Critical Care Bulletin: June 2022

 

The obesity paradox for survivors of critically ill patients

 

by Dawei Zhou, Chao Wang, Qing Lin and Tong Li 

 

Critical Care volume 26, Article number: 198 (2022) Published: 03 July 2022

 

The obesity paradox has been observed in short-term outcomes from critical illness. However, little is known regarding the impact of obesity on long-term outcomes for survivors of critically ill patients. We aimed to evaluate the influence of obesity on long-term mortality outcomes after discharge alive from ICU. The adult patients who were discharged alive from the last ICU admission were extracted. After exclusion, a total of 7619 adult patients discharged alive from ICU were included, with 4-year mortality of 32%. The median body mass index (BMI) was 27.2 (IQR 24–31.4) kg/m2, and 2490 (31.5%) patients were classified as obese or morbidly obese. The morbidly obese patients had the highest ICU and hospital length of stay. However, higher BMI was associated with lower hazard ratio for 4-year mortality. The results showed the obesity paradox may be also suitable for survivors of critically ill patients.

 Response to PEEP in COVID-19 ARDS patients with and without extracorporeal membrane oxygenation. A multicenter case–control computed tomography study

 

by Jean-Christophe Richard, Florian Sigaud, Maxime Gaillet, Maciej Orkisz, Sam Bayat, Emmanuel Roux, Touria Ahaouari, Eduardo Davila, Loic Boussel, Gilbert Ferretti, Hodane Yonis, Mehdi Mezidi, William Danjou, Alwin Bazzani, Francois Dhelft, Laure Folliet… 

 

Critical Care volume 26, Article number: 195 (2022) Published: 02 July 2022

Background

PEEP selection in severe COVID-19 patients under extracorporeal membrane oxygenation (ECMO) is challenging as no study has assessed the alveolar recruitability in this setting. The aim of the study was to compare lung recruitability and the impact of PEEP on lung aeration in moderate and severe ARDS patients with or without ECMO, using computed tomography (CT).

Methods

We conducted a two-center prospective observational case–control study in adult COVID-19-related patients who had an indication for CT within 72 h of ARDS onset in non-ECMO patients or within 72  h after ECMO onset. Ninety-nine patients were included, of whom 24 had severe ARDS under ECMO, 59 severe ARDS without ECMO and 16 moderate ARDS.

Results

Non-inflated lung at PEEP 5 cmH2O was significantly greater in ECMO than in non-ECMO patients. Recruitment induced by increasing PEEP from 5 to 15 cmH2O was not significantly different between ECMO and non-ECMO patients, while PEEP-induced hyperinflation was significantly lower in the ECMO group and virtually nonexistent. The median [IQR] fraction of recruitable lung mass between PEEP 5 and 15 cmH2O was 6 [4–10]%. Total superimposed pressure at PEEP 5 cmH2O was significantly higher in ECMO patients and amounted to 12 [11–13] cmH2O. The hyperinflation-to-recruitment ratio (i.e., a trade-off index of the adverse effects and benefits of PEEP) was significantly lower in ECMO patients and was lower than one in 23 (96%) ECMO patients, 41 (69%) severe non-ECMO patients and 8 (50%) moderate ARDS patients. Compliance of the aerated lung at PEEP 5 cmH2O corrected for PEEP-induced recruitment (CBABY LUNG) was significantly lower in ECMO patients than in non-ECMO patients and was linearly related to the logarithm of the hyperinflation-to-recruitment ratio.

Conclusions

Lung recruitability of COVID-19 pneumonia is not significantly different between ECMO and non-ECMO patients, with substantial interindividual variations. The balance between hyperinflation and recruitment induced by PEEP increase from 5 to 15 cmH2O appears favorable in virtually all ECMO patients, while this PEEP level is required to counteract compressive forces leading to lung collapse. CBABY LUNG is significantly lower in ECMO patients, independently of lung recruitability. 

 

Temperature Management in the ICU

by Drewry, Anne; Mohr, Nicholas M. 

Critical Care Medicine: July 2022 - Volume 50 - Issue 7 - p 1138-1147

 

OBJECTIVE: 

Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients.

DATA SOURCES: 

We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies.

STUDY SELECTION: 

English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence.

DATA EXTRACTION: 

Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed.

