Designing a Bayesian adaptive clinical trial to evaluate novel mechanical ventilation strategies in acute respiratory failure using integrated nested Laplace approximations

BACKGROUND

Adaptive trials usually require simulations to determine values for design parameters, demonstrate error rates, and establish the sample size. We designed a Bayesian adaptive trial comparing ventilation strategies for patients with acute hypoxemic respiratory failure using simulations. The complexity of the analysis would usually require computationally expensive Markov Chain Monte Carlo methods but this barrier to simulation was overcome using the Integrated Nested Laplace Approximations (INLA) algorithm to provide fast, approximate Bayesian inference.

METHODS

We simulated two-arm Bayesian adaptive trials with equal randomization that stratified participants into two disease severity states. The analysis used a proportional odds model, fit using INLA. Trials were stopped based on pre-specified posterior probability thresholds for superiority or futility, separately for each state. We calculated the type I error and power across 64 scenarios that varied the probability thresholds and the initial minimum sample size before commencing adaptive analyses. Two designs that maintained a type I error below 5%, a power above 80%, and a feasible mean sample size were evaluated further to determine the optimal design.

RESULTS

Power generally increased as the initial sample size and the futility threshold increased. The chosen design had an initial recruitment of 500 and a superiority threshold of 0.9925, and futility threshold of 0.95. It maintained high power and was likely to reach a conclusion before exceeding a feasible sample size.

CONCLUSIONS

We designed a Bayesian adaptive trial to evaluate novel strategies for ventilation using the INLA algorithm to efficiently evaluate a wide range of designs through simulation.

Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Recent randomized controlled trials did not show benefit of early/immediate coronary angiography (CAG) over a delayed/selective strategy in patients with out-of-hospital cardiac arrest (OHCA) and no ST-segment elevation. However, whether selected subgroups, specifically those with a high pretest probability of coronary artery disease may benefit from early CAG remains unclear.

METHODS

We included all randomized controlled trials that compared a strategy of early/immediate versus delayed/selective CAG in OHCA patients and no ST elevation and had a follow-up of at least 30 days. The primary outcome of interest was all-cause death. Odds ratios (OR) were calculated and pooled across trials. Interaction testing was used to assess for heterogeneity of treatment effects.

RESULTS

In total, 1512 patients (67 years, 26% female, 23% prior myocardial infarction) were included from 5 randomized controlled trials. Early/immediate versus delayed/selective CAG was not associated with a statistically significant difference in odds of death (OR 1.12, 95%-CI 0.91-1.38), with similar findings for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95%-CI 0.89-1.36). There was no effect modification for death by age, presence of a shockable initial cardiac rhythm, history of coronary artery disease, presence of an ischemic event as the presumed cause of arrest, or time to return of spontaneous circulation (all P-interaction > 0.10). However, early/immediate CAG tended to be associated with higher odds of death in women (OR 1.52, 95%-CI 1.00-2.31, P = 0.050) than in men (OR 1.04, 95%-CI 0.82-1.33, P = 0.74; P-interaction 0.097).

CONCLUSION

In OHCA patients without ST-segment elevation, a strategy of early/immediate versus delayed/selective CAG did not reduce all-cause mortality across major subgroups. However, women tended to have higher odds of death with early CAG.

21st century critical care medicine: An overview

Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.

Through the looking glass: qualitative study of critical care clinicians engaging in humanities

PURPOSE

Critical care medicine is facing an epidemic of burnout and consequent attrition. Interventions are needed to re-establish the medical field as a place of professional growth, resilience, and personal well-being. Humanities facilitate creation, reflection, and meaning-making, holding the promise of personal and community transformation. This study aimed to explore how clinicians engage with a humanities program, and what role and impact do the humanities play in their individual and collective journey.

METHODS

This is a qualitative study employing a phenomenological approach. Participants were faculty and trainees who participated in the program. Data consisted of (a) 60-h observations of humanities evenings, (b) more than 200 humanities artifacts brought by participants, and (c) 15 in-depth participant interviews. Data were analyzed inductively and reflectively by a team of researchers.

RESULTS

Participants were motivated to engage with the humanities curriculum because of past experiences with art, identifying a desire to re-explore their creativity to make meaning from their clinical experiences and a wish to socialize with and understand their colleagues through a different lens. The evenings facilitated self-expression, and inspired and empowered participants to create art pieces and re-engage with art in their daily lives. More importantly, they found a community where they could be vulnerable and supported, where shared experiences were discussed, emotions were validated, and relationships were deepened between colleagues.

CONCLUSIONS

Humanities may impact resilience and personal and community well-being by facilitating reflection and meaning-making of challenging clinical work and building bonds between colleagues.

The FIB-4 scores in the emergency department to predict the outcomes of COVID-19 patients in taiwan

Objective

We aimed to determine the reliability of using the Fibrosis-4 (FIB-4) index in COVID-19 patients without underlying liver illness.

Method

We employed multivariate logistic regression to identify variables that exhibited statistically significant influence on the ultimate outcome. Multilayer perceptron analysis was employed to develop a prediction model for the FIB-4 index concerning ICU admission and intubation rates. However, the scarcity of cases rendered the assessment of the mortality rate unfeasible. We plotted ROC curves to analyze the predictive strength of the FIB-4 index across various age groups.

Result

In univariate logistic regression, only the FIB-4 index and respiratory rate demonstrated statistical significance on all poor outcomes. The FIB-4 index for mortality prediction had an ROC and AUC of 0.863 (95% CI: 0.781-0.9444). It demonstrates predictive power across age groups, particularly for age ≥65 (AUC: 0.812, 95% CI: 0.6571-0.9673) and age <65 (AUC: 0.878, 95% CI: 0.8012-0.9558). Its sensitivity for intubation and ICU admission prediction is suboptimal.

Conclusion

FIB-4 index had promising power in prediction of mortality rate in all age groups.

Circulating endothelial extracellular vesicle signatures correspond with ICU requirement: an exploratory study in COVID-19 patients

Extracellular vesicles (EVs) represent nanometer-sized, subcellular spheres, that are released from almost any cell type and carry a wide variety of biologically relevant cargo. In severe cases of coronavirus disease 2019 (COVID-19) and other states of systemic pro-inflammatory activation, EVs, and their cargo can serve as conveyors and indicators for disease severity and progression. This information may help distinguish individuals with a less severe manifestation of the disease from patients who exhibit severe acute respiratory distress syndrome (ARDS) and require intensive care measures. Here, we investigated the potential of EVs and associated miRNAs to distinguish normal ward patients from intensive care unit (ICU) patients (N = 10/group), with 10 healthy donors serving as the control group. Blood samples from which plasma and subsequently EVs were harvested by differential ultracentrifugation (UC) were obtained at several points in time throughout treatment. EV-enriched fractions were characterized by flow cytometry (FC), nanoparticle tracking analysis (NTA), and qPCR to determine the presence of selected miRNAs. Circulating EVs showed specific protein signatures associated with endothelial and platelet origin over the course of the treatment. Additionally, significantly higher overall EV quantities corresponded with increased COVID-19 severity. MiR-223-3p, miR-191-5p, and miR-126-3p exhibited higher relative expression in the ICU group. Furthermore, EVs presenting endothelial-like protein signatures and the associated miR-126-3p showed the highest area under the curve in terms of receiver operating characteristics regarding the requirement for ICU treatment. In this exploratory investigation, we report that specific circulating EVs and miRNAs appear at higher levels in COVID-19 patients, especially when critical care measures are indicated. Our data suggest that endothelial-like EVs and associated miRNAs likely represent targets for future laboratory assays and may aid in clinical decision-making in COVID-19.

