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Tume LN, Simons C, Latten L, Huang C, Comfort P, Compton V, Wagh A, Veale A, Valla FV. Association between protein intake and muscle wasting in critically ill children: A prospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:615-623. [PMID: 38554130 DOI: 10.1002/jpen.2627] [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: 09/11/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Survival from pediatric critical illness in high-income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness. METHODS A prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10. RESULTS Thirty-four children (median age 6.65 [0.47-57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed-up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: -0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: -0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C-reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: -0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063). CONCLUSION Our study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health, Special Care & Medicine, Edge Hill University, Ormskirk, UK
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Christopher Simons
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lynne Latten
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Chao Huang
- Institute for Clinical and Applied Health Research and Hull York Medical School, University of Hull, Hull, UK
| | - Paul Comfort
- Directorate of Psychology and Sport, University of Salford, Salford, Greater Manchester, UK
| | - Vanessa Compton
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anand Wagh
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Archie Veale
- Patient and Public Engagement Expert, Carlisle, UK
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Caddell AJ, Nagpal D, Hegazy AF. Postarrest Care Bundle Improves Quality of Care and Clinical Outcomes in the Normothermia Era. J Intensive Care Med 2024; 39:623-627. [PMID: 38176890 PMCID: PMC11149385 DOI: 10.1177/08850666231223482] [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] [Indexed: 01/06/2024]
Abstract
PURPOSE Temperature targets in patients with cardiac arrest and return of spontaneous circulation (ROSC) have changed. Changes to higher temperature targets have been associated with higher breakthrough fevers and mortality. A post-ROSC normothermia bundle was developed to improve compliance with temperature targets. METHODS In August 2021, "ad hoc" normothermia at the discretion of the attending intensivist was initiated. In December 2021, a post-ROSC normothermia protocol was implemented, incorporating a rigorous, stepwise approach to fever prevention (temperature ≥ 37.8). We conducted a before-after cohort study of all adult patients post-ROSC who survived to intensive care unit admission between August 1, 2021, and April 1, 2022. They were divided into "ad hoc" and "protocol" groups. Clinical outcomes compared included fevers, active cooling, and paralytic use. RESULTS Fifty-eight post-ROSC patients were admitted; 24 in the "ad hoc" and 34 in the "protocol" groups. Patient demographics were similar between groups. The "ad hoc" group had more shockable rhythms (67% vs 24%, P = .001) and cardiac catheterizations (42% vs 15%, P = .03). The "protocol" group were significantly less likely to have a fever at 40 h (6% vs 40%, P < .001) and 72 h (14% vs 65%, P ≤ .001). Patients in the normothermia "protocol" used significantly less neuromuscular blocking agents (24% vs 50%, P = .05). The normothermia "protocol" resulted in similar mortality (56% vs 58%, P = 1.0). CONCLUSION Use of a normothermia "protocol" resulted in fewer fevers and less neuromuscular blocker administration compared to "ad hoc" management. A protocolized approach for improved quality of care should be considered in institutions adopting normothermia.
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Affiliation(s)
- Andrew J Caddell
- Cardiology Division, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dave Nagpal
- Critical Care, Western University, London, Ontario, Canada
| | - Ahmed F Hegazy
- Critical Care, Western University, London, Ontario, Canada
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Liu J, Xu Z, Luo S, Bai Y, Feng J, Li F. Risk factors for ICU-acquired weakness in sepsis patients: A retrospective study of 264 patients. Heliyon 2024; 10:e32253. [PMID: 38867955 PMCID: PMC11168428 DOI: 10.1016/j.heliyon.2024.e32253] [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: 01/01/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/14/2024] Open
Abstract
Background Sepsis is a common critical illness in intensive care unit (ICU) and an important risk factor for intensive care unit-acquired weakness (ICU-AW). The objective of the study is to analyze the risk factors of ICU-AW in septic patients. Methods A total of 264 septic patients admitted to the General Hospital of the Western Theater Command from January 2018 to April 2022 were included in this study. The cohort was divided into 2 groups according to the presence or absence of ICU-AW. Clinical characteristics included age, sex, body mass index, length of ICU stay, multiple organ dysfunction syndrome, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), mechanical ventilation time, intubation, tracheotomy, protective constraint, lactic acid, fasting blood glucose, etc. The clinical characteristics of sepsis were evaluated using logistic regression analysis. Results A total of 114 septic patients suffered ICU-AW during their ICU stay. Multivariate binary logistic regression analysis showed that APACHE Ⅱ score, mechanical ventilation time, protective constraint, and lactic acid were independent risk factors for ICU-AW in septic patients. The areas under the receiver operating characteristic curve (AUCs) were 0.791, 0.740 and 0.812, all P < 0.05, and the optimal cut-off values were 24 points, 5 days and 2.12 mmol/L, respectively. Conclusions A high APACHE Ⅱ score, long mechanical ventilation time, protective constraint and high lactate concentration are independent risk factors for ICU-AW in septic patients. An APACHE Ⅱ score greater than 24 points, mechanical ventilation time longer than 5 days and lactate concentration higher than 2.12 mmol/L are likely to cause ICU-AW.
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Affiliation(s)
- Jiajiao Liu
- Department of Critical Care Medicine, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
| | - Zhaoxia Xu
- Department of Emergency Department, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
| | - Shuhong Luo
- Department of Critical Care Medicine, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
| | - Yujie Bai
- Department of Critical Care Medicine, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
| | - Jian Feng
- Department of Critical Care Medicine, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
| | - Fuxiang Li
- Department of Critical Care Medicine, The General Hospital of Western Theater Command PLA, Chengdu, 610036, China
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Kataria V, Agha T, Ryman K, Iyer N. Strategic Utilization of Dantrolene in a Case of Severe Acute Generalized Tetanus. J Pharm Pract 2024; 37:766-769. [PMID: 37226965 DOI: 10.1177/08971900231178429] [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] [Indexed: 05/26/2023]
Abstract
Tetanus is a life-threatening, vaccine-preventable disease caused by an endotoxin produced by Clostridium tetani. We report a case of severe tetanus in an adult male with a history of intravenous drug use. The patient presented with a 1-day history of inability to open his jaw and a right lower extremity necrotic wound. Initial management consisted of tetanus toxoid, human tetanus immunoglobulin, antimicrobials and intermittent lorazepam. Due to progressive symptoms, wound debridement and placement of an advanced airway in the operating room ensued. Episodes of tetany were associated with fever, autonomic instability, acute desaturations and preemptive ventilator triggering despite maximum doses of continuous propofol and midazolam. Neuromuscular blockade with cisatracurium was added, resulting in control of tetany. Despite initial control, NMB could not be weaned due to recurrent spasms. Intravenous dantrolene was therefore sought as an alternative antispasmodic. Following an initial load, patient was successfully liberated from cisatracurium. Dantrolene was therefore converted to enteral to facilitate gradual down-titration of intravenous sedatives with subsequent conversion to oral benzodiazepines. After a prolonged hospital course, the patient was able to be discharged home. Dantrolene was thus effectively utilized as an adjunctive antispasmodic agent to facilitate liberation from cisatracurium and continuous sedation.
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Affiliation(s)
- Vivek Kataria
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Terra Agha
- Baylor Scott and White Pulmonary and Critical Care Specialists, Dallas, TX, USA
| | - Klayton Ryman
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Nithya Iyer
- Baylor Scott and White Pulmonary and Critical Care Specialists, Dallas, TX, USA
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Moran JL, Linden A. Problematic meta-analyses: Bayesian and frequentist perspectives on combining randomized controlled trials and non-randomized studies. BMC Med Res Methodol 2024; 24:99. [PMID: 38678213 PMCID: PMC11056075 DOI: 10.1186/s12874-024-02215-4] [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: 10/25/2022] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE In the literature, the propriety of the meta-analytic treatment-effect produced by combining randomized controlled trials (RCT) and non-randomized studies (NRS) is questioned, given the inherent confounding in NRS that may bias the meta-analysis. The current study compared an implicitly principled pooled Bayesian meta-analytic treatment-effect with that of frequentist pooling of RCT and NRS to determine how well each approach handled the NRS bias. MATERIALS & METHODS Binary outcome Critical-Care meta-analyses, reflecting the importance of such outcomes in Critical-Care practice, combining RCT and NRS were identified electronically. Bayesian pooled treatment-effect and 95% credible-intervals (BCrI), posterior model probabilities indicating model plausibility and Bayes-factors (BF) were estimated using an informative heavy-tailed heterogeneity prior (half-Cauchy). Preference for pooling of RCT and NRS was indicated for Bayes-factors > 3 or < 0.333 for the converse. All pooled frequentist treatment-effects and 95% confidence intervals (FCI) were re-estimated using the popular DerSimonian-Laird (DSL) random effects model. RESULTS Fifty meta-analyses were identified (2009-2021), reporting pooled estimates in 44; 29 were pharmaceutical-therapeutic and 21 were non-pharmaceutical therapeutic. Re-computed pooled DSL FCI excluded the null (OR or RR = 1) in 86% (43/50). In 18 meta-analyses there was an agreement between FCI and BCrI in excluding the null. In 23 meta-analyses where FCI excluded the null, BCrI embraced the null. BF supported a pooled model in 27 meta-analyses and separate models in 4. The highest density of the posterior model probabilities for 0.333 < Bayes factor < 1 was 0.8. CONCLUSIONS In the current meta-analytic cohort, an integrated and multifaceted Bayesian approach gave support to including NRS in a pooled-estimate model. Conversely, caution should attend the reporting of naïve frequentist pooled, RCT and NRS, meta-analytic treatment effects.