DATA SYNTHESIS: 

Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes.

CONCLUSIONS: 

Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.

 

 

Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial

Greenberg, Jared A.; Basapur, Santosh; Quinn, Thomas V.; Bulger, Jeffrey L.; Schwartz, Nathaniel H.; Oh, Soo Kyung; Ritz, Ethan M.; Glover, Crystal M.; Shah, Raj C. 

Critical Care Medicine: May 23, 2022 - Volume - Issue - 10.1097

 

Objectives: 

To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients.

Design: 

Randomized controlled trial.

Setting: 

Single, urban academic medical center.

Subjects: 

Surrogates of nondecisional, critically ill adults with high risk of mortality (n = 252) enrolled from June 2019 to January 2021.

Interventions: 

Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day.

Measurements and Main Results: 

Participants completed surveys at three time points during the ICU stay: enrollment (n = 252), 1 week (n = 229), and 2 weeks (n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment (p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2–16.0) versus 16.4, (95% CI, 15.5–17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03–0.82; p = 0.03); 0.15 (95% CI, 0.01–1.87; p = 0.14); and 0.27 (95% CI, 0.06–1.27; p = 0.10), respectively.

Conclusions: 

Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.

 

 

Driving pressure-guided ventilation decreases the mechanical power compared to predicted body weight-guided ventilation in the Acute Respiratory Distress Syndrome

by Anne-Fleur Haudebourg, Samuel Tuffet, François Perier, Keyvan Razazi, Nicolas de Prost, Armand Mekontso Dessap and Guillaume Carteaux 

Critical Care volume 26, Article number: 185 (2022) Published: 20 June 2022

 

Background

Whether targeting the driving pressure (∆P) when adjusting the tidal volume in mechanically ventilated patients with the acute respiratory distress syndrome (ARDS) may decrease the risk of ventilator-induced lung injury remains a matter of research. In this study, we assessed the effect of a ∆P-guided ventilation on the mechanical power.

Methods

We prospectively included adult patients with moderate-to-severe ARDS. Positive end expiratory pressure was set by the attending physician and kept constant during the study. Tidal volume was first adjusted to target 6 ml/kg of predicted body weight (PBW-guided ventilation) and subsequently modified within a range from 4 to 10 ml/kg PBW to target a ∆P between 12 and 14 cm H2O. The respiratory rate was then re-adjusted within a range from 12 to 40 breaths/min until EtCO2 returned to its baseline value (∆P-guided ventilation). Mechanical power was computed at each step.

Results

Fifty-one patients were included between December 2019 and May 2021. ∆P-guided ventilation was feasible in all but one patient. The ∆P during PBW-guided ventilation was already within the target range of ∆P-guided ventilation in five (10%) patients, above in nine (18%) and below in 36 (72%). The change from PBW- to ∆P-guided ventilation was thus accompanied by an overall increase in tidal volume from 6.1 mL/kg PBW [5.9–6.2] to 7.7 ml/kg PBW [6.2–8.7], while respiratory rate was decreased from 29 breaths/min [26–32] to 21 breaths/min [16–28] (p < 0.001 for all comparisons). ∆P-guided ventilation was accompanied by a significant decrease in mechanical power from 31.5 J/min [28–35.7] to 28.8 J/min [24.6–32.6] (p < 0.001), representing a relative decrease of 7% [0–16]. With ∆P-guided ventilation, the PaO2/FiO2 ratio increased and the ventilatory ratio decreased.

Conclusion

As compared to a conventional PBW-guided ventilation, a ∆P-guided ventilation strategy targeting a ∆P between 12 and 14 cm H2O required to change the tidal volume in 90% of the patients. Such ∆P-guided ventilation significantly reduced the mechanical power. Whether this physiological observation could be associated with clinical benefit should be assessed in clinical trials.

 

 

 

 

The sit-to-stand test as a patient-centered functional outcome for critical care research: a pooled analysis of five international rehabilitation studies

by Heather K. O’Grady, Lara Edbrooke, Christopher Farley, Sue Berney, Linda Denehy, Zudin Puthucheary and Michelle E. Kho 

Critical Care volume 26, Article number: 175 (2022) Published: 13 June 2022

 

Background

With ICU mortality rates decreasing, it is increasingly important to identify interventions to minimize functional impairments and improve outcomes for survivors. Simultaneously, we must identify robust patient-centered functional outcomes for our trials. Our objective was to investigate the clinimetric properties of a progression of three outcome measures, from strength to function.