Evaluation of phenobarbital dosing strategies for hospitalized patients with alcohol withdrawal syndrome

OBJECTIVE

Alcohol remains the fourth‑leading preventable cause of death in the U.S. The objective of this study was to compare the incidence of phenobarbital (PHB)-resistant withdrawal and determine risk factors for PHB-resistant alcohol withdrawal syndrome (AWS).

METHODS

This retrospective cohort study included adults admitted to an academic center with AWS who received PHB as part of an institution-specific treatment protocol. The primary outcome was incidence of AWS resistant to initial protocolized PHB load across two cohorts (standard-dose, 10 mg/kg vs. low-dose, 6 mg/kg).

RESULTS

Among 176 included patients, there was no difference in the incidence of PHB-resistant AWS based on initial PHB load [low-dose load, 21 (18.3%) vs. standard-dose load, 12 (19.7%), p = 0.82]. There were also no differences in observed PHB-related ADEs between the groups. Total benzodiazepine dose received (mg) in the 24 h prior to initial PHB load was the only risk factor significantly associated with AWS resistant to initial protocolized PHB load [adjusted OR 1.79 (95% CI 1.24, 2.60)]. PHB-resistant withdrawal occurred in 33 (18.8%) patients with a median cumulative PHB dose of approximately 20 mg/kg during hospitalization.

CONCLUSION(S)

There were no differences in the incidence of PHB-resistant AWS or PHB-related ADEs based on initial PHB loading dose.

Out-of-hospital deaths in Mongolia: a nationwide cohort study on the proportion, causes, and potential impact of emergency and critical care services

Background

Little is known about the proportion and causes of out-of-hospital deaths in Mongolia. In this study, we aimed to determine the proportion and causes of out-of-hospital deaths in Mongolia during a six-month observation period before the COVID-19 pandemic.

Methods

In a retrospective study, the Mongolian National Death Registry was screened for all deaths occurring from 01 to 06/2020. The proportion and causes of out-of-hospital deaths, causes of out-of-hospital deaths likely treatable by emergency/critical care interventions, as well as sex, regional and seasonal differences in the proportion and causes of out-of-hospital deaths were determined. The primary endpoint was the proportion and causes of out-of-hospital death in children and adults. Descriptive statistical methods, the Fisher's Exact, multirow Chi2-or Mann-Whitney-U-rank sum tests were used for data analysis.

Findings

Five-thousand-five-hundred-fifty-three of 7762 deaths (71.5%) occurred outside of a hospital. The proportion of out-of-hospital deaths was lower in children than adults (39.3% vs. 74.8%, p < 0.001). Trauma, chronic neurological diseases, lower respiratory tract infections, congenital birth defects, and neonatal disorders were the causes of out-of-hospital deaths resulting in most years of life lost in children. In adults, chronic heart diseases, trauma, liver cancer, poisonings, and self-harm caused the highest burden of premature mortality. The proportion of out-of-hospital deaths did not differ between females and males (70.5% vs. 72.2%, p = 0.09). The proportion (all, p < 0.001; adults, p < 0.001; children, p < 0.001) and causes (adults, p < 0.001; children, p < 0.001) of out-of-hospital deaths differed between Mongolian regions and Ulaanbaatar. The proportion of out-of-hospital deaths was higher during winter than spring/summer months (72.3% vs. 69.9%, p = 0.03). An expert panel estimated that 49.3% of out-of-hospital deaths were likely treatable by emergency/critical care interventions.

Interpretation

With regional and seasonal variations, about 75% of Mongolian adults and 40% of Mongolian children died outside of a hospital. Heart diseases, trauma, cancer, and poisonings resulted in most years of life lost. About half of the causes of out-of-hospital deaths could be treated by emergency/critical care interventions.

Funding

Institutional funding.

The need for maternal critical care education, point-of-care ultrasound and critical care echocardiography in obstetric anesthesiologists training

Globally, the increase in medically complex obstetric patients is challenging the educational approach and clinical management of critically ill obstetric patients. This increase in medical complexity calls into question the educational paradigm in which future physicians are trained. Obstetric anesthesiologists, physician experts in the perio-perative planning and management of complex obstetric patients, represent an essential workforce in the strategies to address maternal mortality. Unfortunately, the development of peri-operative medicine and maternal critical care curricula has only received minor attention in most countries. Proposed guidelines and models highlight the existing need for tiered maternity care services in which critical care infrastructure plays a central role in the delivery of high-risk peripartum care. Therefore, the development of maternal critical care models designed to prepare obstetric anesthesiologists for the clinical challenges of a medically complex patient are warranted. Key critical care topics such as advanced ultrasonography, with the inclusion of quantitative echocardiographic assessments into obstetric anesthesiology educational curricula, will serve to better prepare physicians for the realities of an increasingly complex pregnant patient population, and further reinforce the critical care infrastructure detailed in the Levels of Maternal Care consensus. Despite an increasingly complex obstetric patient population, heterogeneity of maternal critical care practices exists across the globe, warranting standardization and further development of proposed curricula.

Importance of clinical parameters for cultivation of critical care thinking by online teaching of critical care medicine

BACKGROUND

The teaching of critical care medicine is a very important task, especially during the COVID-19 pandemic. The understanding of critical care parameters is the foundation and core, which is conducive to the formation of clinical thinking. This study is to evaluate the training effect of teaching of critical care parameters based on an online platform, and explore the teaching methods of critical care medicine that can help to cultivate trainees' clinical thinking and practical ability.

METHODS

Questionnaires were released before and after the training through the official new media platform "Yisheng" application (APP) of China Medical Tribune involving 1109 participants. The trainees who filled in the questionnaire in APP and received training were randomly selected as the investigated population. Statistical description and analysis were carried out using SPSS 20.0 and Excel 2020.

