the baseline norepinephrine dose increases. These findings warrant additional investigation. CLINICAL TRIAL REGISTRATION NCT03174002.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark.
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Theis Lange
- Collaboration for Research in Intensive Care, Copenhagen, Denmark; Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Møller
- Collaboration for Research in Intensive Care, Copenhagen, Denmark; Department of Intensive Care 4131, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Collaboration for Research in Intensive Care, Copenhagen, Denmark; Department of Intensive Care 4131, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Anders Granholm
- Collaboration for Research in Intensive Care, Copenhagen, Denmark; Department of Intensive Care 4131, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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19
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Garfield B, Handslip R, Patel BV. Ventilator-Associated Lung Injury. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8128668 DOI: 10.1016/b978-0-08-102723-3.00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilatory support, while life saving, can also cause or aggravate lung injury through several mechanisms which are encompassed within ventilator-associated lung injury (VALI). The important realizationin the acute respiratory distress syndrome that the “baby” lung resided in non-dependent areas led to the conceptualization of “lung rest” to reduce stress and strain to exposed alveolar units. We discuss concepts and mechanisms within VALI that ultimately induce maladaptive lung responses, as well as, current and future management strategies to detect and mitigate VALI at the bedside.
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20
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Okada Y, Komukai S, Kitamura T, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Inoue T, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Matsuyama T, Nishioka N, Kobayashi D, Matsui S, Hirayama A, Yoshimura S, Kimata S, Shimazu T, Ohtsuru S, Iwami T. Clustering out‐of‐hospital cardiac arrest patients with non‐shockable rhythm by machine learning latent class analysis. Acute Med Surg 2022; 9:e760. [PMID: 35664809 PMCID: PMC9136939 DOI: 10.1002/ams2.760] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022] Open
Abstract
Aim We aimed to identify subphenotypes among patients with out‐of‐hospital cardiac arrest (OHCA) with initial non‐shockable rhythm by applying machine learning latent class analysis and examining the associations between subphenotypes and neurological outcomes. Methods This study was a retrospective analysis within a multi‐institutional prospective observational cohort study of OHCA patients in Osaka, Japan (the CRITICAL study). The data of adult OHCA patients with medical causes and initial non‐shockable rhythm presenting with OHCA between 2012 and 2016 were included in machine learning latent class analysis models, which identified subphenotypes, and patients who presented in 2017 were included in a dataset validating the subphenotypes. We investigated associations between subphenotypes and 30‐day neurological outcomes. Results Among the 12,594 patients in the CRITICAL study database, 4,849 were included in the dataset used to classify subphenotypes (median age: 75 years, 60.2% male), and 1,465 were included in the validation dataset (median age: 76 years, 59.0% male). Latent class analysis identified four subphenotypes. Odds ratios and 95% confidence intervals for a favorable 30‐day neurological outcome among patients with these subphenotypes, using group 4 for comparison, were as follows; group 1, 0.01 (0.001–0.046); group 2, 0.097 (0.051–0.171); and group 3, 0.175 (0.073–0.358). Associations between subphenotypes and 30‐day neurological outcomes were validated using the validation dataset. Conclusion We identified four subphenotypes of OHCA patients with initial non‐shockable rhythm. These patient subgroups presented with different characteristics associated with 30‐day survival and neurological outcomes.