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Affiliation(s)
- John L Moran
- The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
| | - Ariel Linden
- Department of Medicine, School of Medicine, University of California, San Francisco, USA
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Plens GM, Droghi MT, Alcala GC, Pereira SM, Wawrzeniak IC, Victorino JA, Crivellari C, Grassi A, Rezoagli E, Foti G, Costa ELV, Amato MBP, Bellani G. Expiratory Muscle Activity Counteracts Positive End-Expiratory Pressure and Is Associated with Fentanyl Dose in Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:563-572. [PMID: 38190718 DOI: 10.1164/rccm.202308-1376oc] [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: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: Hypoxemia during mechanical ventilation might be worsened by expiratory muscle activity, which reduces end-expiratory lung volume through lung collapse. A proposed mechanism of benefit of neuromuscular blockade in acute respiratory distress syndrome (ARDS) is the abolition of expiratory efforts. This may contribute to the restoration of lung volumes. The prevalence of this phenomenon, however, is unknown. Objectives: To investigate the incidence and amount of end-expiratory lung impedance (EELI) increase after the administration of neuromuscular blocking agents (NMBAs), clinical factors associated with this phenomenon, its impact on regional lung ventilation, and any association with changes in pleural pressure. Methods: We included mechanically ventilated patients with ARDS monitored with electrical impedance tomography (EIT) who received NMBAs in one of two centers. We measured changes in EELI, a surrogate for end-expiratory lung volume, before and after NMBA administration. In an additional 10 patients, we investigated the characteristic signatures of expiratory muscle activity depicted by EIT and esophageal catheters simultaneously. Clinical factors associated with EELI changes were assessed. Measurements and Main Results: We included 46 patients, half of whom showed an increase in EELI of >10% of the corresponding Vt (46.2%; IQR, 23.9-60.9%). The degree of EELI increase correlated positively with fentanyl dosage and negatively with changes in end-expiratory pleural pressures. This suggests that expiratory muscle activity might exert strong counter-effects against positive end-expiratory pressure that are possibly aggravated by fentanyl. Conclusions: Administration of NMBAs during EIT monitoring revealed activity of expiratory muscles in half of patients with ARDS. The resultant increase in EELI had a dose-response relationship with fentanyl dosage. This suggests a potential side effect of fentanyl during protective ventilation.
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Affiliation(s)
- Glauco M Plens
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Maddalena T Droghi
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Glasiele C Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Sérgio M Pereira
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Iuri C Wawrzeniak
- Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Josué A Victorino
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Internal Medicine Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Chiara Crivellari
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alice Grassi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy; and
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, Azienda Provinciale per i Servizi Sanitari Trento, Trento, Italy
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Hongo T, Naito H, Liu K, Murakami Y, Nozaki S, Maeyama H, Matsuoka A, Dote H, Inaba K, Miike S, Fujitani S, Hiraoka T, Obara T, Nojima T, Nakao A, Yumoto T. Changes in temporal muscle dimensions and their clinical impact in out-of-hospital cardiac arrest survivors. Resusc Plus 2024; 17:100527. [PMID: 38188596 PMCID: PMC10770543 DOI: 10.1016/j.resplu.2023.100527] [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: 10/19/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 01/09/2024] Open
Abstract
Objective This study investigates temporal muscle atrophy in out-of-hospital cardiac arrest patients post-resuscitation, seeking associations with neurological outcomes and factors associated with atrophy. Methods Using data from six Japanese intensive care units, adult patients' post-resuscitation who underwent head computed tomography scans on admission and two to five days post-admission were assessed. Temporal muscle area, thickness, and density were quantified from a single cross-sectional image. Patients were categorized into 'atrophy' or 'no atrophy' groups based on median daily temporal muscle atrophy rates. The primary outcome was changes in temporal muscle dimensions between admission and follow-up two to five days later. Secondary outcomes included assessing the impact of temporal muscle atrophy on 30-day survival, as well as identifying any clinical factors associated with temporal muscle atrophy. Results A total of 185 patients were analyzed. Measurements at follow-up revealed significant decreases in temporal muscle area (214 vs. 191 mm2, p < 0.001), thickness (4.9 vs. 4.7 mm, p < 0.001), and density (46 vs. 44 HU, p < 0.001) compared to those at admission. The median daily rate for temporal muscle area atrophy was 2.0% per day. There was no significant association between temporal muscle atrophy and 30-day survival (hazard ratios, 0.71; 95% CI, 0.41-1.23, p = 0.231). Multivariable logistic regression found no clinical factors significantly associated with temporal muscle atrophy. Conclusions Temporal muscle atrophy in post-resuscitation patients occurs rapidly at 2.0% per day. However, there was no significant association with 30-day mortality or any identified clinical factors. Further investigation into its long-term functional implications is warranted.
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Affiliation(s)
- Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
- Department of Emergency, Okayama Saiseikai General Hospital, 2-25 Kokutai-cho, Okayama Kita-ku, Okayama 700-8511, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD 4032, Australia
- Institute for Molecular Bioscience, The University of Queensland, 306 Carmody Road, St Lucia, Brisbane, QLD 4072, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yuya Murakami
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Satoshi Nozaki
- Department of Emergency, Okayama Saiseikai General Hospital, 2-25 Kokutai-cho, Okayama Kita-ku, Okayama 700-8511, Japan
| | - Hiroki Maeyama
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Ayaka Matsuoka
- Emergency and Critical Care Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga 849-8501, Japan
| | - Hisashi Dote
- Department of Emergency and Critical Care Medicine, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu Naka-ku, Shizuoka 430-8558, Japan
| | - Kazumasa Inaba
- Department of Emergency and Critical Care Medicine, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu Naka-ku, Shizuoka 430-8558, Japan
| | - Satoshi Miike
- Emergency/Critical Care Medicine Department, St. Marianna Medical School, 2-16-1 Sugao Miyamae-ku, 216-8511 Kawasaki City, Kanagawa, Japan
| | - Shigeki Fujitani
- Emergency/Critical Care Medicine Department, St. Marianna Medical School, 2-16-1 Sugao Miyamae-ku, 216-8511 Kawasaki City, Kanagawa, Japan
| | - Tomohiro Hiraoka
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
| | - Takafumi Obara
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama 700-8558, Japan
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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9
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Rollinson TC, McDonald LA, Rose J, Eastwood G, Costa-Pinto R, Modra L, Maeda A, Bacolas Z, Anstey J, Bates S, Bradley S, Dumbrell J, French C, Ghosh A, Haines K, Haydon T, Hodgson CL, Holmes J, Leggett N, McGain F, Moore C, Nelson K, Presneill J, Rotherham H, Said S, Young M, Zhao P, Udy A, Neto AS, Chaba A, Bellomo R. Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19. J Crit Care 2024; 79:154469. [PMID: 37992464 DOI: 10.1016/j.jcrc.2023.154469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain. METHODS Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position. RESULTS We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001). CONCLUSION During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.
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Affiliation(s)
- Thomas C Rollinson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia; Institute for Breathing and Sleep, Melbourne, VIC, Australia.
| | - Luke A McDonald
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Joleen Rose
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Samantha Bates
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Scott Bradley
- Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia
| | - Jodi Dumbrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Craig French
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Angaj Ghosh
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Kimberley Haines
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Tim Haydon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Carol L Hodgson
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Jennifer Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Nina Leggett
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Forbes McGain
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Cara Moore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Hannah Rotherham
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Simone Said
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Meredith Young
- Department of Intensive Care, Alfred Health, VIC, Australia
| | - Peinan Zhao
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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10
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Kumar N. Advances in post intensive care unit care: A narrative review. World J Crit Care Med 2023; 12:254-263. [DOI: 10.5492/wjccm.v12.i5.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.