Methods

Adults (≥ 18 years) enrolled in five international ICU rehabilitation studies. Participants required ICU admission were mechanically ventilated and previously independent. Outcomes included two components of the Physical Function in ICU Test-scored (PFIT-s): knee extensor strength and assistance required to move from sit to stand (STS); the 30-s STS (30 s STS) test was the third outcome. We analyzed survivors at ICU and hospital discharge. We report participant demographics, baseline characteristics, and outcome data using descriptive statistics. Floor effects represented ≥ 15% of participants with minimum score and ceiling effects ≥ 15% with maximum score. We calculated the overall group difference score (hospital discharge score minus ICU discharge) for participants with paired assessments.

Results

Of 451 participants, most were male (n = 278, 61.6%) with a median age between 60 and 66 years, a mean APACHE II score between 19 and 24, a median duration of mechanical ventilation between 4 and 8 days, ICU length of stay (LOS) between 7 and 11 days, and hospital LOS between 22 and 31 days. For knee extension, we observed a ceiling effect in 48.5% (160/330) of participants at ICU discharge and in 74.7% (115/154) at hospital discharge; the median [1st, 3rd quartile] PFIT-s difference score (n = 139) was 0 [0,1] (p < 0.05). For STS assistance, we observed a ceiling effect in 45.9% (150/327) at ICU discharge and in 77.5% (79/102) at hospital discharge; the median PFIT-s difference score (n = 87) was 1 [0, 2] (p < 0.05). For 30 s STS, we observed a floor effect in 15.0% (12/80) at ICU discharge but did not observe a floor or ceiling effect at hospital discharge. The median 30 s STS difference score (n = 54) was 3 [1, 6] (p < 0.05).

Conclusion

Among three progressive outcome measures evaluated in this study, the 30 s STS test appears to have the most favorable clinimetric properties to assess function at ICU and hospital discharge in moderate to severely ill participants.

 

 

Intravascular Versus Surface Cooling in Patients Resuscitated From Cardiac Arrest: A Systematic Review and Network Meta-Analysis With Focus on Temperature Feedback

 

by Ramadanov, Nikolai; Arrich, Jasmin; Klein, Roman; Herkner, Harald; Behringer, Wilhelm 

 

Critical Care Medicine: June 2022 - Volume 50 - Issue 6 - p 999-1009

 

OBJECTIVE: 

The aim of the study was to compare the effect of intravascular cooling (IC), surface cooling with temperature feedback (SCF), and surface cooling without temperature feedback (SCnoF) on neurologic outcome and survival in patients successfully resuscitated from cardiac arrest (CA) and treated with targeted temperature management (TTM) at 32–34°C.

DATA SOURCES: 

We performed a systematic review on Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, SCOPUS, CINAHL, Web of Science, and Clinical Trials up to June 30, 2021.

STUDY SELECTION: 

We included randomized and nonrandomized studies on IC, SCF, and SCnoF in adult humans resuscitated from CA undergoing TTM, reporting neurologic outcome or survival.

DATA EXTRACTION: 

We performed a network meta-analysis to assess the comparative effects of IC, SCF, and SCnoF. The overall effect between two cooling methods included the effect of direct and indirect comparisons. Results are given as odds ratios (OR) and 95% CIs. Rankograms estimated the probability of TTM methods being ranked first, second, and third best interventions.

DATA SYNTHESIS: 

A total of 14 studies involving 4,062 patients met the inclusion criteria. Four studies were randomized controlled studies, and 10 studies were nonrandomized observational studies. IC compared with SCnoF was significantly associated with better neurologic outcome (OR, 0.6; 95% CI, 0.49–0.74) and survival (OR, 0.8; 95% CI, 0.66–0.96). IC compared with SCF, and SCF compared with SCnoF did not show significant differences in neurologic outcome and survival. The rankogram showed that IC had the highest probability to be the most beneficial cooling method, followed by SCF and SCnoF.