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Affiliation(s)
- Yohei Okada
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine Osaka University Suita Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine Osaka University Osaka Japan
| | - Takeyuki Kiguchi
- Critical Care and Trauma Center Osaka General Medical Center Osaka Japan
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center Osaka Police Hospital Osaka Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine Takii Hospital, Kansai Medical University Moriguchi Japan
| | - Changhwi Park
- Department of Emergency Medicine Tane General Hospital Osaka Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine Osaka City University Osaka Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine Kindai University School of Medicine Osaka‐Sayama Japan
| | - Yoshiki Yagi
- Osaka Mishima Emergency Critical Care Center Takatsuki Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine Higashi‐Osaka Japan
| | | | - Yasuyuki Hayashi
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Center National Hospital Organization Osaka National Hospital Osaka Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Center Osaka City General Hospital Osaka Japan
| | - Haruko Sakamoto
- Department of Pediatrics Osaka Red Cross Hospital Osaka Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Center Kishiwada Tokushukai Hospital Osaka Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Norihiro Nishioka
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Daisuke Kobayashi
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine Osaka University Osaka Japan
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Satoshi Yoshimura
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Shunsuke Kimata
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Taku Iwami
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
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21
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Marshall DC, Komorowski M. Is artificial intelligence ready to solve mechanical ventilation? Computer says blow. Br J Anaesth 2021; 128:231-233. [PMID: 34903359 DOI: 10.1016/j.bja.2021.10.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/20/2022] Open
Abstract
Artificial intelligence (AI) has the potential to identify treatable phenotypes, optimise ventilation strategies, and provide clinical decision support for patients who require mechanical ventilation. Gallifant and colleagues performed a systematic review to identify studies using AI to solve a diverse range of clinical problems in the ventilated patient. They identify 95 studies, the majority of which were reported in the last 5 yr. Their findings indicate that the majority of studies have significant methodological bias and are a long way from deployment.
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22
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Randomised clinical trials in critical care: past, present and future. Intensive Care Med 2021; 48:164-178. [PMID: 34853905 PMCID: PMC8636283 DOI: 10.1007/s00134-021-06587-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
Randomised clinical trials (RCTs) are the gold standard for providing unbiased evidence of intervention effects. Here, we provide an overview of the history of RCTs and discuss the major challenges and limitations of current critical care RCTs, including overly optimistic effect sizes; unnuanced conclusions based on dichotomization of results; limited focus on patient-centred outcomes other than mortality; lack of flexibility and ability to adapt, increasing the risk of inconclusive results and limiting knowledge gains before trial completion; and inefficiency due to lack of re-use of trial infrastructure. We discuss recent developments in critical care RCTs and novel methods that may provide solutions to some of these challenges, including a research programme approach (consecutive, complementary studies of multiple types rather than individual, independent studies), and novel design and analysis methods. These include standardization of trial protocols; alternative outcome choices and use of core outcome sets; increased acceptance of uncertainty, probabilistic interpretations and use of Bayesian statistics; novel approaches to assessing heterogeneity of treatment effects; adaptation and platform trials; and increased integration between clinical trials and clinical practice. We outline the advantages and discuss the potential methodological and practical disadvantages with these approaches. With this review, we aim to inform clinicians and researchers about conventional and novel RCTs, including the rationale for choosing one or the other methodological approach based on a thorough discussion of pros and cons. Importantly, the most central feature remains the randomisation, which provides unparalleled restriction of confounding compared to non-randomised designs by reducing confounding to chance.
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23
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Khan YA, Fan E, Ferguson ND. Precision Medicine and Heterogeneity of Treatment Effect in Therapies for Acute Respiratory Distress Syndrome. Chest 2021; 160:1729-1738. [PMID: 34270967 PMCID: PMC8277554 DOI: 10.1016/j.chest.2021.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically heterogenous syndrome, rather than a distinct disease. This heterogeneity at least partially explains the difficulty in studying treatments for these patients and contributes to the numerous trials of therapies for the syndrome that have not shown benefit. Recent studies have identified different subphenotypes within the heterogenous patient population. These different subphenotypes likely have variable clinical responses to specific therapies, a concept known as heterogeneity of treatment effect (HTE). Recognizing different subphenotypes and HTE has important implications for the clinical management of patients with ARDS. In this review, we will present studies that have identified different subphenotypes and discuss how they can modify the effects of therapies evaluated in trials that are commonly considered to have demonstrated no overall benefit in patients with ARDS.