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Affiliation(s)
- Nishant Kumar
- Department of Anaesthesiology and Critical Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
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11
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Lin C, Chao WC, Pai KC, Yang TY, Wu CL, Chan MC. Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: a retrospective cohort study. J Intensive Care 2023; 11:55. [PMID: 37978572 PMCID: PMC10655355 DOI: 10.1186/s40560-023-00696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Neuromuscular blockade agents (NMBAs) can be used to facilitate mechanical ventilation in critically ill patients. Accumulating evidence has shown that NMBAs may be associated with intensive care unit (ICU)-acquired weakness and poor outcomes. However, the long-term impact of NMBAs on mortality is still unclear. METHODS We conducted a retrospective analysis using the 2015-2019 critical care databases at Taichung Veterans General Hospital, a referral center in central Taiwan, as well as the Taiwan nationwide death registry profile. RESULTS A total of 5709 ventilated patients were eligible for further analysis, with 63.8% of them were male. The mean age of enrolled subjects was 67.8 ± 15.8 years, and the one-year mortality was 48.3% (2755/5709). Compared with the survivors, the non-survivors had a higher age (70.4 ± 14.9 vs 65.4 ± 16.3, p < 0.001), Acute Physiology and Chronic Health Evaluation II score (28.0 ± 6.2 vs 24.7 ± 6.5, p < 0.001), a longer duration of ventilator use (12.6 ± 10.6 days vs 7.8 ± 8.5 days, p < 0.001), and were more likely to receive NMBAs for longer than 48 h (11.1% vs 7.8%, p < 0.001). After adjusting for age, sex, and relevant covariates, the use of NMBAs for longer than 48 h was found to be independently associated with an increased risk of mortality (adjusted HR: 1.261; 95% CI: 1.07-1.486). The analysis of effect modification revealed that this association was tended to be strong in patients with a Charlson Comorbidity Index of 3 or higher. CONCLUSIONS Our study demonstrated that prolonged use of NMBAs was associated with an increased risk of long-term mortality in critically ill patients requiring mechanical ventilation. Further studies are needed to validate our findings.
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Affiliation(s)
- Chun Lin
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
- Big Data Center, Chung Hsing University, Taichung, Taiwan
| | - Kai-Chih Pai
- College of Engineering, Tunghai University, Taichung, Taiwan
| | - Tsung-Ying Yang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
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12
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Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
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Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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13
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 152] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - 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
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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14
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Yang J, Cao J, Min S, Li P, Lv F, Ren L. Recombinant human neuregulin-1 alleviates immobilization-induced neuromuscular dysfunction via neuregulin-1/ErbB signaling pathway in rat. Arch Biochem Biophys 2023:109631. [PMID: 37276924 DOI: 10.1016/j.abb.2023.109631] [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: 12/05/2022] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023]
Abstract
Immobilization-induced Neuromuscular Dysfunction (NMD) increases morbidity and mortality of patients in Intensive Care Units. However, the underlying mechanism of NMD remain poorly elucidated which limited the development of therapeutic method for NMD. Here we developed an immobilization rat model and tested the hypothesis that decreased expression of NRG-1, abnormal expression and distribution of nicotinic acetylcholine receptors (nAChRs) in skeletal muscle caused by immobilization can lead to NMD. To investigate the role of NRG-1/ErbB pathway on immobilization-induced NMD, exogenous recombinant human neuregulin-1 (rhNRG-1) was used to increase the expression of NRG-1 in skeletal muscle during immobilization. It was observed rhNRG-1 significantly alleviated the muscle loss and enhanced the expression of ε-nAChR, while diminished the expression of γ- and α7-nAChR and NMD. Interestingly, ErbB inhibitor PD158780 blocked the protective effects of rhNRG-1. Collectively, the results of present study suggested that rhNRG-1 attenuated immobilization-induced muscle loss and NMD, suppressed γ- and α7-nAChR production, enhanced ε-nAChR synthesis via activating NRG-1/ErbB pathway. Taken together, our findings provide novel insights into NMD contribution, suggesting that the rhNRG-1 is a promising therapy to protect against immobilization-induced myopathy.
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Affiliation(s)
- Jun Yang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jun Cao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Ping Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Feng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Li Ren
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
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15
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Odish M, Pollema T, Meier A, Hepokoski M, Yi C, Spragg R, Patel HH, Alexander LEC, Sun XS, Jain S, Simonson TS, Malhotra A, Owens RL. Very Low Driving-Pressure Ventilation in Patients With COVID-19 Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation: A Physiologic Study. J Cardiothorac Vasc Anesth 2023; 37:423-431. [PMID: 36567221 PMCID: PMC9701579 DOI: 10.1053/j.jvca.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/01/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine in patients with acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) whether reducing driving pressure (ΔP) would decrease plasma biomarkers of inflammation and lung injury (interleukin-6 [IL-6], IL-8, and the soluble receptor for advanced glycation end-products sRAGE). DESIGN A single-center prospective physiologic study. SETTING At a single university medical center. PARTICIPANTS Adult patients with severe COVID-19 ARDS on VV ECMO. INTERVENTIONS Participants on VV ECMO had the following biomarkers measured: (1) pre-ECMO with low-tidal-volume ventilation (LTVV), (2) post-ECMO with LTVV, (3) during low-driving-pressure ventilation (LDPV), (4) after 2 hours of very low driving-pressure ventilation (V-LDPV, main intervention ΔP = 1 cmH2O), and (5) 2 hours after returning to LDPV. MAIN MEASUREMENTS AND RESULTS Twenty-six participants were enrolled; 21 underwent V-LDPV. There was no significant change in IL-6, IL-8, and sRAGE from LDPV to V-LDPV and from V-LDPV to LDPV. Only participants (9 of 21) with nonspontaneous breaths had significant change (p < 0.001) in their tidal volumes (Vt) (mean ± SD), 1.9 ± 0.5, 0.1 ± 0.2, and 2.0 ± 0.7 mL/kg predicted body weight (PBW). Participants with spontaneous breathing, Vt were unchanged-4.5 ± 3.1, 4.7 ± 3.1, and 5.6 ± 2.9 mL/kg PBW (p = 0.481 and p = 0.065, respectively). There was no relationship found when accounting for Vt changes and biomarkers. CONCLUSIONS Biomarkers did not significantly change with decreased ΔPs or Vt changes during the first 24 hours post-ECMO. Despite deep sedation, reductions in Vt during V-LDPV were not reliably achieved due to spontaneous breaths. Thus, patients on VV ECMO for ARDS may have higher Vt (ie, transpulmonary pressure) than desired despite low ΔPs or Vt.
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Affiliation(s)
- Mazen Odish
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA.
| | - Travis Pollema
- UC San Diego Department of Surgery, Division of Cardiovascular and Thoracic Surgery, La Jolla, CA
| | - Angela Meier
- UC San Diego Department of Anesthesiology, Division of Critical Care, La Jolla, CA
| | - Mark Hepokoski
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Cassia Yi
- UC San Diego Health Department of Nursing, La Jolla, CA
| | - Roger Spragg
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Hemal H Patel
- UC San Diego Department of Anesthesiology, Division of Critical Care, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Laura E Crotty Alexander
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Xiaoying Shelly Sun
- UC San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA
| | - Sonia Jain
- UC San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA
| | - Tatum S Simonson
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Atul Malhotra
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Robert L Owens
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
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16
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Bellaver P, Schaeffer AF, Leitao CB, Rech TH, Nedel WL. Association between neuromuscular blocking agents and the development of intensive care unit-acquired weakness (ICU-AW): A systematic review with meta-analysis and trial sequential analysis. Anaesth Crit Care Pain Med 2023; 42:101202. [PMID: 36804373 DOI: 10.1016/j.accpm.2023.101202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/21/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The present study aims to review the literature and synthesize evidence concerning the effects of the use of neuromuscular blocking agents (NMBA) regarding the development of intensive care unit-acquired weakness (ICU-AW). METHODS This study was registered in the PROSPERO database CRD42020142916. Systematic review in PubMed, Embase, and the Cochrane Central, Randomized clinical trials (RCTs), and cohort studies with adults that reported the use of NMBA and the development of ICU-AW were included. Pre-specified subgroup analyses were performed for presence of sepsis and type of NMBA used. The quality of evidence for intervention effects was summarized. The certainty of evidence was assessed using the GRADE approach. RESULTS We included 30 studies, four RCTs, 21 prospective and 5 retrospective cohorts, enrolling a total of 3839 patients. Most of the included studies were observational with high heterogeneity, whereas the RCTs had a high risk of bias. The use of NMBA increased the odds of developing ICU-AW (OR = 2.77 [95% CI 1.98-3.88], I2 = 62%), with low-quality of evidence. A trial sequential analysis showed the need to include 22,330 patients in order to provide evidence for either beneficial or harmful intervention effects. CONCLUSIONS This meta-analysis suggests that the use of NMBA might be implicated in the development of ICU-AW. However, there is not enough evidence to definitively conclude about the association between the use of NMBA and the development of ICU-AW, as these results are based mostly on observational studies with high heterogeneity.