CONCLUSIONS: 

Our results suggest that in patients resuscitated from CA and treated with TTM at 32–34°C, IC has the highest probability of being the most beneficial cooling method for survival and neurologic outcome.

 

 

 

Association of Metformin Use During Hospitalization and Mortality in Critically Ill Adults With Type 2 Diabetes Mellitus and Sepsis*

 

 by Gómez, Hernando; Del Rio-Pertuz, Gaspar; Priyanka, Priyanka; Manrique-Caballero, Carlos L.; Chang, Chung-Chou H.; Wang, Shu; Liu, Qing; Zuckerbraun, Brian S.; Murugan, Raghavan; Angus, Derek C.; Kellum, John A. 

 

Critical Care Medicine: June 2022 - Volume 50 - Issue 6 - p 935-944

 

OBJECTIVES: 

Whether metformin exposure is associated with improved outcomes in patients with type 2 diabetes mellitus and sepsis.

DESIGN: 

Retrospective cohort study.

SETTING: 

Patients admitted to ICUs in 16 hospitals in Pennsylvania from October 2008 to December 2014.

PATIENTS: 

Adult critical ill patients with type 2 diabetes mellitus and sepsis.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

We conducted a retrospective cohort study to compare 90-day mortality in diabetic patients with sepsis with and without exposure to metformin during hospitalization. Data were obtained from the electronic health record of a large healthcare system in Pennsylvania from October 2008 to December 2014, on patients admitted to the ICU at any of the 16 hospitals within the system. The primary outcome was mortality at 90 days. The absolute and adjusted odds ratio (OR) with 95% CI were calculated in a propensity score-matched cohort. Among 14,847 patients with type 2 diabetes mellitus and sepsis, 682 patients (4.6%) were exposed to metformin during hospitalization and 14,165 (95.4%) were not. Within a total of 2,691 patients subjected to propensity score-matching at a 1:4 ratio, exposure to metformin (n = 599) was associated with decreased 90-day mortality (71/599, 11.9% vs 475/2,092, 22.7%; OR, 0.46; 95% CI, 0.35–0.60), reduced severe acute kidney injury (50% vs 57%; OR, 0.75; 95% CI, 0.62–0.90), less Major Adverse Kidney Events at 1 year (OR, 0.27; 95% CI, 0.22–0.68), and increased renal recovery (95% vs 86%; OR, 6.43; 95% CI, 3.42–12.1).

CONCLUSIONS: 

Metformin exposure during hospitalization is associated with a decrease in 90-day mortality in patients with type 2 diabetes mellitus and sepsis.

 

 

Systematic Review and Comparison of Publicly Available ICU Data Sets—A Decision Guide for Clinicians and Data Scientists

 

by Sauer, Christopher M.; Dam, Tariq A.; Celi, Leo A.; Faltys, Martin; de la Hoz, Miguel A. A.; Adhikari, Lasith; Ziesemer, Kirsten A.; Girbes, Armand; Thoral, Patrick J.; Elbers, Paul 

 

Critical Care Medicine: June 2022 - Volume 50 - Issue 6 - p e581-e588

 

OBJECTIVE: 

As data science and artificial intelligence continue to rapidly gain traction, the publication of freely available ICU datasets has become invaluable to propel data-driven clinical research. In this guide for clinicians and researchers, we aim to: 1) systematically search and identify all publicly available adult clinical ICU datasets, 2) compare their characteristics, data quality, and richness and critically appraise their strengths and weaknesses, and 3) provide researchers with suggestions, which datasets are appropriate for answering their clinical question.

DATA SOURCES: 

A systematic search was performed in Pubmed, ArXiv, MedRxiv, and BioRxiv.

STUDY SELECTION: 

We selected all studies that reported on publicly available adult patient-level intensive care datasets.

DATA EXTRACTION: 

A total of four publicly available, adult, critical care, patient-level databases were included (Amsterdam University Medical Center data base [AmsterdamUMCdb], eICU Collaborative Research Database eICU CRD], High time-resolution intensive care unit dataset [HiRID], and Medical Information Mart for Intensive Care-IV). Databases were compared using a priori defined categories, including demographics, patient characteristics, and data richness. The study protocol and search strategy were prospectively registered.