RESULTS

The trainees were mainly attending physicians in tertiary hospitals and above. Among all critical care parameters, trainees paid more attention to critical hemodynamics, respiratory mechanics, severity of illness scoring systems, critical ultrasound, and critical hemofiltration. The degree of satisfaction with the courses was high, especially the course of critical hemodynamics was scored the highest. The trainees believed that the course contents were of great help to clinical work. However, no significant difference was found in the trainees' understanding or cognition of the connotation of the parameters before and after the training.

CONCLUSION

Teaching of critical care parameters based on an online platform is conducive to improving and consolidating the clinical care ability of trainees. However, it is still necessary to strengthen the cultivation of clinical thinking in critical care. In the future, the integration of theory with practice must be strengthened in clinical practice, ultimately achieving the homogeneous diagnosis and treatment of patients with critical illness.

Association of blood viscosity and device-free days among hospitalized patients with COVID-19

BACKGROUND

Increased estimated whole blood viscosity (eWBV) predicts higher mortality in patients hospitalized for coronavirus disease 2019 (COVID-19). This study assesses whether eWBV is an early predictor of non-fatal outcomes among patients hospitalized for acute COVID-19 infection.

METHODS

This retrospective cohort study included 9278 hospitalized COVID-19 patients diagnosed within 48 h of admission between February 27, 2020 to November 20, 2021 within the Mount Sinai Health System in New York City. Patients with missing values for major covariates, discharge information, and those who failed to meet the criteria for the non-Newtonian blood model were excluded. 5621 participants were included in the main analysis. Additional analyses were performed separately for 4352 participants who had measurements of white blood cell count, C-reactive protein and D-dimer. Participants were divided into quartiles based on estimated high-shear blood viscosity (eHSBV) and estimated low-shear blood viscosity (eLSBV). Blood viscosity was calculated using the Walburn-Schneck model. The primary outcome was evaluated as an ordinal scale indicating the number of days free of respiratory organ support through day 21, and those who died in-hospital were assigned a value of -1. Multivariate cumulative logistic regression was conducted to evaluate the association between quartiles of eWBV and events.

RESULTS

Among 5621 participants, 3459 (61.5%) were male with mean age of 63.2 (SD 17.1) years. The linear modeling yielded an adjusted odds ratio (aOR) of 0.68 (95% CI 0.59-0.79, p value < 0.001) per 1 centipoise increase in eHSBV.

CONCLUSIONS

Among hospitalized patients with COVID-19, elevated eHSBV and eLSBV at presentation were associated with an increased need for respiratory organ support at 21 days. These findings are highly relevant, as they demonstrate the utility of eWBV in identifying hospitalized patients with acute COVID-19 infection at increased risk for non-fatal outcomes in early stages of the disease.

The furosemide stress test predicts the timing of continuous renal replacement therapy initiation in critically ill patients with acute kidney injury: a double-blind prospective intervention cohort study

BACKGROUND

Continuous renal replacement therapy (CRRT) remains a crucial treatment for critically ill patients with acute kidney injury (AKI), although the timing of its initiation is still a matter of contention. Furosemide stress testing (FST) may be a practical and beneficial prediction instrument. This research was meant to examine if FST can be used to identify high-risk patients for CRRT.

METHODS

This study is a double-blind, prospective interventional cohort study. For patients with AKI receiving intensive care unit (ICU) income, FST was selected with furosemide 1 mg/kg intravenous (1.5 mg/kg intravenous if a loop diuretic was received within 7 days). Urinary volume more than 200 ml at 2 h after FST was FST-responsive, less than 200 ml was FST-nonresponsive. The FST results are kept strictly confidential from the clinician, who decides whether to initiate CRRT based on laboratory testing and clinical symptoms other than the FST data. The FST data are concealed from both the patients and the clinician.

RESULTS

FST was delivered to 187 of 241 patients who satisfied the inclusion and exclusion criteria, with 48 patients responding to the test and 139 patients not responding. 18/48 (37.5%) of the FST-responsive patients received CRRT, while 124/139 (89.2%) of the FST-nonresponsive patients received CRRT. There was no significant difference between the CRRT and non-CRRT groups in terms of general health and medical history (P > 0.05). Urine volume after 2 h of FST was considerably lower in the CRRT group than in the non-CRRT group (35 ml, IQR5-143.75 versus 400 ml, IQR210-890; P = 0.000). FST non-responders were 2.379 times more likely to initiate CRRT than FST responders (95% CI 1.644-3.443, P = 0.000). The area under the curve (AUC) for initiating CRRT was 0.966 (cutoff of 156 ml, sensitivity of 94.85%, specificity of 98.04%, P < 0.001).

CONCLUSION

This study demonstrated that FST is a safe and practical approach for predicting the initiation of CRRT in critically ill AKI patients. Trial registration www.chictr.org.cn , ChiCTR1800015734, Registered 17 April 2018.

Feasibility of bedside portable MRI in neonates and children during ECLS

Magnetic resonance imaging (MRI) is the preferred neuroimaging technique in pediatric patients. However, in neonates and instable pediatric patients accessibility to MRI is often not feasible due to instability of patients and equipment not being feasible for MRI. Low-field MRI has been shown to be a feasible neuroimaging tool in pediatric patients. We present the first four patients receiving bedside high-quality MRI during ECLS treatment. We show that it is safe and feasible to perform bedside MRI in this patient population. This opens the route to additional treatment decisions and may guide optimized treatment in these patients.

The hypoxia-age-shock index at triage to predict the outcomes of Covid-19 patients

STUDY OBJECTIVE

The coronavirus disease 2019 (COVID-19) outbreak has caused a severe burden on medical professionals, as the rapid disposition of patients is important. Therefore, we aimed to develop a new clinical assessment tool based on the shock index (SI) and age-shock index (ASI). We proposed the hypoxia-age-shock index (HASI) and determined the usability of triage for COVID-19 infected patients in the first scene.

METHODS

The predictive power for three indexes on mortality, intensive care unit (ICU) admission, and endotracheal intubation rate was evaluated using the receiver operating curve (ROC). We used DeLong's method for comparing the ROCs.

RESULTS

The area under the curve (AUC) for ROC on mortality for SI, ASI, and HASI were 0.546, 0.771, and 0.773, respectively. The AUC on ICU admission mortality for SI, ASI, and HASI were 0.581, 0.700, and 0.743, respectively. The AUC for intubation for SI, ASI, and HASI were 0.592, 0.708, and 0.757, respectively. The AUC differences between HASI and SI showed statistically significant (P = 0.001) results on mortality, ICU admission, and intubation. Additionally, statistically significant results were found for the AUC difference between the HASI and ASI on ICU admission and intubation (P = 0.001 and P = 0.004, respectively).

CONCLUSION

HASI can provide a better prediction compared to ASI on ICU admission and endotracheal intubation. HASI was more sensitive in mortality, ICU admission, and intubation prediction than the ASI.