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Affiliation(s)
- Priscila Bellaver
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ariell F Schaeffer
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Cristiane B Leitao
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Tatiana H Rech
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Wagner L Nedel
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Brazilian Research in Intensive Care Network - BRICNet, Brazil.
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17
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Reliability and feasibility of skeletal muscle ultrasound in the acute burn setting. Burns 2023; 49:68-79. [PMID: 35361498 DOI: 10.1016/j.burns.2022.03.003] [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: 12/16/2021] [Revised: 02/11/2022] [Accepted: 03/12/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Despite the impact of muscle wasting after burn, tools to quantify muscle wasting are lacking. This multi-centre study examined the utility of ultrasound to measure muscle mass in acute burn patients comparing different methodologies. METHODS B-mode ultrasound was used by two raters to determine feasibility and inter-rater reliability in twenty burned adults following admission. Quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA) were measured, comparing the use of i) a single versus average measurements, ii) a proximal versus distal location for QMLT, and iii) a maximum- versus no-compression technique for QMLT. RESULTS Analysis of twenty burned adults (50 years [95%CI 42-57], 32%TBSA [95%CI 23-40]) yielded ICCs of> 0.97 for QMLT (for either location and compression technique) and> 0.95 for RF-CSA, using average measurements. Relative minimal detectable changes were smaller using no-compression than maximum-compression (6.5% vs. 15%). Using no-compression to measure QMLT was deemed feasible for both proximal and distal locations (94% and 96% of attempted measurements). In 9.5% of cases maximum-compression was not feasible. 95% of RF-CSA measurements were successfully completed. CONCLUSION Ultrasound provides feasible and reliable values of quadriceps muscle architecture that can be adapted to clinical scenarios commonly encountered in acute burn settings.
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18
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Martyn JAJ, Sparling JL, Bittner EA. Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review. Br J Anaesth 2023; 130:39-50. [PMID: 36175185 DOI: 10.1016/j.bja.2022.08.009] [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: 04/11/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023] Open
Abstract
Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.
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Affiliation(s)
- J A Jeevendra Martyn
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jamie L Sparling
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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19
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Baek MS, Kim JH, Lim Y, Kwon YS. Neuromuscular blockade in mechanically ventilated pneumonia patients with moderate to severe hypoxemia: A multicenter retrospective study. PLoS One 2022; 17:e0277503. [PMID: 36520923 PMCID: PMC9754162 DOI: 10.1371/journal.pone.0277503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 10/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/PURPOSE The benefit of neuromuscular blockades (NMBs) in critically ill patients receiving mechanical ventilation remains uncertain. Therefore, we aimed to investigate whether NMB use is associated with improved survival of mechanically ventilated pneumonia patients with moderate to severe hypoxemia. METHODS This retrospective multicenter study was conducted at five university-affiliated hospitals. Data of pneumonia patients aged 18 years and older who received mechanical ventilation between January 1, 2011, and December 31, 2020, were analyzed. RESULTS In a total of 1,130 patients, the mean patient age was 73.1 years (SD±12.6), and the overall mortality rate at 30 d was 29.5% (n = 333). NMB users had a higher 30 d mortality rate than NMB nonusers (33.9% vs. 26.8%, P = 0.014). After PS matching, the 30 d mortality rate was not significantly different between NMB users and nonusers (33.4% vs. 27.8%, p = 0.089). However, 90 d mortality rate was significantly increased in NMB users (39.7% vs. 31.9%, p = 0.021). Univariable Cox proportional hazard regression analyses showed that NMB use ≥ 3 d was significant risk factor for the 90 d mortality than those with < 3 d use (90 d mortality HR 1.39 [95% CI: 1.01-1.91], P = 0.045). CONCLUSIONS NMB use was not associated with lower 30 d mortality among mechanically ventilated pneumonia patients with moderate to severe hypoxemia. Rather, NMB users had higher 90 d mortality, furthermore, and NMB use ≥ 3 d was associated with a higher risk of long-term mortality compared to NMB use < 3 d. Therefore, care should be taken to avoid extended use of NMB in critically ill pneumonia patients during mechanical ventilation.
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Affiliation(s)
- Moon Seong Baek
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jong Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Yaeji Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Young Suk Kwon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
- * E-mail:
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20
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Sasano N, Yasuda M, Yamada G. Quadriplegia after
ECMO
therapy with sluggish recovery in a
COVID
‐19 patient: A case report with a 14‐month follow‐up. Clin Case Rep 2022; 10:e6735. [PMCID: PMC9748240 DOI: 10.1002/ccr3.6735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/05/2022] [Accepted: 11/26/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nobuko Sasano
- Department of Intensive Care Medicine Nagoya City University West Medical Center Nagoya Japan
| | - Masami Yasuda
- Department of Rehabilitation Nagoya City University West Medical Center Nagoya Japan
| | - Gohei Yamada
- Department of Neurology Nagoya City University West Medical Center Nagoya Japan
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21
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Yang Z, Wang X, Wang F, Peng Z, Fan Y. A systematic review and meta-analysis of risk factors for intensive care unit acquired weakness. Medicine (Baltimore) 2022; 101:e31405. [PMID: 36316900 PMCID: PMC9622703 DOI: 10.1097/md.0000000000031405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The aim of this meta-analysis is to systematically evaluate and summarize the risk factors of intensive care unit acquired weakness (ICU-AW), to provide evidence-based evidence for the formulation of prevention strategies for ICU-AW. METHODS PubMed, EMBASE, Web of Science, CBM (China Biology Medicine, China), Chinese National Knowledge Infrastructure, Chinese WANFANG, and VIP will be searched to define relevant risk factors for ICU-AW. The databases search period is from January 1, 2005 to August 13, 2021. The Newcastle Ottawa Scale (NOS) is used to evaluate the quality of the included studies. RevMan 5.3 analysis software will be used for meta-analysis. RESULTS This systematic review and meta-analysis included a total of 12 cohort studies, including 9 international journals and 3 Chinese journals, with a total of 1950 patients, of which 856 had ICU-AW. The results showed that the significant risk factors for ICU-AW included female (odds ratio [OR] = 1.34, 95% confidence interval [CI]: 1.06-1.71; P = .02), mechanical ventilation days (OR = 3.04, 95% CI: 1.82-4.26; P < .00001), age (OR = 6.33, 95% CI: 5.05-7.61; P < .00001), length of intensive care unit (ICU) stay (OR = 3.78, 95% CI: 2.06-5.51; P < .0001), infectious disease (OR = 1.67, 95% CI: 1.20-2.33; P = .002), renal replacement therapy (OR = 1.59, 95% CI: 1.11-2.28; P = .01), use of aminoglucoside drugs (OR = 2.51, 95% CI: 1.54-4.08; P = .0002), sepsis related organ failure assessment (SOFA) score (OR = 1.07, 95% CI: 0.24-1.90; P = .01), hyperglycemia (OR = 2.95, 95% CI: 1.70-5.11; P = .0001). CONCLUSION This meta-analysis provides comprehensive evidence-based on the assessment of the risk factors for ICU-AW, their multifactorial etiology was confirmed. This study indicated that female, mechanical ventilation days, age, length of ICU stay, infectious disease, renal replacement therapy, use of aminoglucoside drugs, SOFA score, and hyperglycemia are independent risk factors for ICU-AW. We have not found consistent evidence that corticosteroids, neuromuscular blockers, sepsis have any effect on ICU-AW risk.
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Affiliation(s)
- Zi Yang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Xiaohui Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Faying Wang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Zeyu Peng
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Yuying Fan
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
- *Correspondence: Yuying Fan, Harbin Medical University, Heilongjiang Province, 150081, China (e-mail: )
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22
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Grover KM, Sripathi N. Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders. Semin Neurol 2022; 42:594-610. [PMID: 36400111 DOI: 10.1055/s-0042-1758779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.