DATA SYNTHESIS: 

Four ICU databases fulfilled all criteria for inclusion and were queried using SQL (PostgreSQL version 12; PostgreSQL Global Development Group) and analyzed using R (R Foundation for Statistical Computing, Vienna, Austria). The number of unique patient admissions varied between 23,106 (AmsterdamUMCdb) and 200,859 (eICU-CRD). Frequency of laboratory values and vital signs was highest in HiRID, for example, 5.2 (±3.4) lactate values per day and 29.7 (±10.2) systolic blood pressure values per hour. Treatment intensity varied with vasopressor and ventilatory support in 69.0% and 83.0% of patients in AmsterdamUMCdb versus 12.0% and 21.0% in eICU-CRD, respectively. ICU mortality ranged from 5.5% in eICU-CRD to 9.9% in AmsterdamUMCdb.

CONCLUSIONS: 

We identified four publicly available adult clinical ICU datasets. Sample size, severity of illness, treatment intensity, and frequency of reported parameters differ markedly between the databases. This should guide clinicians and researchers which databases to best answer their clinical questions.

 

Nicotine patches in patients on mechanical ventilation for severe COVID-19: a randomized, double-blind, placebo-controlled, multicentre trial

Intensive Care Medicine (2022) Published: 09 June 2022

Purpose

Epidemiologic studies have documented lower rates of active smokers compared to former or non-smokers in symptomatic patients affected by coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of nicotine administered by a transdermal patch in critically ill patients with COVID-19 pneumonia.

Methods

In this multicentre, double-blind, placebo-controlled trial conducted in 18 intensive care units in France, we randomly assigned adult patients (non-smokers, non-vapers or who had quit smoking/vaping for at least 12 months) with proven COVID-19 pneumonia receiving invasive mechanical ventilation for up to 72 h to receive transdermal patches containing either nicotine at a daily dose of 14 mg or placebo until 48 h following successful weaning from mechanical ventilation or for a maximum of 30 days, followed by 3-week dose tapering by 3.5 mg per week. Randomization was stratified by centre, non- or former smoker status and Sequential Organ Function Assessment score (< or ≥ 7). The primary outcome was day-28 mortality. Main prespecified secondary outcomes included 60-day mortality, time to successful extubation, days alive and free from mechanical ventilation, renal replacement therapy, vasopressor support or organ failure at day 28.

Results

Between November 6th 2020, and April 2nd 2021, 220 patients were randomized from 18 active recruiting centers. After excluding 2 patients who withdrew consent, 218 patients (152 [70%] men) were included in the analysis: 106 patients to the nicotine group and 112 to the placebo group. Day-28 mortality did not differ between the two groups (30 [28%] of 106 patients in the nicotine group vs 31 [28%] of 112 patients in the placebo group; odds ratio 1.03 [95% confidence interval, CI 0.57–1.87]; p = 0.46). The median number of day-28 ventilator-free days was 0 (IQR 0–14) in the nicotine group and 0 (0–13) in the placebo group (with a difference estimate between the medians of 0 [95% CI -3–7]). Adverse events likely related to nicotine were rare (3%) and similar between the two groups.

Conclusion

In patients having developed severe COVID-19 pneumonia requiring invasive mechanical ventilation, transdermal nicotine did not significantly reduce day-28 mortality. There is no indication to use nicotine in this situation.

 

 

 

 

Pentraxin-3 as a predictive marker of mortality in sepsis: an updated systematic review and meta-analysis

by Guobin Wang, Chunyan Jiang, Junjun Fang, Zhitao Li and Hongliu Cai 

Critical Care volume 26, Article number: 167 (2022) Published: 08 June 2022

 

Background

The purpose of this study was to clarify the prognostic value of Pentraxin-3 (PTX3) on the mortality of patients with sepsis.

Methods

Publications published up to January 2021 were retrieved from PubMed, EMBASE, and the Cochrane library. Data from eligible cohort and case–control studies were extracted for the meta-analysis. Multivariate regression analysis was used to evaluate the correlation of the outcomes with sample size and male proportion.