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Affiliation(s)
- Yasin A Khan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
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24
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Kudo D, Goto T, Uchimido R, Hayakawa M, Yamakawa K, Abe T, Shiraishi A, Kushimoto S. Coagulation phenotypes in sepsis and effects of recombinant human thrombomodulin: an analysis of three multicentre observational studies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:114. [PMID: 33741010 PMCID: PMC7978458 DOI: 10.1186/s13054-021-03541-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
Background A recent randomised trial showed that recombinant thrombomodulin did not benefit patients who had sepsis with coagulopathy and organ dysfunction. Several recent studies suggested presence of clinical phenotypes in patients with sepsis and heterogenous treatment effects across different sepsis phenotypes. We examined the latent phenotypes of sepsis with coagulopathy and the associations between thrombomodulin treatment and the 28-day and in-hospital mortality for each phenotype. Methods This was a secondary analysis of multicentre registries containing data on patients (aged ≥ 16 years) who were admitted to intensive care units for severe sepsis or septic shock in Japan. Three multicentre registries were divided into derivation (two registries) and validation (one registry) cohorts. Phenotypes were derived using k-means with coagulation markers, platelet counts, prothrombin time/international normalised ratios, fibrinogen, fibrinogen/fibrin-degradation-products (FDP), D-dimer, and antithrombin activities. Associations between thrombomodulin treatment and survival outcomes (28-day and in-hospital mortality) were assessed in the derived clusters using a generalised estimating equation. Results Four sepsis phenotypes were derived from 3694 patients in the derivation cohort. Cluster dA (n = 323) had severe coagulopathy with high FDP and D-dimer levels, severe organ dysfunction, and high mortality. Cluster dB had severe disease with moderate coagulopathy. Clusters dC and dD had moderate and mild disease with and without coagulopathy, respectively. Thrombomodulin was associated with a lower 28-day (adjusted risk difference [RD]: − 17.8% [95% CI − 28.7 to − 6.9%]) and in-hospital (adjusted RD: − 17.7% [95% CI − 27.6 to − 7.8%]) mortality only in cluster dA. Sepsis phenotypes were similar in the validation cohort, and thrombomodulin treatment was also associated with lower 28-day (RD: − 24.9% [95% CI − 49.1 to − 0.7%]) and in-hospital mortality (RD: − 30.9% [95% CI − 55.3 to − 6.6%]). Conclusions We identified four coagulation marker-based sepsis phenotypes. The treatment effects of thrombomodulin varied across sepsis phenotypes. This finding will facilitate future trials of thrombomodulin, in which a sepsis phenotype with high FDP and D-dimer can be targeted. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03541-5.
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Affiliation(s)
- Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ryo Uchimido
- Intensive Care Unit, Tokyo Medical and Dental University Medical Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Kita 14 Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Kazuma Yamakawa
- Division of Emergency Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, 300-2622, Japan.,Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, 305-8577, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929 Higashimachi, Kamogawa, 296-8602, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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25
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Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent literature on mechanical ventilation strategies in patients with septic shock. RECENT FINDINGS Indirect clinical trial evidence has refined the use of neuromuscular blocking agents, positive end-expiratory pressure (PEEP) and recruitment manoeuvres in septic shock patients with acute respiratory distress syndrome. Weaning strategies and devices have also been recently evaluated. The role of lung protective ventilation in patients with healthy lungs, while recognized, still needs to be further refined. The possible detrimental effects of spontaneous breathing in patients who develop acute respiratory distress syndrome is increasingly recognized, but clinical trial evidence is still lacking to confirm this hypothesis. A new concept of lung and diaphragm protective is emerging in the critical care literature, but its application will need a complex intervention implementation approach to allow adequate scrutiny of this concept and uptake by clinicians. SUMMARY Many advances in the management of the mechanically ventilated patient with sepsis and septic shock have occurred in recent years, but clinical trial evidence is still necessary to translate new hypotheses to the bedside and find the right balance between benefits and risks of these new strategies.