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Affiliation(s)
- Kavita M Grover
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
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23
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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A Global Survey on Diagnostic, Therapeutic and Preventive Strategies in Intensive Care Unit-Acquired Weakness. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081068. [PMID: 36013535 PMCID: PMC9416039 DOI: 10.3390/medicina58081068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent neuromuscular complications in critically ill patients. We conducted a global survey to evaluate the current practices of diagnostics, treatment and prevention in patients with ICU-AW. Materials and Methods: A pre-survey was created with international experts. After revision, the final survey was endorsed by the European Society of Intensive Care Medicine (ESICM) using the online platform SurveyMonkey®. In 27 items, we addressed strategies of diagnostics, therapy and prevention. An invitation link was sent by email to all ESICM members. Furthermore, the survey was available on the ESICM homepage. Results: A total of 154 healthcare professionals from 39 countries participated in the survey. An ICU-AW screening protocol was used by 20% (28/140) of participants. Forty-four percent (62/141) of all participants reported performing routine screening for ICU-AW, using clinical examination as the method of choice (124/141, 87.9%). Almost 63% (84/134) of the participants reported using current treatment strategies for patients with ICU-AW. The use of treatment and prevention strategies differed between intensivists and non-intensivists regarding the reduction in sedatives (80.0% vs. 52.6%, p = 0.002), neuromuscular blocking agents (76.4% vs. 50%, p = 0.004), corticosteroids (69.1% vs. 37.2%, p < 0.001) and glycemic control regimes (50.9% vs. 23.1%, p = 0.002). Mobilization and physical activity are the most frequently reported treatment strategies for ICU-AW (111/134, 82.9%). The availability of physiotherapists (92/134, 68.7%) and the lack of knowledge about ICU-AW within the medical team (83/134, 61.9%) were the main obstacles to the implementation of the strategies. The necessity to develop guidelines for the screening, diagnosing, treatment and prevention of ICU-AW was recognized by 95% (127/133) of participants. Conclusions: A great heterogeneity regarding diagnostics, treatment and prevention of ICU-AW was reported internationally. Comprehensive guidelines with evidence-based recommendations for ICU-AW management are needed.
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25
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Núñez-Seisdedos MN, Lázaro-Navas I, López-González L, López-Aguilera L. Intensive Care Unit- Acquired Weakness and Hospital Functional Mobility Outcomes Following Invasive Mechanical Ventilation in Patients with COVID-19: A Single-Centre Prospective Cohort Study. J Intensive Care Med 2022; 37:1005-1014. [PMID: 35578542 PMCID: PMC9117955 DOI: 10.1177/08850666221100498] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Acute physical function outcomes in ICU survivors of COVID-19 pneumonia has received little attention. Critically ill patients with COVID-19 infection who require invasive mechanical ventilation may undergo greater exposure to some risk factors for ICU-acquired weakness (ICUAW). Purpose: To determine incidence and factors associated with ICUAW at ICU discharge and gait dependence at hospital discharge in mechanically ventilated patients with COVID-19 pneumonia. Methods: Single-centre, prospective cohort study conducted at a tertiary hospital in Madrid, Spain. We evaluated ICUAW with the Medical Research Council Summary Score (MRC-SS). Gait dependence was assessed with the Functional Status Score for the ICU (FSS-ICU) walking subscale. Results: During the pandemic second wave, between 27 July and 15 December, 2020, 70 patients were enrolled. ICUAW incidence was 65.7% and 31.4% at ICU discharge and hospital discharge, respectively. Gait dependence at hospital discharge was observed in 66 (54.3%) patients, including 9 (37.5%) without weakness at ICU discharge. In univariate analysis, ICUAW was associated with the use of neuromuscular blockers (crude odds ratio [OR] 9.059; p = 0.01) and duration of mechanical ventilation (OR 1.201; p = 0.001), but not with the duration of neuromuscular blockade (OR 1.145, p = 0.052). There was no difference in corticosteroid use between patients with and without weakness. Associations with gait dependence were lower MRC-SS at ICU discharge (OR 0.943; p = 0.015), older age (OR 1.126; p = 0.001), greater Charlson Comorbidity Index (OR 1.606; p = 0.011), longer duration of mechanical ventilation (OR 1.128; p = 0.001) and longer duration of neuromuscular blockade (OR 1.150; p = 0.029). Conclusions: In critically ill COVID-19 patients, the incidence of ICUAW and acute gait dependence were high. Our study identifies factors influencing both outcomes. Future studies should investigate optimal COVID-19 ARDS management and impact of dyspnea on acute functional outcomes of COVID-19 ICU survivors.
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Affiliation(s)
| | - Irene Lázaro-Navas
- Physiotherapy Department, 16507Ramón y Cajal University Hospital, Madrid, Spain
| | - Luís López-González
- Physiotherapy Department, 16507Ramón y Cajal University Hospital, Madrid, Spain
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Phrenic Nerve Block and Respiratory Effort in Pigs and Critically Ill Patients with Acute Lung Injury. Anesthesiology 2022; 136:763-778. [PMID: 35348581 DOI: 10.1097/aln.0000000000004161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Strong spontaneous inspiratory efforts can be difficult to control and prohibit protective mechanical ventilation. Instead of using deep sedation and neuromuscular blockade, the authors hypothesized that perineural administration of lidocaine around the phrenic nerve would reduce tidal volume (VT) and peak transpulmonary pressure in spontaneously breathing patients with acute respiratory distress syndrome. METHODS An established animal model of acute respiratory distress syndrome with six female pigs was used in a proof-of-concept study. The authors then evaluated this technique in nine mechanically ventilated patients under pressure support exhibiting driving pressure greater than 15 cm H2O or VT greater than 10 ml/kg of predicted body weight. Esophageal and transpulmonary pressures, electrical activity of the diaphragm, and electrical impedance tomography were measured in pigs and patients. Ultrasound imaging and a nerve stimulator were used to identify the phrenic nerve, and perineural lidocaine was administered sequentially around the left and right phrenic nerves. RESULTS Results are presented as median [interquartile range, 25th to 75th percentiles]. In pigs, VT decreased from 7.4 ml/kg [7.2 to 8.4] to 5.9 ml/kg [5.5 to 6.6] (P < 0.001), as did peak transpulmonary pressure (25.8 cm H2O [20.2 to 27.2] to 17.7 cm H2O [13.8 to 18.8]; P < 0.001) and driving pressure (28.7 cm H2O [20.4 to 30.8] to 19.4 cm H2O [15.2 to 22.9]; P < 0.001). Ventilation in the most dependent part decreased from 29.3% [26.4 to 29.5] to 20.1% [15.3 to 20.8] (P < 0.001). In patients, VT decreased (8.2 ml/ kg [7.9 to 11.1] to 6.0 ml/ kg [5.7 to 6.7]; P < 0.001), as did driving pressure (24.7 cm H2O [20.4 to 34.5] to 18.4 cm H2O [16.8 to 20.7]; P < 0.001). Esophageal pressure, peak transpulmonary pressure, and electrical activity of the diaphragm also decreased. Dependent ventilation only slightly decreased from 11.5% [8.5 to 12.6] to 7.9% [5.3 to 8.6] (P = 0.005). Respiratory rate did not vary. Variables recovered 1 to 12.7 h [6.7 to 13.7] after phrenic nerve block. CONCLUSIONS Phrenic nerve block is feasible, lasts around 12 h, and reduces VT and driving pressure without changing respiratory rate in patients under assisted ventilation. EDITOR’S PERSPECTIVE
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Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review. Life (Basel) 2022; 12:life12010107. [PMID: 35054500 PMCID: PMC8778667 DOI: 10.3390/life12010107] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 12/21/2022] Open
Abstract
Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.