A pilot study to predict cardiac arrest in the pediatric intensive care unit

BACKGROUND

Cardiac arrest is a leading cause of mortality prior to discharge for children admitted to the pediatric intensive care unit. To address this problem, we used machine learning to predict cardiac arrest up to three hours in advance.

METHODS

Our data consists of 240 Hz ECG waveform data, 0.5 Hz physiological time series data, medications, and demographics from 1,145 patients in the pediatric intensive care unit at the Johns Hopkins Hospital, 15 of whom experienced a cardiac arrest. The data were divided into training, validating, and testing sets, and features were generated every five minutes. 23 heart rate variability (HRV) metrics were determined from ECG waveforms. 96 summary statistics were calculated for 12 vital signs, such as respiratory rate and blood pressure. Medications were classified into 42 therapeutic drug classes. Binary features were generated to indicate the administration of these different drugs. Next, six machine learning models were evaluated: logistic regression, support vector machine, random forest, XGBoost, LightGBM, and a soft voting ensemble.

RESULTS

XGBoost performed the best, with 0.971 auROC, 0.797 auPRC, 99.5% sensitivity, and 69.6% specificity on an independent test set.

CONCLUSION

We have created high-performing models that identify signatures of in-hospital cardiac arrest (IHCA) that may not be evident to clinicians. These signatures include a combination of heart rate variability metrics, vital signs data, and therapeutic drug classes. These machine learning models can predict IHCA up to three hours prior to onset with high performance, allowing clinicians to intervene earlier, improving patient outcomes.

Boosting ICU capacity during the COVID-19 pandemic in the western Balkan region, The Republic of Srpska experience

Background

Response to the outbreak of poliomyelitis in mid-1950 led to recognition and consequent development of critical care. Seventy years later the humankind was struck by COVID-19, another major challenge for critical care medicine which was especially big in Low-Resources-Settings where more than two thirds of the world population live, including the population of the Republic of Srpska (RS).

Design and methods

The main aim was to show an overview of all interventions in order to boost hospitals' capacities to the level which is sufficient to manage high amount of critically ill COVID-19 patients in the RS. A before-after cohort study design was conducted to evaluate the effects of interventions for increase in preparedness and capacity of ICUs for admission and treatment of COVID-19 critically ill patients in nine hospitals in the RS. Results: Following interventions, the biggest and university affiliated hospital in the RS has increased ICU capacities: total number of ICU beds increased by 38% and number of ventilators by 114%. Availability of machines for veno-venous extracorporeal membrane oxygenation (vvECMO) increased by 100%. Number of doctors who were involved in treatment of critically ill patients increased by 47% and nurse/patient's ratio reached 1:2.5. Similarly, all other hospitals experienced boosting of ICU beds by 189% and ventilators by 373% while number of doctors increased by 108% and nurse/patient's ratio reached 1:4.

Conclusion

All interventions implemented during COVID-19 pandemic outbreak in the RS resulted in increasing capacity for treatment of critically ill patients, but the education of health care professionals was identified as the most important conducted intervention.

Association between admission serum phosphate and risk of acute kidney injury in critically ill patients with rhabdomyolysis: A retrospective study based on MIMIC-Ⅲ

BACKGROUND

The incidence of acute kidney injury (AKI) is high in critically ill patients with rhabdomyolysis. Limited evidence was proved of the association between serum phosphate levels at intensive care unit (ICU) admission and the subsequent risk of AKI. Our study aims to assess if serum phosphate levels at admission were independently associated with AKI risk in these patients.

METHODS

This study extracted and analyzed data from Medical Information Mart for Intensive Care-Ⅲ (MIMIC-Ⅲ, version1.4). Rhabdomyolysis was defined as a peak creatine kinase (CK) level higher than 1000 U/L. Serum phosphate was measured within the first day into the ICU and was categorized to 4 groups (<2.6, 2.6-3.4, 3.5-4.5, >4.5mg/dl). AKI was defined according to the Kidney Disease Improving Global Outcome (KDIGO) guidelines. Adjusted smoothing spline plots and multivariable logistic regressions were carried out to explode the association between serum phosphate and risk of AKI. Subgroup analyse was applied to verify the consistency of the association.

RESULTS

Three hundred and twenty-one patients (68% male) diagnosed as rhabdomyolysis were eligible for this analysis. AKI occurred in 204 (64%) patients of total. Incidence of AKI with admission serum phosphate groups<2.6, 2.6-3.4, 3.5-4.5 and>4.5mg/dl were 53%, 57%, 68% and 76%, respectively. Smoothing spline curve showed that there was a positive curve between the elevated phosphate values and increasing risk of AKI, and there was no threshold saturation effect. In multivariable logistic regression, OR was 1.2 (95%CI 1.0-1.5, P=0.035, P trend=0.041) after adjusting confounders. Subgroup analyses proved the consistency of the relationship in these patients, possibly, except in the strata of potassium.

CONCLUSION

In rhabdomyolysis patients admitted to ICU, serum phosphate levels at admission were independently associated with an increased risk of AKI. As phosphate levels rise, the risk of AKI increased.

Development of a prediction model for enteral feeding intolerance in intensive care unit patients: A prospective cohort study

BACKGROUND

Enteral nutrition (EN) is essential for critically ill patients. However, some patients will have enteral feeding intolerance (EFI) in the process of EN.

AIM

To develop a clinical prediction model to predict the risk of EFI in patients receiving EN in the intensive care unit.

METHODS

A prospective cohort study was performed. The enrolled patients’ basic information, medical status, nutritional support, and gastrointestinal (GI) symptoms were recorded. The baseline data and influencing factors were compared. Logistic regression analysis was used to establish the model, and the bootstrap resampling method was used to conduct internal validation.

RESULTS

The sample cohort included 203 patients, and 37.93% of the patients were diagnosed with EFI. After the final regression analysis, age, GI disease, early feeding, mechanical ventilation before EN started, and abnormal serum sodium were identified. In the internal validation, 500 bootstrap resample samples were performed, and the area under the curve was 0.70 (95%CI: 0.63-0.77).

CONCLUSION

This clinical prediction model can be applied to predict the risk of EFI.

Virtual and augmented reality in critical care medicine: the patient's, clinician's, and researcher's perspective

Virtual reality (VR) and augmented reality (AR) are aspiring, new technologies with increasing use in critical care medicine. While VR fully immerses the user into a virtual three-dimensional space, AR adds overlaid virtual elements into a real-world environment. VR and AR offer great potential to improve critical care medicine for patients, relatives and health care providers. VR may help to ameliorate anxiety, stress, fear, and pain for the patient. It may assist patients in mobilisation and rehabilitation and can improve communication between all those involved in the patient's care. AR can be an effective tool to support continuous education of intensive care medicine providers, and may complement traditional learning methods to acquire key practical competences such as central venous line placement, cardiopulmonary resuscitation, extracorporeal membrane oxygenation device management or endotracheal intubation. Currently, technical, human, and ethical challenges remain. The adaptation and integration of VR/AR modalities into useful clinical applications that can be used routinely on the ICU is challenging. Users may experience unwanted side effects (so-called "cybersickness") during VR/AR sessions, which may limit its applicability. Furthermore, critically ill patients are one of the most vulnerable patient groups and warrant special ethical considerations if new technologies are to be introduced into their daily care. To date, most studies involving AR/VR in critical care medicine provide only a low level of evidence due to their research design. Here we summarise background information, current developments, and key considerations that should be taken into account for future scientific investigations in this field.