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26
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Zampieri FG, Casey JD, Shankar-Hari M, Harrell FE, Harhay MO. Using Bayesian Methods to Augment the Interpretation of Critical Care Trials. An Overview of Theory and Example Reanalysis of the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial. Am J Respir Crit Care Med 2021; 203:543-552. [PMID: 33270526 PMCID: PMC7924582 DOI: 10.1164/rccm.202006-2381cp] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/03/2020] [Indexed: 12/27/2022] Open
Abstract
Most randomized trials are designed and analyzed using frequentist statistical approaches such as null hypothesis testing and P values. Conceptually, P values are cumbersome to understand, as they provide evidence of data incompatibility with a null hypothesis (e.g., no clinical benefit) and not direct evidence of the alternative hypothesis (e.g., clinical benefit). This counterintuitive framework may contribute to the misinterpretation that the absence of evidence is equal to evidence of absence and may cause the discounting of potentially informative data. Bayesian methods provide an alternative, probabilistic interpretation of data. The reanalysis of completed trials using Bayesian methods is becoming increasingly common, particularly for trials with effect estimates that appear clinically significant despite P values above the traditional threshold of 0.05. Statistical inference using Bayesian methods produces a distribution of effect sizes that would be compatible with observed trial data, interpreted in the context of prior assumptions about an intervention (called "priors"). These priors are chosen by investigators to reflect existing beliefs and past empirical evidence regarding the effect of an intervention. By calculating the likelihood of clinical benefit, a Bayesian reanalysis can augment the interpretation of a trial. However, if priors are not defined a priori, there is a legitimate concern that priors could be constructed in a manner that produces biased results. Therefore, some standardization of priors for Bayesian reanalysis of clinical trials may be desirable for the critical care community. In this Critical Care Perspective, we discuss both frequentist and Bayesian approaches to clinical trial analysis, introduce a framework that researchers can use to select priors for a Bayesian reanalysis, and demonstrate how to apply our proposal by conducting a novel Bayesian trial reanalysis.
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Affiliation(s)
- Fernando G. Zampieri
- Research Institute, HCor‐Hospital do Coração, São Paulo, Brazil
- Center for Epidemiological Research, Southern Denmark University, Odense, Denmark
| | | | - Manu Shankar-Hari
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Guy’s and St. Thomas’ NHS Foundation Trust, ICU Support Offices, St. Thomas’ Hospital, London, United Kingdom
| | - Frank E. Harrell
- School of Immunology & Microbial Sciences, King’s College London, London, United Kingdom; and
| | - Michael O. Harhay
- PAIR (Palliative and Advanced Illness Research) Center Clinical Trials Methods and Outcomes Lab
- Department of Biostatistics, Epidemiology, and Informatics, and
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Battaglini D, Ball L, Wittenstein J, Cohen E, Gama DE Abreu M, Pelosi P. PEEP in thoracic anesthesia: pros and cons. Minerva Anestesiol 2020; 87:223-229. [PMID: 33300325 DOI: 10.23736/s0375-9393.20.14797-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Protective ventilation includes a strategy with low tidal volume, Plateau pressure, driving pressure, positive end-expiratory pressure (PEEP), and recruitment maneuvers on the ventilated lung. The rationale for the application of PEEP during one-lung ventilation (OLV) is that PEEP may contribute to minimize atelectrauma, preventing airway closure and alveolar collapse and improving the ventilation/perfusion to the ventilated lung. However, in case of high partial pressure of oxygen the application of PEEP may cause increased pulmonary vascular resistance, thus diverting blood flow to the non-ventilated lung, and worsening ventilation/perfusion. Further, PEEP may be associated with higher risk of hemodynamic impairment, increased need for fluids and vasoactive drugs. Positive effects on outcome have been reported by titrating PEEP according to driving pressure, targeted to obtain the optimum respiratory as well as pulmonary system compliance. This may vary according to the method employed for titration and should be performed individually for each patient. In summary, the potential for harm combined with the lack of evidence for improved outcome suggest that PEEP must be judiciously used during OLV even when titrated to a safe target, and only as much as necessary to maintain an appropriate gas exchange under low protective tidal volumes and driving pressures.