Results

A total of 17 studies covering 3658 sepsis patients were included. PTX3 level was significantly higher in non-survivor compared to survivor patients (SMD (95% CI): −1.06 (−1.43, −0.69), P < 0.001). Increased PTX3 level was significantly associated with mortality (HR (95% CI): 2.09 (1.55, 2.81), P < 0.001). PTX3 showed good predictive capability for mortality (AUC:ES (95% CI): 0.73 (0.70, 0.77), P < 0.001). The outcome comparing PTX3 level in non-survivors vs. survivors and the outcome of the association between PTX3 and mortality were associated with sample size but not male proportion. AUC was associated with both sample size and male proportion.

Conclusions

PTX3 level was significantly higher in non-survivor compared to survivor patients with sepsis. Elevated PTX3 level was significantly associated with mortality. Furthermore, the level of PTX3 might predict patient mortality.

 

Early intubation and patient-centered outcomes in septic shock: a secondary analysis of a prospective multicenter study

 

by Ricard Mellado-Artigas, Carlos Ferrando, Frédéric Martino, Agathe Delbove, Bruno L. Ferreyro, Cedric Darreau, Sophie Jacquier, Laurent Brochard and Nicolas Lerolle 

 

Critical Care volume 26, Article number: 163 (2022) Published: 07 June 2022

 

Purpose

Despite the benefits of mechanical ventilation, its use in critically ill patients is associated with complications and had led to the growth of noninvasive techniques. We assessed the effect of early intubation (first 8 h after vasopressor start) in septic shock patients, as compared to non-early intubated subjects (unexposed), regarding in-hospital mortality, intensive care and hospital length of stay.

Methods

This study involves secondary analysis of a multicenter prospective study. To adjust for baseline differences in potential confounders, propensity score matching was carried out. In-hospital mortality was analyzed in a time-to-event fashion, while length of stay was assessed as a median difference using bootstrapping.

Results

A total of 735 patients (137 intubated in the first 8 h) were evaluated. Propensity score matching identified 78 pairs with similar severity and characteristics on admission. Intubation was used in all patients in the early intubation group and in 27 (35%) subjects beyond 8 h in the unexposed group. Mortality occurred in 35 (45%) and in 26 (33%) subjects in the early intubation and unexposed groups (hazard ratio 1.44 95% CI 0.86–2.39, p = 0.16). ICU and hospital length of stay were not different among groups [9 vs. 5 (95% CI 1 to 7) and 14 vs. 16 (95% CI − 7 to 8) days]. All sensitivity analyses confirmed the robustness of our findings.

Conclusions

An early approach to invasive mechanical ventilation did not improve outcomes in this matched cohort of patients. The limited number of patients included in these analyses out the total number included in the study may limit generalizability of these findings.

 

 

 

 

Respiratory distress observation scales to predict weaning outcome

by Maxens Decavèle, Emmanuel Rozenberg, Marie-Cécile Niérat, Julien Mayaux, Elise Morawiec, Capucine Morélot-Panzini, Thomas Similowski, Alexandre Demoule and Martin Dres 

 

Critical Care volume 26, Article number: 162 (2022) Published: 06 June 2022

 

Background

Whether dyspnea is present before starting a spontaneous breathing trial (SBT) and whether it may affect the outcome of the SBT is unknown. Mechanical Ventilation—Respiratory Distress Observation Scale (MV-RDOS) has been proposed as a reliable surrogate of dyspnea in non-communicative intubated patients. In the present study, we sought (1) to describe the evolution of the MV-RDOS during a SBT and (2) to investigate whether MV-RDOS can predict the outcome of the SBT.

Methods

Prospective, single-center study in a twenty-two bed ICU in a tertiary center. Patients intubated since more 48 h who had failed a first SBT were eligible if they meet classical readiness to wean criteria. The MV-RDOS was assessed before, at 2-min, 15-min and 30-min (end) of the SBT. The presence of clinically important dyspnea was inferred by a MV-RDOS value ≥  2.6.

Results

Fifty-eight patients (age 63 [51–70], SAPS II 66 [51–76]; med [IQR]) were included. Thirty-three (57%) patients failed the SBT, whose 18 (55%) failed before 15-min. Twenty-five (43%) patients successfully passed the SBT. A MV-RDOS ≥ 2.6 was present in ten (17%) patients before to start the SBT. All these ten patients subsequently failed the SBT. A MV-RDOS ≥ 2.6 at 2-min predicted a SBT failure with a 51% sensibility and a 88% specificity (AUC 0.741 95% confidence interval [CI] 0.616–0.866, p = 0.002). Best cut-off value at 2-min was 4.3 and predicted SBT failure with a 27% sensibility and a 96% specificity.