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Qin ES, Hough CL, Andrews J, Bunnell AE. Intensive Care Unit-Acquired Weakness and the COVID-19 Pandemic: A Clinical Review. PM R 2022; 14:227-238. [PMID: 35014183 DOI: 10.1002/pmrj.12757] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 12/08/2021] [Accepted: 12/28/2021] [Indexed: 01/08/2023]
Abstract
Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Due to the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients which include premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. While the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing post-acute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Evelyn S Qin
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Catherine L Hough
- Department of Pulmonary and Critical Care Medicine, Oregon Health Science University, Portland, OR
| | - James Andrews
- Department of Medicine, University of Washington, Seattle, WA 325 9th Ave., Seattle, WA, USA
| | - Aaron E Bunnell
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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Kopanczyk R, Kumar N, Papadimos T. Post-Acute COVID-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care. J Cardiothorac Vasc Anesth 2021; 36:2727-2737. [PMID: 34688543 PMCID: PMC8487462 DOI: 10.1053/j.jvca.2021.09.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/29/2021] [Indexed: 02/07/2023]
Abstract
Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as "COVID-19 long-haulers," often present with nonspecific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There currently is no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the United States over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized, as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use, such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung-protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and, thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, the authors define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Nicolas Kumar
- The Ohio State University College of Medicine, Columbus, OH
| | - Thomas Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Postintensive Care Syndrome in Survivors of Critical Illness Related to Coronavirus Disease 2019: Cohort Study From a New York City Critical Care Recovery Clinic. Crit Care Med 2021; 49:1427-1438. [PMID: 33769771 DOI: 10.1097/ccm.0000000000005014] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Determine the characteristics of postintensive care syndrome in the cognitive, physical, and psychiatric domains in coronavirus disease 2019 ICU survivors. DESIGN Single-center descriptive cohort study from April 21, to July 7, 2020. SETTING Critical care recovery clinic at The Mount Sinai Hospital in New York City. PATIENTS Adults who had critical illness due to coronavirus disease 2019 requiring an ICU stay of 7 days or more and who agreed to a telehealth follow-up in the critical care recovery clinic 1-month post hospital discharge. INTERVENTIONS None. MEASURES AND MAIN RESULTS Patient-reported outcome measures assessing physical and psychiatric domains were collected electronically, a cognitive test was performed by a clinician, and clinical data were obtained through electronic medical records. Outcome measures assessed postintensive care syndrome symptoms in the physical (Modified Rankin Scale, Dalhousie Clinical Frailty Scale, Neuro-Quality of Life Upper Extremity and Lower Extremity Function, Neuro-Quality of Life Fatigue), psychiatric (Insomnia Severity Scale; Patient Health Questionnaire-9; and Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and cognitive (Telephone Montreal Cognitive Assessment) domains. The 3-Level Version of Euro-QoL-5D was used to assess the physical and psychiatric domains. A diagnosis of postintensive care syndrome was made in cases with evidence of impairment in at least one postintensive care syndrome domain. We included 45 patients with a mean (sd) age of 54 (13) years, and 73% were male. Ninety-one percent of coronavirus disease 2019 ICU survivors fit diagnostic criteria for postintensive care syndrome. 86.7 % had impairments in the physical domain, 22 (48%) reported impairments in the psychiatric domain, and four (8%) had impairments on cognitive screening. We found that 58% had some degree of mobility impairment. In the psychiatric domain, 38% exhibited at least mild depression, and 18 % moderate to severe depression. Eighteen percent presented Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores suggestive of posttraumatic stress syndrome diagnosis. In the Telephone Montreal Cognitive Assessment, 9% had impaired cognition. CONCLUSIONS Survivors of critical illness related to coronavirus disease 2019 are at high risk of developing postintensive care syndrome. These findings highlight the importance of planning for appropriate post-ICU care to diagnose and treat this population.
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Use of Organ Dysfunction as a Primary Outcome Variable Following Cecal Ligation and Puncture: Recommendations for Future Studies. Shock 2021; 54:168-182. [PMID: 31764625 DOI: 10.1097/shk.0000000000001485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Outcomes variables for research on sepsis have centered on mortality and changes in the host immune response. However, a recent task force (Sepsis-3) revised the definition of sepsis to "life-threatening organ dysfunction caused by a dysregulated host response to infection." This new definition suggests that human studies should focus on organ dysfunction. The appropriate criteria for organ dysfunction in either human sepsis or animal models are, however, poorly delineated, limiting the potential for translation. Further, in many systems, the difference between "dysfunction" and "injury" may not be clear. In this review, we identify criteria for organ dysfunction and/or injury in human sepsis and in rodents subjected to cecal ligation and puncture (CLP), the most commonly used animal model of sepsis. We further examine instances where overlap between human sepsis and CLP is sufficient to identify translational endpoints. Additional verification may demonstrate that these endpoints are applicable to other animals and to other sepsis models, for example, pneumonia. We believe that the use of these proposed measures of organ dysfunction will facilitate mechanistic studies on the pathobiology of sepsis and enhance our ability to develop animal model platforms to evaluate therapeutic approaches to human sepsis.
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Tsonas AM, Botta M, Serpa Neto A, Horn J, Paulus F, Schultz MJ. Ventilation management in acute respiratory failure related to COVID-19 versus ARDS from another origin - a descriptive narrative review. Expert Rev Respir Med 2021; 15:1013-1023. [PMID: 33847219 PMCID: PMC8054495 DOI: 10.1080/17476348.2021.1913060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction It is uncertain whether ventilation in patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) differs from that in patients with acute respiratory distress syndrome (ARDS) from another origin. Areas covered We undertook two literature searches in PubMed to identify observational studies reporting on ventilation management––one in patients with acute respiratory failure related to COVID-19, and one in patients with ARDS from another origin. The searches identified 14 studies in patients with acute respiratory failure related to COVID-19, and 8 studies in patients with ARDS from another origin. Expert opinion In patients with acute respiratory failure related to COVID-19, ventilation management seems to be similar to that of patients with ARDS from another origin. The future lies in studies focused on personalized treatment of ARDS of all origins, including COVID-19.
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Affiliation(s)
- Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Australian and New Zealand Intensive Care Research Center (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia.,Melbourne Medical School, Department of Critical Care, Austin Hospital and University of Melbourne, Melbourne, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,, ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 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, UK
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Welhengama C, Hall A, Hunter JM. Neuromuscular blocking drugs in the critically ill. BJA Educ 2021; 21:258-263. [PMID: 34178382 DOI: 10.1016/j.bjae.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/17/2022] Open
Affiliation(s)
- C Welhengama
- St. Helen's and Knowsley Teaching Hospitals, Prescot, UK
| | - A Hall
- Liverpool University Foundation Trust, Liverpool, UK
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34
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Cheung K, Rathbone A, Melanson M, Trier J, Ritsma BR, Allen MD. Pathophysiology and management of critical illness polyneuropathy and myopathy. J Appl Physiol (1985) 2021; 130:1479-1489. [PMID: 33734888 PMCID: PMC8143786 DOI: 10.1152/japplphysiol.00019.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Critical illness-associated weakness (CIAW) is an umbrella term used to describe a group of neuromuscular disorders caused by severe illness. It can be subdivided into three major classifications based on the component of the neuromuscular system (i.e. peripheral nerves or skeletal muscle or both) that are affected. This includes critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and an overlap syndrome, critical illness polyneuromyopathy (CIPNM). It is a common complication observed in people with critical illness requiring intensive care unit (ICU) admission. Given CIAW is found in individuals experiencing grave illness, it can be challenging to study from a practical standpoint. However, over the past 2 decades, many insights into the pathophysiology of this condition have been made. Results from studies in both humans and animal models have found that a profound systemic inflammatory response and factors related to bioenergetic failure as well as microvascular, metabolic, and electrophysiological alterations underlie the development of CIAW. Current management strategies focus on early mobilization, achieving euglycemia, and nutritional optimization. Other interventions lack sufficient evidence, mainly due to a dearth of large trials. The goal of this Physiology in Medicine article is to highlight important aspects of the pathophysiology of these enigmatic conditions. It is hoped that improved understanding of the mechanisms underlying these disorders will lead to further study and new investigations for novel pharmacologic, nutritional, and exercise-based interventions to optimize patient outcomes.
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Affiliation(s)
- Kevin Cheung
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Alasdair Rathbone
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Michel Melanson
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jessica Trier
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Benjamin R Ritsma
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Matti D Allen
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada.,School of Kinesiology, Faculty of Arts and Sciences, Queen's University, Kingston, Ontario, Canada
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35
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Lyu T, Lee YS, Dhanvijay S, Freebairn R. The effect of neuromuscular blocking agents uses in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Minerva Anestesiol 2020; 87:341-350. [PMID: 33300324 DOI: 10.23736/s0375-9393.20.14783-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION With the latest addition from Re-evaluation of Systemic Early Neuromuscular Blockade (ROSE) Trial result, the question of mortality benefit from neuromuscular blocking agents (NMBAs) in different studies, remained unanswered. We hypothesize that NMBAs use in moderate to severe acute respiratory distress syndrome (ARDS) does not influence intensive care unit (ICU) mortality. EVIDENCE ACQUISITION Pubmed, Embase and the Cochrane Library were searched for randomized controlled trials (RCTs) related to NMBAs infusion in patients with ARDS. The primary outcome was ICU mortality. Secondary outcomes were mortality at day 28 and day 90, oxygenation response to NMBA, ICU length of stay (LOS), ICU Acquired weakness (ICU-AW) and ventilator-free days (VFDs). Meta-analysis was conducted to re-evaluate the effect of NMBAs on patients with ARDS with all randomized controlled trials available. EVIDENCE SYNTHESIS NMBAs infusion was associated with reduced ICU mortality (relative ratio [RR]: 0.69; 95% confidence-interval [CI]: 0.55-0.88; I2=0%), but not 28 days mortality (RR: 0.76; 95% CI: 0.57-1.0; I2=49%) and 90-day mortality (RR: 0.87; 95% CI: 0.70-1.08; I2=46%). NMBA use was not associated with increased risk of ICU-AW (RR: 1.21; 95% CI, 0.84 to 1.76; I2=34%). CONCLUSIONS Early 48-hour NMBAs infusion in patients with moderate to severe ARDS was associated with reduced ICU mortality without improvement in oxygenation, VFDs, 28-day and 90-day mortality. It did not contribute significantly to ICU-AW. Based on these results, NMBAs infusion is recommended for moderate to severe ARDS for its short-term benefit in early phase of disease. Prolonged use of NMBAs beyond 48 hours requires further study.