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Affiliation(s)
- Denise Battaglini
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy
| | - Lorenzo Ball
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Edmond Cohen
- Department of Anesthesiology and Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marcelo Gama DE Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Paolo Pelosi
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy - .,Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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28
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Severac M, Chiali W, Severac F, Perus O, Orban JC, Iannelli A, Debs T, Gugenheim J, Raucoules-Aimé M. Alveolar recruitment manoeuvre results in improved pulmonary function in obese patients undergoing bariatric surgery: a randomised trial. Anaesth Crit Care Pain Med 2020; 40:100775. [PMID: 33137453 DOI: 10.1016/j.accpm.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/14/2019] [Accepted: 09/25/2020] [Indexed: 12/16/2022]
Abstract
Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p = 0.043) and 77% versus 88% at postoperative day 1 (p = 0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.
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Affiliation(s)
- Mathilde Severac
- Department of Anaesthesia, Nice University Hospital, University Côte d'Azur, Nice, France.
| | - Walid Chiali
- Department of Anaesthesia, Nice University Hospital, University Côte d'Azur, Nice, France
| | - François Severac
- Department of Biostatistics, Strasbourg University Hospital, Strasbourg, France
| | - Olivier Perus
- Department of Anaesthesia, Nice University Hospital, University Côte d'Azur, Nice, France
| | - Jean-Christophe Orban
- Department of Anaesthesia, Nice University Hospital, University Côte d'Azur, Nice, France
| | - Antonio Iannelli
- Department of Digestive Surgery and Liver Transplantation, Nice University Hospital, University Côte d'Azur, Nice, France; Inserm, U1065, Team 8 "Hepatic complications of obesity", University Côte d'Azur, Nice, France
| | - Tarek Debs
- Department of Digestive Surgery and Liver Transplantation, Nice University Hospital, University Côte d'Azur, Nice, France
| | - Jean Gugenheim
- Department of Digestive Surgery and Liver Transplantation, Nice University Hospital, University Côte d'Azur, Nice, France
| | - Marc Raucoules-Aimé
- Department of Anaesthesia, Nice University Hospital, University Côte d'Azur, Nice, France
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29
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Pimenta LBM, Sanson NZ, Volpe MS, Amato MBP, Micheletti AMR, Teixeira LDAS. Protective mechanical ventilation in suspected influenza infection. Rev Soc Bras Med Trop 2020; 53:e20190481. [PMID: 33027412 PMCID: PMC7534969 DOI: 10.1590/0037-8682-0481-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/28/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION: Patients with acute respiratory failure due to influenza require ventilatory support. However, mechanical ventilation itself can exacerbate lung damage and increase mortality. METHODS: The aim of this study was to describe a feasible and protective ventilation protocol, with limitation of the tidal volume to ≤6 mL/kg of the predicted weight and a driving pressure ≤15 cmH2O after application of the alveolar recruitment maneuver and PEEP titration. RESULTS: Initial improvement in oxygenation and respiratory mechanics were observed in the four cases submitted to the proposed protocol. CONCLUSIONS: Our results indicate that the mechanical ventilation strategy applied could be optimized.
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Affiliation(s)
- Letícia Brito Mendes Pimenta
- Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação Stricto Sensu em Medicina Tropical e Infectologia, Uberaba, MG, Brasil
| | - Nicole Zanzarini Sanson
- Universidade Federal do Triângulo Mineiro, Curso de Graduação em Medicina, Uberaba, MG, Brasil
| | - Márcia Souza Volpe
- Universidade Federal de São Paulo, Campus Baixada Santista, Departamento de Ciências do Movimento Humano, Santos, SP, Brasil
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30
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Serpa Neto A, Naorungroj T, Murugan R, Kellum JA, Gallagher M, Bellomo R. Heterogeneity of Effect of Net Ultrafiltration Rate among Critically Ill Adults Receiving Continuous Renal Replacement Therapy. Blood Purif 2020; 50:336-346. [PMID: 33027799 DOI: 10.1159/000510556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In continuous renal replacement therapy (CRRT)-treated patients, a net ultrafiltration (NUF) rate >1.75 mL/kg/h has been associated with increased mortality. However, there may be heterogeneity of effect of NUF rate on mortality, according to patient characteristics. METHODS To investigate the presence and impact of heterogeneity of effect, we performed a secondary analysis of the "Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy" (RENAL) trial. Exposure was NUF rate (weight-adjusted fluid volume removed per hour) stratified into tertiles (<1.01 mL/kg/h; 1.01-1.75 mL/kg/h; or >1.75 mL/kg/h). Primary outcome was 90-day mortality. Patients were clustered according to baseline characteristics. Heterogeneity of effect was assessed according to clusters and baseline