Evaluation of 4 quantification methods for monitoring 16 antibiotics and 1 beta-lactamase inhibitor in human serum by high-performance liquid chromatography with tandem mass spectrometry detection

Antibiotic (ATB) prescription in an intensive care unit (ICU) requires continuous monitoring of serum dosages due to the patient's pathophysiological condition. Dosing adjustment is necessary to achieve effective targeted concentrations. Since ICUs routinely use a large number of ATBs, global monitoring needs to be developed. In the present study, we developed a global analytical method for extracting, separating and quantifying the most widely used ATBs in ICUs: amoxicillin, piperacillin, cefazolin, cefepime, cefotaxime, ceftazidime, ceftolozane, ceftriaxone, ertapenem, meropenem, ciprofloxacin, moxifloxacin, levofloxacin, daptomycin, dalbavancin, linezolid and a beta-lactamase inhibitor: tazobactam. To guarantee the robustness of the quantification, we differentiated the 16 ATBs and the beta lactamase inhibitor into 4 pools (ATB1 to ATB4), taking into account prescription frequency in the ICU, the physicochemical properties and the calibration ranges of the ATBs selected. The whole ATB was then separated with two LC columns in reversed phase: Kinetex Polar-C18 100 Å and Polar-RP-80 synergy, in less than 6.5 min. Detection was carried out by electrospray in positive ion mode, by tandem mass spectrometry (LC-MS/MS. The four quantification methods were validated according to the European guidelines on bioanalytical method validation (EMEA guide), after determining the extraction yields, matrix effects, recovery, precision, accuracy, within-run precision and between-run precision. For all analyses, bias is < 15% and is comparable to the literature and LOQs vary from 0.05 mg.L^-1 for ciprofloxacin to 1.00 mg.L^-1 for ceftriaxone and dalbavancin. The stability time of cefepime and piperacillin is 3 hrs and for the other ATBs 6 hrs in serum at room temperature. For long-term stability, freezing at - 80 °C guarantees 3 months of stability for ceftriaxone and dalbavancin and more than 6 months for the other ATBs.

LIBERATE: a study protocol for midodrine for the early liberation from vasopressor support in the intensive care unit (LIBERATE): protocol for a randomized controlled trial

Background

Intravenous (IV) vasopressors to support hemodynamics are a primary indication for intensive care unit (ICU) admission. Utilization of oral vasopressor therapy may offer an alternative to IV vasopressor therapy in the ICU, thus decreasing the need for ICU admission. Oral vasopressors, such as midodrine, have been used for hemodynamic support in non-critically ill patients, but their evaluation in critically ill patients to potentially spare IV vasopressor therapy has been limited.

Methods

The LIBERATE study will be a multicenter, parallel-group, blinded, randomized placebo-controlled trial. It will recruit adult (i.e., age ≥ 18 years) critically ill patients receiving stable or decreasing doses of IV vasopressors. Eligible patients will be randomized to receive either midodrine 10 mg administered enterally every 8 h or placebo until 24 h post-discontinuation of IV vasopressors. The primary outcome will be ICU length of stay. Secondary outcomes include all-cause mortality at 90 days, hospital length of stay, length of IV vasopressor support, re-initiation of IV vasopressors, rates of ICU readmission, and occurrence of AEs. Health economic outcomes including ICU, hospital and healthcare costs, and cost-effectiveness will be evaluated. Pre-planned subgroup analyses include age, sex, frailty, severity of illness, etiology of shock, and comorbid conditions.

Discussion

LIBERATE will rigorously evaluate the effect of oral midodrine on duration of ICU stay and IV vasopressor support in critically ill patients.

Trial registration

ClinicalTrials.gov NCT05058612. Registered on September 28, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06115-0.

Noninvasive respiratory support following extubation in critically ill adults: a systematic review and network meta-analysis

PURPOSE

Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults.

METHODS

We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings.

RESULTS

We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52-0.82]) and HFNC (OR 0.63 [95% CI 0.45-0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78-1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61-1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66-1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations.

CONCLUSIONS

Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.

Is intensive care unit mortality a valid survival outcome measure related to critical illness?

RATIONALE

Use of death as an outcome of intensive care unit (ICU) admission may be biased by differential discharge decisions.

OBJECTIVE

To determine the validity of ICU survival status as an outcome measure of all cause case-fatality.

METHODS

A retrospective cohort of first admissions among adults to four ICUs in North Brisbane, Australia was assembled. Death in ICU (censored at discharge or 30 days) was compared with 30-day overall case-fatality.

RESULTS

The 30-day overall case-fatality was 8.1% (2436/29,939). One thousand six hundred and thirty-one deaths occurred within the ICU stay and 576 subsequent during hospital post-ICU discharge within 30-days; ICU and hospital case-fatality rates were 5.4% and 7.4%, respectively. An additional 229 patients died after hospital separation within 30 days of ICU admission of which 110 (48.0%) were transferred to another acute care hospital, 80 (34.9%) discharged home, and 39 (17.0%) transferred to an aged care/chronic care/rehabilitation facility. Patients who died after ICU discharge were older, had higher APACHE III scores, were more likely to be elective surgical patients, and were less likely to be out of state residents or managed in a tertiary referral hospital. Limiting determination of case-fatality to ICU information alone would correctly detect 95% (780/821) of all-cause mortality at day 3, 90% (1093/1213) at day 5, 75% (1524/2019) at day 15, 72% (1592/2244) at day 21, and 67% (1631/2436) at day 30 of follow-up.

CONCLUSIONS

Use of ICU case-fatality significantly underestimates the true burden and biases assessment of determinants of critical illness-related mortality in our region.

Data-driven clustering identifies features distinguishing multisystem inflammatory syndrome from acute COVID-19 in children and adolescents

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) consensus criteria were designed for maximal sensitivity and therefore capture patients with acute COVID-19 pneumonia.

METHODS

We performed unsupervised clustering on data from 1,526 patients (684 labeled MIS-C by clinicians) <21 years old hospitalized with COVID-19-related illness admitted between 15 March 2020 and 31 December 2020. We compared prevalence of assigned MIS-C labels and clinical features among clusters, followed by recursive feature elimination to identify characteristics of potentially misclassified MIS-C-labeled patients.