Conclusion

Despite patients met classical readiness to wean criteria, respiratory distress assessed with the MV-RDOS was frequent at the beginning of SBT. Measuring MV-RDOS before to initiate a SBT could avoid undue procedure and reduce patient’s exposure to unnecessary mechanical ventilation weaning failure and distress.

 

 

Probiotics in Critical Illness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

 

 by Sharif, Sameer; Greer, Alisha; Skorupski, Clarissa; Hao, Qiukui; Johnstone, Jennie; Dionne, Joanna C.; Lau, Vincent; Manzanares, William; Eltorki, Mohamed; Duan, Erick; Lauzier, Francois; Marshall, John C.; Heels-Ansdell, Diane; Thabane, Lehana; Cook, Deborah J.; Rochwerg, Bram 

 

Critical Care Medicine: May 25, 2022 - Volume - Issue - 10.1097/CCM.0000000000005580

 

Objectives: 

To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

Data Sources: 

We searched MEDLINE, EMBASE, CENTRAL, and unpublished sources from inception to May 4, 2021.

Study Selection: 

We performed a systematic search for randomized controlled trials (RCTs) that compared enteral probiotics or synbiotics to placebo or no treatment in critically ill patients. We screened studies independently and in duplicate.

Data Extraction: 

Independent reviewers extracted data in duplicate. A random-effects model was used to pool data. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

Data Synthesis: 

Sixty-five RCTs enrolled 8,483 patients. Probiotics may reduce ventilator-associated pneumonia (VAP) (relative risk [RR], 0.72; 95% CI, 0.59 to 0.89 and risk difference [RD], 6.9% reduction; 95% CI, 2.7–10.2% fewer; low certainty), healthcare-associated pneumonia (HAP) (RR, 0.70; 95% CI, 0.55–0.89; RD, 5.5% reduction; 95% CI, 8.2–2.0% fewer; low certainty), ICU length of stay (LOS) (mean difference [MD], 1.38 days fewer; 95% CI, 0.57–2.19 d fewer; low certainty), hospital LOS (MD, 2.21 d fewer; 95% CI, 1.18–3.24 d fewer; low certainty), and duration of invasive mechanical ventilation (MD, 2.53 d fewer; 95% CI, 1.31–3.74 d fewer; low certainty). Probiotics probably have no effect on mortality (RR, 0.95; 95% CI, 0.87–1.04 and RD, 1.1% reduction; 95% CI, 2.8% reduction to 0.8% increase; moderate certainty). Post hoc sensitivity analyses without high risk of bias studies negated the effect of probiotics on VAP, HAP, and hospital LOS.

Conclusions: 

Low certainty RCT evidence suggests that probiotics or synbiotics during critical illness may reduce VAP, HAP, ICU and hospital LOS but probably have no effect on mortality.

 

A Randomized Double-Blinded Placebo Controlled Trial of Clazakizumab for the Treatment of COVID-19 Pneumonia With Hyperinflammation

by Lonze, Bonnie E.; Spiegler, Peter; Wesson, Russell N.; Alachkar, Nada; Petkova, Eva; Weldon, Elaina P.; Dieter, Rebecca A.; Li, Yi; Quinn, Max; Mattoo, Aprajita; Soomro, Irfana; Cohen, Steven M.; Leung, Sherry; Deterville, Cecilia L.; Landrum, B. Mark; Ali, Muhammad Imran; Cohen, David J.; Singer, Andrew L.; Sen, Ayan; Chong, Edward; Hochman, Judith S.; Troxel, Andrea B.; Montgomery, Robert A. 

Critical Care Medicine: May 18, 2022 - Volume - Issue - 10.1097/CCM.0000000000005591

 

Objectives: 

We designed this study to test whether clazakizumab, a direct interleukin-6 inhibitor, benefits patients hospitalized with severe or critical COVID-19 disease accompanied by hyperinflammation.

Design: 

Multicenter, randomized, double-blinded, placebo-controlled, seamless phase II/III trial.

Setting: 

Five U.S. medical centers.

Patients: 

Adults inpatients with severe COVID-19 disease and hyperinflammation.