edema and related to the additional impact of baseline cardiovascular Sequential Organ Failure Assessment (SOFA) score. We excluded patients with missing values for baseline weight and/or treatment duration. RESULTS We identified 2 clusters. The largest (cluster 1; n = 941) included more severely ill patients, with more sepsis, more edema, and more vasopressor therapy (all p < 0.001). Compared to the middle tertile, the probability of harm was greater with the high tertile of NUF rate in patients in cluster 1 and in patients with baseline edema (probability of harm, cluster 1: 99.9%; edema: 99.1%). Moreover, higher baseline cardiovascular SOFA score also increased mortality risk with both high and low compared to middle NUF rates in cluster 1 patients and in patients with edema. CONCLUSIONS In CRRT patients, both high and low NUF rates may be harmful, especially in those with edema, sepsis, and greater illness severity. Cardiovascular SOFA scores modulate this association. Additional studies are needed to test these hypotheses, and targeted trials of NUF rates based on risk stratification appear justified. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00221013.
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Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Amsterdam University Medical Centers, Location "AMC", Amsterdam, The Netherlands
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia, .,Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand,
| | - Raghavan Murugan
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modelling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John A Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modelling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Martin Gallagher
- Department of Nephrology, The George Institute for Global Health and University of Sydney, Sidney, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation (DARE) Centre, The University of Melbourne, Melbourne, Victoria, Australia
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31
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Data-driven ICU management: Using Big Data and algorithms to improve outcomes. J Crit Care 2020; 60:300-304. [PMID: 32977139 DOI: 10.1016/j.jcrc.2020.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/17/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022]
Abstract
The digitalization of the Intensive Care Unit (ICU) led to an increasing amount of clinical data being collected at the bedside. The term "Big Data" can be used to refer to the analysis of these datasets that collect enormous amount of data of different origin and format. Complexity and variety define the value of Big Data. In fact, the retrospective analysis of these datasets allows to generate new knowledge, with consequent potential improvements in the clinical practice. Despite the promising start of Big Data analysis in medical research, which has seen a rising number of peer-reviewed articles, very limited applications have been used in ICU clinical practice. A close future effort should be done to validate the knowledge extracted from clinical Big Data and implement it in the clinic. In this article, we provide an introduction to Big Data in the ICU, from data collection and data analysis, to the main successful examples of prognostic, predictive and classification models based on ICU data. In addition, we focus on the main challenges that these models face to reach the bedside and effectively improve ICU care.
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32
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Abstract
Supplemental Digital Content is available in the text. Influenza virus is a major cause of acute hypoxemic respiratory failure. Early identification of patients who will suffer severe complications can help stratify patients for clinical trials and plan for resource use in case of pandemic.
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33
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Debnath S, Barnaby DP, Coppa K, Makhnevich A, Kim EJ, Chatterjee S, Tóth V, Levy TJ, Paradis MD, Cohen SL, Hirsch JS, Zanos TP. Machine learning to assist clinical decision-making during the COVID-19 pandemic. Bioelectron Med 2020; 6:14. [PMID: 32665967 PMCID: PMC7347420 DOI: 10.1186/s42234-020-00050-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The number of cases from the coronavirus disease 2019 (COVID-19) global pandemic has overwhelmed existing medical facilities and forced clinicians, patients, and families to make pivotal decisions with limited time and information. MAIN BODY While machine learning (ML) methods have been previously used to augment clinical decisions, there is now a demand for "Emergency ML." Throughout the patient care pathway, there are opportunities for ML-supported decisions based on collected vitals, laboratory results, medication orders, and comorbidities. With rapidly growing datasets, there also remain important considerations when developing and validating ML models. CONCLUSION This perspective highlights the utility of evidence-based prediction tools in a number of clinical settings, and how similar models can be deployed during the COVID-19 pandemic to guide hospital frontlines and healthcare administrators to make informed decisions about patient care and managing hospital volume.