FINDINGS

Of 94 clinical features tested, 46 were retained for clustering. Cluster 1 patients (N = 498; 92% labeled MIS-C) were mostly previously healthy (71%), with mean age 7·2 ± 0·4 years, predominant cardiovascular (77%) and/or mucocutaneous (82%) involvement, high inflammatory biomarkers, and mostly SARS-CoV-2 PCR negative (60%). Cluster 2 patients (N = 445; 27% labeled MIS-C) frequently had pre-existing conditions (79%, with 39% respiratory), were similarly 7·4 ± 2·1 years old, and commonly had chest radiograph infiltrates (79%) and positive PCR testing (90%). Cluster 3 patients (N = 583; 19% labeled MIS-C) were younger (2·8 ± 2·0 y), PCR positive (86%), with less inflammation. Radiographic findings of pulmonary infiltrates and positive SARS-CoV-2 PCR accurately distinguished cluster 2 MIS-C labeled patients from cluster 1 patients.

INTERPRETATION

Using a data driven, unsupervised approach, we identified features that cluster patients into a group with high likelihood of having MIS-C. Other features identified a cluster of patients more likely to have acute severe COVID-19 pulmonary disease, and patients in this cluster labeled by clinicians as MIS-C may be misclassified. These data driven phenotypes may help refine the diagnosis of MIS-C.

Novel biomarker for predicting sepsis mortality: vitamin D receptor

Objective

There are currently no studies on the role of vitamin D receptor (VDR) levels as a cause of or risk factor for sepsis. We aimed to establish the association between VDR levels and 28-day mortality in critically ill patients with sepsis.

Methods

This prospective cross-sectional observational study included 148 patients diagnosed with sepsis who were treated in the intensive care unit. We measured VDR levels, laboratory characteristics, and health scores and related them to survival.

Results

The 148 patients included 96 survivors and 52 non-survivors, with VDR levels of 1.92 and 1.36 ng/mL, respectively. Baseline VDR was a significant predictor of 28-day mortality, with an area under the curve of 0.778. A low VDR level was significantly associated with lower overall survival in patients with sepsis according to Kaplan–Meier curve analysis. VDR levels were also negatively correlated with lactate, C-reactive protein, acute physiological and clinical health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores, and disease severity.

Conclusions

VDR levels were associated with high 28-day mortality and negatively correlated with lactate, C-reactive protein, APACHE II and SOFA scores, and disease severity in patients with sepsis. VDR levels can predict poor outcomes in patients with sepsis.

Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets

PURPOSE

Targeted temperature management (TTM) may improve survival and functional outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA), though the optimal target temperature remains unknown. We conducted a systematic review and network meta-analysis to investigate the efficacy and safety of deep hypothermia (31-32 °C), moderate hypothermia (33-34 °C), mild hypothermia (35-36 °C), and normothermia (37-37.8 °C) during TTM.

METHODS

We searched six databases from inception to June 2021 for randomized controlled trials (RCTs) evaluating TTM in comatose OHCA survivors. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was survival with good functional outcome. We used GRADE to rate our certainty in estimates.

RESULTS

We included 10 RCTs (4218 patients). Compared with normothermia, deep hypothermia (odds ratio [OR] 1.30, 95% confidence interval [CI] 0.73-2.30), moderate hypothermia (OR 1.34, 95% CI 0.92-1.94) and mild hypothermia (OR 1.44, 95% CI 0.74-2.80) may have no effect on survival with good functional outcome (all low certainty). Deep hypothermia may not improve survival with good functional outcome, as compared to moderate hypothermia (OR 0.97, 95% CI 0.61-1.54, low certainty). Moderate hypothermia (OR 1.23, 95% CI 0.86-1.77) and deep hypothermia (OR 1.27, 95% CI 0.70-2.32) may have no effect on survival, as compared to normothermia. Finally, incidence of arrhythmia was higher with moderate hypothermia (OR 1.45, 95% CI 1.08-1.94) and deep hypothermia (OR 3.58, 95% CI 1.77-7.26), compared to normothermia (both high certainty).

CONCLUSIONS

Mild, moderate, or deep hypothermia may not improve survival or functional outcome after OHCA, as compared to normothermia. Moderate and deep hypothermia were associated with higher incidence of arrhythmia. Routine use of moderate or deep hypothermia in comatose survivors of OHCA may potentially be associated with more harm than benefit.

Delirium Variability is Influenced by the Sound Environment (DEVISE Study): How Changes in the Intensive Care Unit soundscape affect delirium incidence

Quantitative data on the sensory environment of intensive care unit (ICU) patients and its potential link to increased risk of delirium is limited. We examined whether higher average sound and light levels in ICU environments are associated with delirium incidence. Over 111 million sound and light measurements from 143 patient stays in the surgical and trauma ICUs were collected using Quietyme® (Neshkoro, Wisconsin) sensors from May to July 2018 and analyzed. Sensory data were grouped into time of day, then normalized against their ICU environments, with Confusion Assessment Method (CAM-ICU) scores measured each shift. We then performed logistic regression analysis, adjusting for possible confounding variables. Lower morning sound averages (8 am-12 pm) (OR = 0.835, 95% OR CI = [0.746, 0.934], p = 0.002) and higher daytime sound averages (12 pm-6 pm) (OR = 1.157, 95% OR CI = [1.036, 1.292], p = 0.011) were associated with an increased odds of delirium incidence, while nighttime sound averages (10 pm-8 am) (OR = 0.990, 95% OR CI = [0.804, 1.221], p = 0.928) and the ICU light environment did not show statistical significance. Our results suggest an association between the ICU soundscape and the odds of developing delirium. This creates a future paradigm for studies of the ICU soundscape and lightscape.

Pheochromocytoma/paraganglioma crisis: case series from a tertiary referral center for pheochromocytomas and paragangliomas

Pheochromocytoma/paraganglioma (PPGL)-induced catecholamine crisis is a rare endocrine emergency leading to life-threatening hemodynamic instability causing end-organ damage or dysfunction. As it is associated with a significant mortality rate of approximately 15%, recognizing the signs and symptoms and making the appropriate diagnosis are critical. For this purpose, we report the clinical course of the crisis in four out of a total of six patients with a PPGL crisis from a cohort of 199 PPGL patients of a single tertiary referral center for PPGL patients in the Netherlands diagnosed between 2002 and 2020. Successful treatment of a PPGL crisis demands prompt diagnosis, vigorous pharmacological therapy, and emergency tumor removal if the patient continues to deteriorate.