Interventions: 

Eighty-one patients enrolled in phase II, randomized 1:1:1 to low-dose (12.5 mg) or high-dose (25 mg) clazakizumab or placebo. Ninety-seven patients enrolled in phase III, randomized 1:1 to high-dose clazakizumab or placebo.

Measurements and Main Results: 

The primary outcome was 28-day ventilator-free survival. Secondary outcomes included overall survival ,frequency and duration of intubation, and frequency and duration of ICU admission. Per Data Safety and Monitoring Board recommendations, additional secondary outcomes describing clinical status and status changes, as measured by an ordinal scale, were added. Bayesian cumulative proportional odds, logistic, and Poisson regression models were used. The low-dose arm was dropped when the phase II study suggested superiority of the high-dose arm. We report on 152 patients, 74 randomized to placebo and 78 to high-dose clazakizumab. Patients receiving clazakizumab had greater odds of 28-day ventilator-free survival (odds ratio [OR] = 3.84; p [OR > 1] 99.9%), as well as overall survival at 28 and 60 days (OR = 1.75; p [OR > 1] 86.5% and OR = 2.53; p [OR > 1] 97.7%). Clazakizumab was associated with lower odds of intubation (OR = 0.2; p [OR] < 1; 99.9%) and ICU admission (OR = 0.26; p [OR < 1] 99.6%); shorter durations of ventilation and ICU stay (risk ratio [RR] < 0.75; p [RR < 1] > 99% for both); and greater odds of improved clinical status at 14, 28, and 60 days (OR = 2.32, p [OR > 1] 98.1%; OR = 3.36, p [OR > 1] 99.6%; and OR = 3.52, p [OR > 1] 99.8%, respectively).

Conclusions: 

Clazakizumab significantly improved 28-day ventilator-free survival, 28- and 60-day overall survival, as well as clinical outcomes in hospitalized patients with COVID-19 and hyperinflammation.

 

Sex Differences in Treatment of Adult Intensive Care Patients: A Systematic Review and Meta-Analysis

 

by Modra, Lucy J.; Higgins, Alisa M.; Abeygunawardana, Vihangi S.; Vithanage, Ruvini N.; Bailey, Michael J.; Bellomo, Rinaldo 

 

Critical Care Medicine: June 2022 - Volume 50 - Issue 6 - p 913-923

 

OBJECTIVES: 

To evaluate and synthesize the available literature on sex differences in the treatment of adult ICU patients.

DATA SOURCES: 

MEDLINE and EMBASE.

STUDY SELECTION: 

Two reviewers independently screened publications to identify observational studies of adult ICU patients that explicitly examined the association between sex and ICU treatment—specifically, mechanical ventilation, renal replacement therapy, and length of stay.

DATA EXTRACTION: 

We extracted data independently and in duplicate: mean age, illness severity, use of mechanical ventilation and renal replacement therapy, and length of stay in ICU and hospital. We assessed risk of bias using the Newcastle-Ottawa Scale. We used a DerSimonian-Laird random-effects model to calculate pooled odds ratios (ORs) and mean differences between women and men.

DATA SYNTHESIS: 

We screened 4,098 publications, identifying 21 eligible studies with 545,538 participants (42.7% women). The study populations ranged from 246 to 261,255 participants (median 4,420). Most studies (76.2%) were at high risk of bias in at least one domain, most commonly representativeness or comparability. Women were less likely than men to receive invasive mechanical ventilation (OR, 0.83; 95% CI, 0.77–0.89; I2 = 90.4%) or renal replacement therapy (OR, 0.79; 95% CI, 0.70–0.90; I2 = 76.2%). ICU length of stay was shorter in women than men (mean difference, –0.24 d; 95% CI, –0.37 to –0.12; I2 = 89.9%). These findings persisted in meta-analysis of data adjusted for illness severity and other confounders and also in sensitivity analysis excluding studies at high risk of bias. There was no significant sex difference in duration of mechanical ventilation or hospital length of stay.

CONCLUSIONS: 

Women were less likely than men to receive mechanical ventilation or renal replacement therapy and had shorter ICU length of stay than men. There is substantial heterogeneity and risk of bias in the literature; however, these findings persisted in sensitivity analyses.