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Affiliation(s)
- Ting Lyu
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore, Singapore -
| | - Yee S Lee
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Shekhar Dhanvijay
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Ross Freebairn
- Intensive Care Services, Fallen Soldiers Memorial, Hawke's Bay Hospital, Hastings, New Zealand
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Schefold JC, Wollersheim T, Grunow JJ, Luedi MM, Z'Graggen WJ, Weber-Carstens S. Muscular weakness and muscle wasting in the critically ill. J Cachexia Sarcopenia Muscle 2020; 11:1399-1412. [PMID: 32893974 PMCID: PMC7749542 DOI: 10.1002/jcsm.12620] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/10/2020] [Accepted: 08/23/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Wollersheim
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurology and Neurosurgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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37
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Fordyce CB, Katz JN, Alviar CL, Arslanian-Engoren C, Bohula EA, Geller BJ, Hollenberg SM, Jentzer JC, Sims DB, Washam JB, van Diepen S. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e379-e406. [DOI: 10.1161/cir.0000000000000909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non–CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.
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Current and evolving standards of care for patients with ARDS. Intensive Care Med 2020; 46:2157-2167. [PMID: 33156382 PMCID: PMC7646492 DOI: 10.1007/s00134-020-06299-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards – treatments that have a solid evidence base and are well established as targets for usual care – and also evolving standards – treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.
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Abstract
Critical illness myopathy (CIM) is a primary myopathy associated with increased mortality and morbidity, which frequently develops in severely ill patients. Several risk factors have been suggested for the development of critical illness myopathy. However, neither the exact etiology nor the underlying mechanisms are known in detail. Although for definite diagnosis muscle biopsy is needed, electrophysiological tests are crucial for the diagnosis of probable critical illness myopathy and differential diagnosis. In this review, conventional electrophysiological tests such as nerve conduction studies, needle electromyography, direct muscle stimulation, and repetitive stimulation for diagnosis of critical illness myopathy are summarized. Moreover, studies using the novel method of recording muscle velocity recovery cycles are addressed.
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40
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Li Z, Cai Y, Zhang Q, Zhang P, Sun R, Jiang H, Wan J, Wu F, Wang X, Tao X. Intensive care unit acquired weakness: A protocol for an overview of systematic reviews and meta-analysis. Medicine (Baltimore) 2020; 99:e21926. [PMID: 32846861 PMCID: PMC7447417 DOI: 10.1097/md.0000000000021926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICU-AW) is an acquired neuromuscular lesion and a common occurrence in patients who are critically ill. There are already systematic reviews on ICU-AW. Therefore, we provide a protocol for an overview of systematic reviews to improve the effectiveness of the construction of an evidence-based practice for prevention of ICU-AW. METHODS We will search the PubMed, CINAHL, EMBASE, and the Cochrane Library for the relevant systematic review or meta-analyses about ICU-AW. Study selection, data extraction, and the quality assessment of the included studies will be performed independently by 2 reviewers. And the methodological quality, report quality and evidence quality will be evaluated by Assessment of Multiple Systematic Reviews-2 tool, Preferred Reporting Items for Systematic Reviews and Meta Analyses Statement checklist and Grading of Recommendations Assessment, Development and Evaluation system, respectively. RESULTS This overview of systematic reviews and meta-analysis will collect the evidence published about the ICU-AW. CONCLUSION We hope that our research will contribute to clinicians and public decision making about the ICU-AW. REGISTRATION NUMBER INPLASY202070067.
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Affiliation(s)
- Zheng Li
- Graduate College, Wannan Medical College, Wuhu
| | - Yitong Cai
- School of Nursing, Lanzhou University, Lanzhou
| | - Qian Zhang
- School of Nursing, Lanzhou University, Lanzhou
| | - Peng Zhang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Ruixiang Sun
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Haijiao Jiang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | | | - Fang Wu
- Graduate College, Wannan Medical College, Wuhu
| | - Xiaoye Wang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Xiubin Tao
- Graduate College, Wannan Medical College, Wuhu
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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Lee SJ, Lee Y, Kong A, Ng SY. Airway Pressure Release Ventilation Combined With Prone Positioning in Acute Respiratory Distress Syndrome: Old Tricks New Synergy: A Case Series. A A Pract 2020; 14:e01231. [PMID: 32496425 DOI: 10.1213/xaa.0000000000001231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Airway pressure release ventilation (APRV) shares several overlapping mechanisms with prone positioning in improving ventilation-perfusion mismatch in patients with acute respiratory distress syndrome (ARDS). However, the combination of APRV and prone positioning is seldom performed because assist/controlled ventilation remains the mainstay ventilatory mode. We describe 5 cases of severe ARDS where APRV and prone positioning were applied. All patients' partial pressure of arterial oxygen (PaO2):inspired oxygen concentration (FiO2) ratios improved after treatment, and 3 patients were extubated within 72 hours of turning supine. In our experience, APRV can be safely used in the prone position in a select subgroup of ARDS patients with resulting significant oxygenation improvement.
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Affiliation(s)
- Si Jia Lee
- From Department of Surgical Intensive Care, SingHealth, Singapore
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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Abdelaal Ahmed Mahmoud A, Mahmoud HE, Mahran MA, Khaled M. Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls. J Cardiothorac Vasc Anesth 2020; 34:436-443. [DOI: 10.1053/j.jvca.2019.05.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023]
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Ho ATN, Patolia S, Guervilly C. Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. J Intensive Care 2020; 8:12. [PMID: 32015880 PMCID: PMC6986163 DOI: 10.1186/s40560-020-0431-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results. Method A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and meta-regression analysis were performed. Results From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO2/FIO2 of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78–1.03; I2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I2 = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)–induced weakness. The PaO2/FIO2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO2/FIO2 ratio, positive end-expiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes. Conclusion NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.
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Affiliation(s)
- An Thi Nhat Ho
- 1Pulmonary and Critical Care Medicine, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63104 USA
| | - Setu Patolia
- 1Pulmonary and Critical Care Medicine, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63104 USA
| | - Christophe Guervilly
- 2Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,3CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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Hua Y, Ou X, Li Q, Zhu T. Neuromuscular blockers in the acute respiratory distress syndrome: A meta-analysis. PLoS One 2020; 15:e0227664. [PMID: 31961896 PMCID: PMC6974254 DOI: 10.1371/journal.pone.0227664] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/24/2019] [Indexed: 02/05/2023] Open
Abstract
Background The effects of neuromuscular blocking agents (NMBAs) on adult patients with acute respiratory distress syndrome (ARDS) remain unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate its effect on mortality. Methods We searched the Cochrane (Central) database, Medline, Embase, the Chinese Biomedical Literature Database (SinoMed), WanFang data and ClinicalTrials from inception to June 2019, with language restriction to English and Chinese. We included published RCTs and eligible clinical trials from ClinicalTrials.gov that compared NMBAs with placebo or usual treatment in adults with ARDS. We pooled data using random-effects models. The primary outcome was mortality. The secondary outcomes were the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FIO2), total positive end expiratory pressure (PEEP), plateau pressure (Pplat), days free of ventilator at day 28, barotrauma and ICU-acquired weakness. Results We included 6 RCTs (n = 1557). Compared with placebo or usual treatment, NMBAs were associated with lower 21 to 28-day mortality (RR 0.72, 95% CI 0.53–0.97, I2 = 59%). NMBAs significantly improved oxygenation (Pao2:Fio2 ratios) at 48 hours (MD 27.26 mm Hg, 95% CI 1.67, 52.84, I2 = 92%) and reduced the incidence of barotrauma (RR 0.55, 95% CI 0.35, 0.85, I2 = 0). However, NMBAs had no effect on oxygenation (Pao2:Fio2 ratios) (MD 18.41 mm Hg, 95% CI -0.33, 37.14, I2 = 72%) at 24 hours. We also found NMBAs did not affect total PEEP, plateau pressure, days free of ventilation at day 28 and ICU-acquired weakness. Conclusions In patients with moderate-to-severe ARDS, the administration of NMBAs could reduce 21 to 28-day mortality and barotrauma, and improve oxygenation at 48 hours, but have no significant effects on 90-day/ICU mortality, days free of ventilation at day 28 and the risk of ICU-acquired weakness. Further large-scale, high-quality RCTs are needed to confirm our findings. Registration: PROSPERO (ID: CRD 42019139656).