Predictors of failure of high flow nasal cannula failure in acute hypoxemic respiratory failure due to COVID-19

Hypoxemic respiratory failure is a common manifestation of COVID-19 pneumonia. Early in the COVID-19 pandemic, patients with hypoxemic respiratory failure were, at times, being intubated earlier than normal; in part because the options of heated humidified high flow nasal cannula (HFNC) and non-invasive ventilation (NIV) were considered potentially inadequate and to increase risk of virus aerosolization. To understand the benefits and factors that predict success and failure of HFNC in this population, we evaluated data from the first 30 sequential patients admitted with COVID-19 pneumonia to our center who were managed with HFNC. We conducted Cox Proportional Hazards regression models to evaluate the factors associated with high flow nasal cannula failure (outcome variable), using time to intubation (censoring variable), while adjusting for comorbidities and immunosuppression. In the majority of our patients (76.7%), the use of HFNC failed and the patients were ultimately placed on mechanical ventilation. Those at increased risk of failure had a higher sequential organ failure assessment score, and at least one comorbidity or history of immunosuppression. Our data suggest that high flow nasal cannula may have a role in some patients with COVID-19 presenting with hypoxemic respiratory failure, but careful patient selection is the likely key to its success.

Machine learning predicts mortality based on analysis of ventilation parameters of critically ill patients: multi-centre validation

BACKGROUND

Mechanical Ventilation (MV) is a complex and central treatment process in the care of critically ill patients. It influences acid-base balance and can also cause prognostically relevant biotrauma by generating forces and liberating reactive oxygen species, negatively affecting outcomes. In this work we evaluate the use of a Recurrent Neural Network (RNN) modelling to predict outcomes of mechanically ventilated patients, using standard mechanical ventilation parameters.

METHODS

We performed our analysis on VENTILA dataset, an observational, prospective, international, multi-centre study, performed to investigate the effect of baseline characteristics and management changes over time on the all-cause mortality rate in mechanically ventilated patients in ICU. Our cohort includes 12,596 adult patients older than 18, associated with 12,755 distinct admissions in ICUs across 37 countries and receiving invasive and non-invasive mechanical ventilation. We carry out four different analysis. Initially we select typical mechanical ventilation parameters and evaluate the machine learning model on both, the overall cohort and a subgroup of patients admitted with respiratory disorders. Furthermore, we carry out sensitivity analysis to evaluate whether inclusion of variables related to the function of other organs, improve the predictive performance of the model for both the overall cohort as well as the subgroup of patients with respiratory disorders.

RESULTS

Predictive performance of RNN-based model was higher with Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.72 (± 0.01) and Average Precision (AP) of 0.57 (± 0.01) in comparison to RF and LR for the overall patient dataset. Higher predictive performance was recorded in the subgroup of patients admitted with respiratory disorders with AUC of 0.75 (± 0.02) and AP of 0.65 (± 0.03). Inclusion of function of other organs further improved the performance to AUC of 0.79 (± 0.01) and AP 0.68 (± 0.02) for the overall patient dataset and AUC of 0.79 (± 0.01) and AP 0.72 (± 0.02) for the subgroup with respiratory disorders.

CONCLUSION

The RNN-based model demonstrated better performance than RF and LR in patients in mechanical ventilation and its subgroup admitted with respiratory disorders. Clinical studies are needed to evaluate whether it impacts decision-making and patient outcomes.

TRIAL REGISTRATION

NCT02731898 ( https://clinicaltrials.gov/ct2/show/NCT02731898 ), prospectively registered on April 8, 2016.

The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation

Post-operative delirium after lung transplantation is common. Its associations with health-related quality of life (HRQL), depression, and mortality remains unknown. In 236 lung transplant recipients, HRQL and depressive symptoms were assessed as part of a structured survey battery before and after transplantation. Surveys included the Geriatric Depressive Scale (GDS) and Short Form 12 (SF12). Delirium was assessed throughout the post-operative intensive care unit (ICU) stay with Confusion Assessment Method for ICU. Delirium and mortality data were extracted from electronic medical records. We examined associations between delirium and changes in depressive symptoms and HRQL using linear mixed effects models and association between delirium and mortality with Cox-proportional hazard models. Post-operative delirium occurred in 34 participants (14%). Delirium was associated with attenuated improvements in SF12-PCS (difference ₋4.0; 95%CI: -7.4, -0.7) but not SF12-MCS (difference 2.2; 95%CI: -0.7,5.7) or GDS (difference ₋0.4; 95%CI: -1.5,0.7). Thirty-two participants died during the study period. Delirium was associated with increased adjusted hazard risk of mortality (HR 17.9, 95%CI: 4.4,72.5). Delirium after lung transplantation identifies a group at increased risk for poorer HRQL and death within the first post-operative year. Further studies should investigate potential causal links between delirium, and poorer HRQL and mortality risk after lung transplantation.

Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

A 5G-powered robot-assisted teleultrasound diagnostic system in an intensive care unit

Background

Teleultrasound provides an effective solution to problems that arise from limited medical resources, a lack of local expertise, and scenarios where the risk of infection is high. This study aims to explore the feasibility of the application of a 5G-powered robot-assisted teleultrasound diagnostic system in an intensive care unit.

Methods

In this study, the robot-assisted teleultrasound diagnostic system MGIUS-R3 was used. Using 5G network technology, the doctor manipulates the robotic arm to perform teleultrasound examination. The doctor can adjust parameters via the teleultrasound control panel, and real-time transmission of audio, video and ultrasound images can facilitate simultaneous communication between both parties. All patients underwent robot-assisted teleultrasound examination and bedside ultrasound examination of the liver, gallbladder, pancreas, spleen, kidney, as well as assessment for pleural effusion and abdominal effusion. We evaluated the feasibility of the application of the robot-assisted teleultrasound diagnosis system in the intensive care unit in terms of consultation duration, image quality, and safety. We also compared diagnostic consistency and differences.

Results

Apart from one patient who was excluded due to severe intestinal gas interference and poor image quality, a total of 32 patients were included in this study. Every patient completed all relevant examinations. Among them, 20 patients were male; 12 were female. The average age of the patients was 61 ± 20 years. The average duration of teleultrasound diagnosis was 17 ± 7 min. Of the 32 patients, 26 had positive results, 6 had negative results, and 5 had inconsistent diagnoses. The overall diagnostic results were basically the same, and there were no differences in diagnostic levels between the two. The overall average image quality score was 4.73 points, which represented a high-quality image. After robot-assisted teleultrasound examination, no significant changes were observed in the vital signs of patients as compared to before examination, and no examination-related complications were found.

Conclusion

The 5G-powered robot-assisted teleultrasound diagnostic system was associated with the benefits of clear images, simple operation, relatively high levels of consistency in terms of diagnostic results, higher levels of safety, and has considerable application value in the intensive care unit.

Successful implementation of modern critical care in the low-resources country Bosnia and Herzegovina : Single-center experience

Background

Critical care medicine is a relatively young discipline, developed in the mid-1950s in response to the outbreak of poliomyelitis. The mass application of mechanical ventilation and its subsequent technical advancement helped manage large numbers of patients with respiratory failure. This branch of medicine evolved much faster in high-income (HIC) than low- and middle-income countries (LMIC). Seventy years later, mankind’s encounter with coronavirus disease 2019 (COVID-19) represents another major challenge for critical care medicine especially in LMIC countries where over two thirds of the world population live.