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Affiliation(s)
- Shubham Debnath
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - Douglas P. Barnaby
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY USA
| | - Kevin Coppa
- Department of Information Services, Northwell Health, NYC Metro Area, NY USA
| | - Alexander Makhnevich
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY USA
| | - Eun Ji Kim
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY USA
| | - Saurav Chatterjee
- Cardiology, Long Island Jewish Medical Center and Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - Viktor Tóth
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - Todd J. Levy
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | | | - Stuart L. Cohen
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY USA
| | - Jamie S. Hirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY USA
- Department of Information Services, Northwell Health, NYC Metro Area, NY USA
| | - Theodoros P. Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
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Protić A, Bura M, Juričić K. A 23-year-old man with left lung atelectasis treated with a targeted segmental recruitment maneuver: a case report. J Med Case Rep 2020; 14:77. [PMID: 32576293 PMCID: PMC7311183 DOI: 10.1186/s13256-020-02409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/25/2020] [Indexed: 11/21/2022] Open
Abstract
Background Lung atelectasis are nonventilated parts of lung tissue and occur as a result of the collapse of the pulmonary parenchyma (alveoli). Various therapeutic procedures for inflating the collapsed pulmonary parenchyma, such as bronchial aspiration and/or standard recruitment maneuvers, are not always successful. Case presentation We report a case of a 23-year-old Croatian man with a parapharyngeal abscess on the left side of the neck with spreading of infection in the mediastinum and left side of the thorax and consequent major atelectasis of the left lung. The patient was mechanically ventilated. We decided to apply a new method in which a pulmonary artery catheter was placed (guided by bronchoscope) on the entrance to the lower left bronchus. The pulmonary artery catheter balloon was inflated to achieve bronchial closure. Using another respirator, we ventilated the affected lobe separately with continuously high pressure of 30 cmH2O. After 30 minutes, we removed the pulmonary artery catheter from the lower left bronchus and placed it in the upper left bronchus and repeated the procedure. Our method allowed a significantly longer duration (30 minutes) of continuously high pressure of 30 cmH2O separately to only one of the total of five lobes of the lungs while the other four lobes were simultaneously ventilated continuously with protective ventilation mode. Conclusion Use of a pulmonary artery catheter and two respirators in our patient’s case proved to be a successful method for recruiting the atelectatic lung while maintaining protective ventilation of the lung segments without atelectasis.
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Affiliation(s)
- Alen Protić
- Department of Anesthesiology and ICU, University Hospital Rijeka, Tome Strizica 3, 51 000, Rijeka, Croatia.
| | - Matej Bura
- Department of Anesthesiology and ICU, University Hospital Rijeka, Tome Strizica 3, 51 000, Rijeka, Croatia
| | - Kazimir Juričić
- Department of Anesthesiology and ICU, University Hospital Rijeka, Tome Strizica 3, 51 000, Rijeka, Croatia
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35
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Møller MH, Derde LPG, Sweeney RM. Focus on clinical trial interpretation. Intensive Care Med 2020; 46:790-792. [PMID: 32166347 DOI: 10.1007/s00134-020-06000-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Centre for Research in Intensive Care, Copenhagen, Denmark.
| | - Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
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36
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Sahetya SK. Searching for the optimal positive end-expiratory pressure for lung protective ventilation. Curr Opin Crit Care 2020; 26:53-58. [DOI: 10.1097/mcc.0000000000000685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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37
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Granholm A, Marker S, Krag M, Zampieri FG, Thorsen-Meyer HC, Kaas-Hansen BS, van der Horst ICC, Lange T, Wetterslev J, Perner A, Møller MH. Heterogeneity of treatment effect of prophylactic pantoprazole in adult ICU patients: a post hoc analysis of the SUP-ICU trial. Intensive Care Med 2020; 46:717-726. [DOI: 10.1007/s00134-019-05903-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022]
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38
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Turbil E, Galerneau LM, Terzi N, Schwebel C, Argaud L, Guérin C. Positive-end expiratory pressure titration and transpulmonary pressure: the EPVENT 2 trial. J Thorac Dis 2019; 11:S2012-S2017. [PMID: 31632813 DOI: 10.21037/jtd.2019.06.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Emanuele Turbil
- Anesthesiology and Intensive Care, Università degli Studi di Sassari, Sassari, Italy
| | - Louis Marie Galerneau
- Medical ICU, University Hospital, Grenoble, France.,University of Grenoble-Alpes, Grenoble, France
| | - Nicolas Terzi
- Medical ICU, University Hospital, Grenoble, France.,University of Grenoble-Alpes, Grenoble, France
| | - Carole Schwebel
- Medical ICU, University Hospital, Grenoble, France.,University of Grenoble-Alpes, Grenoble, France
| | - Laurent Argaud
- Medical ICU, University Hospital Lyon Center, Lyon, France.,University of Lyon, Lyon, France
| | - Claude Guérin
- University of Lyon, Lyon, France.,INSERM 955, Créteil, France
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39
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Gambus PL, Jaramillo S. Machine learning in anaesthesia: reactive, proactive… predictive! Br J Anaesth 2019; 123:401-403. [DOI: 10.1016/j.bja.2019.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/09/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
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40
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Granholm A, Marker S, Krag M, Zampieri FG, Thorsen‐Meyer H, Kaas‐Hansen BS, Horst ICC, Lange T, Wetterslev J, Perner A, Møller MH. Heterogeneity of treatment effect of stress ulcer prophylaxis in ICU patients: A secondary analysis protocol. Acta Anaesthesiol Scand 2019; 63:1251-1256. [PMID: 31321771 DOI: 10.1111/aas.13432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND In the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial, 3291 adult ICU patients at risk for gastrointestinal (GI) bleeding were randomly allocated to intravenous pantoprazole 40 mg or placebo once daily in the ICU. No difference was observed between the groups in the primary outcome 90-day mortality or the secondary outcomes, except for clinically important gastrointestinal bleeding. However, heterogeneity of treatment effect (HTE) not detected by conventional subgroup analyses could be present. METHODS This is a protocol and statistical analysis plan for a secondary, post hoc, exploratory analysis of the SUP-ICU trial. We will explore HTE in one set of subgroups based on severity of illness (using the Simplified Acute Physiology Score [SAPS] II) and another set of subgroups based on the total number of risk factors for GI bleeding in each patient using Bayesian hierarchical models. We will summarise posterior probability distributions using medians and 95% credible intervals and present probabilities for different levels of benefit and harm of the intervention in each subgroup. Finally, we will assess if the treatment effect interacts with SAPS II and the number of risk factors separately on the continuous scale using marginal effects plots. CONCLUSIONS The outlined post hoc analysis will explore whether HTE was present in the SUP-ICU trial and may help answer some of the remaining questions regarding the balance between benefits and harms of pantoprazole in ICU patients at risk of GI bleeding. CLINICALTRIALS. GOV REGISTRATION NCT02467621.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Mette Krag
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | | | - Hans‐Christian Thorsen‐Meyer
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
- NNF Center for Protein Research University of Copenhagen Copenhagen Denmark
| | - Benjamin S. Kaas‐Hansen
- NNF Center for Protein Research University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | - Iwan C. C. Horst
- Department of Critical Care University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Theis Lange
- Centre for Research in Intensive Care Copenhagen Denmark
- Department of Public Health, Section of Biostatistics University of Copenhagen Copenhagen Denmark
- Center for Statistical Science Peking University Beijing China
| | - Jørn Wetterslev
- Centre for Research in Intensive Care Copenhagen Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care Copenhagen University Hospital — Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
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41
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Komorowski M, Lemyze M. Informing future intensive care trials with machine learning. Br J Anaesth 2019; 123:14-16. [PMID: 31076087 DOI: 10.1016/j.bja.2019.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 12/16/2022] Open
Affiliation(s)
- Matthieu Komorowski
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Intensive Care Unit, Charing Cross Hospital, London, UK.
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