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Affiliation(s)
- Yusi Hua
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaofeng Ou
- Department of Critical Care, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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Li T, Liu L, Wang X. [Sepsis impairs aggregation of nicotinic acetylcholine receptors on murine skeletal muscle cell membranes by inhibiting AKT/GSK3β phosphorylation]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:1337-1343. [PMID: 31852639 DOI: 10.12122/j.issn.1673-4254.2019.11.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To investigate the role of the protein-serine-threonine kinase (AKT)/glycogen synthase kinase 3β (GSK3β) signaling pathway in nicotinic acetylcholine receptors (nAChRs) aggregation disorder on skeletal muscle cell membranes induced by sepsis. METHODS Mouse C2C12 myoblasts were differentiated into myotubes by horse serum, and then C2C12 myotubes were randomly divided into four groups: the Sham group treated with serum from sham-operated mice, the Sepsis group treated with serum from septic mice, the Sepsis+D group treated with serum from septic mice and dimethyl sulfoxide (DMSO), the Sepsis+SB group treated with serum from septic mice and GSK3β inhibitor SB216763. Agrin was added into the cell culture to induce nAChRs aggregation before the treatment. After serum treatment for 5.5 h, the myotubes were examined for nAChRs clusters using Alexa Fluor 594-conjugated α-bungarotoxin (α- BTX). The expression levels of AKT, GSK3β and CLIP- associated protein 2 (CLASP2) and the phosphorylation of AKT, GSK3β were examined with Western blotting. The phosphorylation of CLASP2 and the interaction between CLASP2 and α-tubulin were detected with co-immunoprecipitation (Co-IP) assay. RESULTS Compared with the serum from sham-operated mice, the serum from septic mice caused significant reduction in the area and density of nAChRs clusters on C2C12 myotubes, lowered the levels of phosphorylated AKT (p-AKT) and phosphorylated GSK3β (p-GSK3β), increased the expression of phosphorylated CLASP2 (p-CLASP2), and obviously reduced the binding between CLASP2 and α-tubulin. Compared with DMSO, SB216763 significantly increased the area and density of nAChRs clusters on C2C12 myotubes treated with serum from septic mice, decreased the expression of p-CLASP2, and enhanced the interaction between CLASP2 and α-tubulin. CONCLUSIONS Septic mouse serum impairs nAChRs aggregation on C2C12 myotubes possibly by suppressing AKT/GSK3β phosphorylation to cause reduced interaction between CLASP2 and α-tubulin.
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Affiliation(s)
- Tianmei Li
- Department of Anesthesiology, First Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Li Liu
- Department of Anesthesiology, First Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Xiaobin Wang
- Department of Anesthesiology, First Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
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Lozada MJ, Goyal V, Levin D, Walden RL, Osmundson SS, Pacheco LD, Malbrain MLNG. Management of peripartum intra-abdominal hypertension and abdominal compartment syndrome. Acta Obstet Gynecol Scand 2019; 98:1386-1397. [PMID: 31070780 PMCID: PMC7313226 DOI: 10.1111/aogs.13638] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/09/2019] [Accepted: 05/02/2019] [Indexed: 12/24/2022]
Abstract
Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.
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Affiliation(s)
- M. James Lozada
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Varun Goyal
- Department of Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Danielle Levin
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Sarah S. Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luis D. Pacheco
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Manu L. N. G. Malbrain
- Intensive Care Unit, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Minà C, Bagnato S, Sant'Angelo A, Falletta C, Gesaro GD, Agnese V, Tuzzolino F, Galardi G, Clemenza F. Risk Factors Associated With Peripheral Neuropathy in Heart Failure Patients Candidates for Transplantation. Prog Transplant 2019; 28:36-42. [PMID: 29592634 DOI: 10.1177/1526924818765091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Peripheral neuropathy can affect patients with heart failure, though its prevalence is unknown. After heart transplantation, it can influence the postoperative course and quality of life, but screening for neuromuscular disease is not routinely performed. OBJECTIVE The aim of this study was to identify the factors associated with neuropathy in a population of patients with heart failure who are candidates for heart transplantation. STUDY DESIGN Data regarding patients' clinical history, including recent hospitalizations, were collected. All patients underwent a complete neurological examination and a neurophysiological protocol including nerve conduction studies and concentric needle electromyography. RESULTS Thirty-two patients were included in the study, and neuropathy was diagnosed in 10 (31.3%). Neuropathy was associated with the number of admissions ( P = .023; odds ratio [OR]: 1.96) and the total number of days of hospitalization in the year prior to inclusion in the study ( P = .010; OR: 1.03). The majority of hospitalizations occurred in the step-down unit (85%), with acute heart failure the leading cause of admission (42%). CONCLUSIONS This study shows that neuropathy is frequent in patients with advanced heart failure and that hospitalization for cardiac care, also in the absence of intensive care, is a marker of high risk of neurologic damage. These data can help physicians in selecting and managing candidates for transplantation and can guide decisions on the best immunosuppressive regimen or rehabilitation strategy.
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Affiliation(s)
- Chiara Minà
- 1 Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Sergio Bagnato
- 2 Unit of Neurophysiology and Rehabilitation Department, Foundation Institute G. Giglio, Cefalù, Italy
| | - Antonino Sant'Angelo
- 2 Unit of Neurophysiology and Rehabilitation Department, Foundation Institute G. Giglio, Cefalù, Italy
| | - Calogero Falletta
- 1 Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Gabriele Di Gesaro
- 1 Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Valentina Agnese
- 1 Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- 3 Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Giuseppe Galardi
- 2 Unit of Neurophysiology and Rehabilitation Department, Foundation Institute G. Giglio, Cefalù, Italy
| | - Francesco Clemenza
- 1 Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, Grissom CK, Gundel S, Hayden D, Hite RD, Hou PC, Hough CL, Iwashyna TJ, Khan A, Liu KD, Talmor D, Thompson BT, Ulysse CA, Yealy DM, Angus DC. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med 2019; 380:1997-2008. [PMID: 31112383 PMCID: PMC6741345 DOI: 10.1056/nejmoa1901686] [Citation(s) in RCA: 496] [Impact Index Per Article: 99.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefits of early continuous neuromuscular blockade in patients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation remain unclear. METHODS We randomly assigned patients with moderate-to-severe ARDS (defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure [PEEP] of ≥8 cm of water) to a 48-hour continuous infusion of cisatracurium with concomitant deep sedation (intervention group) or to a usual-care approach without routine neuromuscular blockade and with lighter sedation targets (control group). The same mechanical-ventilation strategies were used in both groups, including a strategy involving a high PEEP. The primary end point was in-hospital death from any cause at 90 days. RESULTS The trial was stopped at the second interim analysis for futility. We enrolled 1006 patients early after the onset of moderate-to-severe ARDS (median, 7.6 hours after onset). During the first 48 hours after randomization, 488 of the 501 patients (97.4%) in the intervention group started a continuous infusion of cisatracurium (median duration of infusion, 47.8 hours; median dose, 1807 mg), and 86 of the 505 patients (17.0%) in the control group received a neuromuscular blocking agent (median dose, 38 mg). At 90 days, 213 patients (42.5%) in the intervention group and 216 (42.8%) in the control group had died before hospital discharge (between-group difference, -0.3 percentage points; 95% confidence interval, -6.4 to 5.9; P = 0.93). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. There were no consistent between-group differences in end points assessed at 3, 6, and 12 months. CONCLUSIONS Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets. (Funded by the National Heart, Lung, and Blood Institute; ROSE ClinicalTrials.gov number, NCT02509078.).
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Affiliation(s)
- Marc Moss
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - David T Huang
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Roy G Brower
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Niall D Ferguson
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Adit A Ginde
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - M N Gong
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Colin K Grissom
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Stephanie Gundel
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Douglas Hayden
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - R Duncan Hite
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Peter C Hou
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Catherine L Hough
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Theodore J Iwashyna
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Akram Khan
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Kathleen D Liu
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Daniel Talmor
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - B Taylor Thompson
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Christine A Ulysse
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Donald M Yealy
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Derek C Angus
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
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Stressing the Brain: The Immune System, Hypothalamic-Pituitary-Adrenal Axis, and Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors. Ann Am Thorac Soc 2019; 14:839-841. [PMID: 28570150 DOI: 10.1513/annalsats.201703-203ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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