Methods

Systematic analysis of written documents related to the establishment of the first multidisciplinary medical intensive care unit (MICU) in Bosnia and Herzegovina and its development to the present day.

Results

We describe the experience of setting up a modern critical care program under LMIC constraints as a promising way forward to meet the increased worldwide demand for critical care. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local health care authorities, development of a formal subspecialty training, academic faculty development, and research. Novel technologies including tele-education provide additional opportunities for rapid development and dissemination of critical care medicine programs in LMIC.

Conclusion

Critical care medicine is a critical public health need in HIC and LMIC alike. The challenges associated with the coronavirus pandemic should serve as a wakeup call for rapid development of critical care programs around the world.

Focused Cardiac Ultrasound is Applicable to Internal Medicine and Critical Care but Skill Gaps Currently Limit Use

Context

Coronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS). However, the spectra of cardiac disease, and the resources available for investigation vary internationally. The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown.

Aims

To determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents’ current proficiency, accreditation and use of FoCUS.

Methods

A questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability.

Results

In total, 110 residents (IM 100/108; CCM 10/10) participated (Response rate 93.2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function. Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall self-reported proficiency was poor. In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS. Two were accredited.

Conclusions

Whilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist. The skills gap in CCM is lower but unaccredited practice is common. Our residents’ responses were similar to those from Canada. Thus, international standardization of FoCUS training could be considered.

Septic shock with emphysematous cholecystitis and disseminated infection caused by hypervirulent Klebsiella pneumoniae capsular genotype K2-ST65 in a Japanese man with diabetes mellitus: A case report

Hypervirulent Klebsiella pneumoniae capsular genotypes K1 and K2 are common pathogens responsible for community-acquired liver abscesses and invasive infections especially in East Asia. We report a Japanese man with diabetes mellitus who rapidly developed emphysematous cholecystitis and fulminant disseminated infection with life-threatening multiple organ-system failure due to K. pneumoniae K2 strains belonging to sequence type 65. In East Asia, clinicians should be aware of fulminant infections caused by hypervirulent K2 strains in patients with community-acquired K. pneumoniae infections. Further epidemiological studies are warranted to elucidate the clinical features associated with the virulence K. pneumoniae K2 strains.

Clinical trial registry searches are under-utilized in systematic reviews from critical care journals: A bibliometric analysis

PURPOSE

Publication bias has a significant impact on the results of systematic reviews. Clinical trial registry searches, which include unpublished research, should be conducted when performing systematic reviews to reduce publication bias. We aimed to analyze the use of clinical trial registry searches in critical care systematic reviews.

METHODS

Systematic reviews published between 01/01/2010-02/18/2020 from the top 5 critical care journals were extracted from PubMed and screened for trial registry use. Additionally, of the studies not performing registry searches, we assessed ClinicalTrials.gov for potentially relevant trials that were missed by not performing a registry search.

RESULTS

Three hundred and twenty six systematic reviews were analyzed, of which 37 (11.3%) performed trial registry searches. Of the studies not performing clinical trial registry searches, 56% had at least 1 potentially relevant trial that was missed.

CONCLUSIONS

The omission of relevant, unpublished clinical trial results may be negatively impacting the accuracy of critical care systematic reviews. We recommend all systematic reviewers conduct clinical trial registry searches to reduce publication bias.

Left pulmonary artery pseudoaneurysm secondary to post-operative lung abscess

A prompt diagnosis is mandatory to avoid fatal complications in case of pulmonary artery pseudoaneurysm.

Impact of critical care medicine publications from intensive care department at King Abdulaziz Medical City, Riyadh in the last two decades

Introduction :

The volume and quality of biomedical research publications from an institution are considered adequate indicators of the quality of medical care in that institute. King Abdulaziz Medical City (KAMC), Riyadh, Kingdom of Saudi Arabia (KSA), is one of the oldest and most distinguished medical centers in the country.

Methods:

In this study, we analyzed the number of publications from the Critical Care Unit of the hospital in the past two decades, from 1996 to 2016. The research publications were evaluated on various parameters. Moreover, the impact of their study on global medicine was determined.

Results:

Our results indicate a steady progression in the number of publications from the institute in the past two decades. An average of 17.3 papers was published each year during this time. Out of the 283 publications from KAMC included in this study, the majority of the publications were original articles, 61 were review articles, 66 were multicenter trial studies and 28 were randomized control trials. The citation profile of the publications was good indicating global impact of the studies.

Conclusion:

The global impact of research as evaluated through published manuscripts in KAMC is overall good. This was deduced from both the increase in the number of publications each year and also the quality of papers as evidenced by the citation index of the papers published between 1996 and 2016.

Complex dynamics of skin sympathetic nerve activities as a prognostic predictor for critically ill patients

BACKGROUND

The skin sympathetic nerve activity (SKNA) is a new method to measure sympathetic nerve activity by using conventional ECG electrodes. We developed a novel approach to analyze the complexity of SKNA time series under different time scales and showed its prognostic significance in patients receiving critical care.

METHODS

This study measured SKNA in patients admitted to an intensive care unit (ICU). Each recording is 10-minute long with 10000Hz sampling rate. Multi-scale fluctuation analysis (MSFA) was developed to quantify the variation within each time scale after removing the linear trend. The prognostic value of SKNA was combined with traditional prognostics scoring system to improve the predictive values.

RESULTS

155 patients were recruited. After 30 and 90 days, 30 and 48 patients expired. MSFA was significantly higher in survival group than mortality group for 30-day (0.487 ± 0.185 vs 0.401 ± 0.045, p = 0.018) and 90-day (0.499 ± 0.196 vs 0.414 ± 0.061, p = 0.001) follow-up. Sequential Organ Failure Assessment (SOFA) score was significantly lower in the survival group compared to the expired group for 30-day and 90-day (4.1 ± 2.9 vs. 5.5 ± 4.1, p = 0.032 and 3.9 ± 3.0 vs. 5.4 ± 3.5, p = 0.012). The Kaplan-Meier survival analysis showed MSFA lower than 0.401 (log-rank test:4.96, p = 0.03) or with SOFA score lower than 5 (log-rank test:5.49, p = 0.019) have a significantly higher mortality rate. A multivariate Cox regression model showed that the MSFA is an independent predictor for 30-day mortality (HR = 2.35, 1.08-5.09, p = 0.031) and 90-day mortality (HR = 1.96, 1.08-3.58, p = 0.027).

CONCLUSION

MSFA was a significant prognostic predictor for critically ill patients. MSFA adding to SOFA score could help improve risk prediction.

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.