Critical Care Bulletin: September 2023

 Post-hospital recovery trajectories of family members of critically ill COVID-19 survivors: an international qualitative investigation

Intensive Care Medicine: Published: 12 September 2023

 

Purpose

The immediate impact of coronavirus disease 2019 (COVID-19) visiting restrictions for family members has been well-documented. However, the longer-term trajectory, including mechanisms for support, is less well-known. To address this knowledge gap, we aimed to explore the post-hospital recovery trajectory of family members of patients hospitalised with a critical care COVID-19 admission. We also sought to understand any differences across international contexts.

Methods

We undertook semi-structured interviews with family members of patients who had survived a COVID-19 critical care admission. Family members were recruited from Spain and the United Kingdom (UK) and telephone interviews were undertaken. Interviews were analysed using a thematic content analysis.

Results

Across the international sites, 19 family members were interviewed. Four themes were identified: changing relationships and carer burden; family health and trauma; social support and networks and differences in lived experience. We found differences in the social support and networks theme across international contexts, with Spanish participants more frequently discussing religion as a form of support.

Conclusions

This international qualitative investigation has demonstrated the challenges which family members of patients hospitalised with a critical care COVID-19 admission experience following hospital discharge. Specific support mechanisms which could include peer support networks, should be implemented for family members to ensure ongoing needs are met.

 

 

 

 

 

Acute-on-chronic liver failure alters linezolid pharmacokinetics in critically ill patients with continuous hemodialysis: an observational study

 

by Tjokosela Tikiso, Valentin Fuhrmann, Christina König, Dominik Jarczak, Stefanie Iwersen-Bergmann, Stefan Kluge, Sebastian G. Wicha and Jörn Grensemann 

 

Annals of Intensive Care volume 13, Article number: 83 (2023)

 

Background

In acute-on-chronic liver failure (ACLF), adequate antibiotic dosing is challenging due to changes of drug distribution and elimination. We studied the pharmacokinetics of linezolid in critically ill patients with ACLF during continuous renal replacement therapy compared to patients without concomitant liver failure (NLF).

Methods

In this prospective cohort study, patients received linezolid 600 mg bid. Linezolid serum samples were analyzed by high-performance liquid chromatography. Population pharmacokinetic modelling was performed followed by Monte-Carlo simulations of 150 mg bid, 300 mg bid, 450 mg bid, 600 mg bid, and 900 mg bid to assess trough concentration target attainment of 2–7 mg/L.

Results

Eighteen patients were included in this study with nine suffering from ACLF. Linezolid body clearance was lower in the ACLF group with mean (standard deviation) 1.54 (0.52) L/h versus 6.26 (2.43) L/h for NLF, P < 0.001. A trough concentration of 2–7 mg/L was reached with the standard dose of 600 mg bid in the NLF group in 47%, with 42% being underexposed and 11% overexposed versus 20% in the ACLF group with 77% overexposed and 3% underexposed. The highest probability of target exposure was attained with 600 mg bid in the NLF group and 150 mg bid in the ACLF group with 53%.

Conclusion

Linezolid body clearance in ACLF was markedly lower than in NLF. Given the overall high variability, therapeutic drug monitoring (TDM) with dose adjustments seems required to optimize target attainment. Until TDM results are available, a dose reduction may be considered in ACLF patients to prevent overexposure.

 

Outcomes of patients aged ≥80 years with respiratory failure initially treated with non-invasive ventilation in European intensive care units before and during COVID-19 pandemic

 

by Kamil Polok, Jakub Fronczek, Bertrand Guidet, Antonio Artigas, Dylan W. De Lange, Jesper Fjølner, Susannah Leaver, Michael Beil, Sigal Sviri, Raphael Romano Bruno, Bernhard Wernly, Bernardo Bollen Pinto, Joerg C. Schefold, Dorota Studzińska, Michael Joannidis, Sandra Oeyen… 

 

Annals of Intensive Care volume 13, Article number: 82 (2023)

 

Background

Non-invasive ventilation (NIV) has been commonly used to treat acute respiratory failure due to COVID-19. In this study we aimed to compare outcomes of older critically ill patients treated with NIV before and during the COVID-19 pandemic.

Methods

We analysed a merged cohort of older adults admitted to intensive care units (ICUs) due to respiratory failure. Patients were enrolled into one of two prospective observational studies: before COVID-19 (VIP2—2018 to 2019) and admitted due to COVID-19 (COVIP—March 2020 to January 2023). The outcomes included: 30-day mortality, intubation rate and NIV failure (death or intubation within 30 days).

Results

The final cohort included 1986 patients (1292 from VIP2, 694 from COVIP) with a median age of 83 years. NIV was used as a primary mode of respiratory support in 697 participants (35.1%). ICU admission due to COVID-19 was associated with an increased 30-day mortality (65.5% vs. 36.5%, HR 2.18, 95% CI 1.71 to 2.77), more frequent intubation (36.9% vs. 17.5%, OR 2.63, 95% CI 1.74 to 3.99) and NIV failure (76.2% vs. 45.3%, OR 4.21, 95% CI 2.84 to 6.34) compared to non-COVID causes of respiratory failure. Sensitivity analysis after exclusion of patients in whom life supporting treatment limitation was introduced during primary NIV confirmed higher 30-day mortality in patients with COVID-19 (52.5% vs. 23.4%, HR 2.64, 95% CI 1.83 to 3.80).

Conclusion

The outcomes of patients aged ≥80 years treated with NIV during COVID-19 pandemic were worse compared then those treated with NIV in the pre-pandemic era.

 

Virtual and augmented reality in intensive care medicine: a systematic review

 

by Dominika Kanschik, Raphael Romano Bruno, Georg Wolff, Malte Kelm and Christian Jung 

 

Annals of Intensive Care volume 13, Article number: 81 (2023) 

 

Background

Virtual reality (VR) and augmented reality (AR) are rapidly developing technologies that offer a wide range of applications and enable users to experience digitally rendered content in both physical and virtual space. Although the number of studies about the different use of VR and AR increases year by year, a systematic overview of the applications of these innovative technologies in intensive care medicine is lacking. The aim of this systematic review was to provide a detailed summary of how VR and AR are currently being used in various areas of intensive care medicine.

Methods

We systematically searched PubMed until 1st March 2023 to identify the currently existing evidence for different applications of VR and AR for both health care providers in the intensive care unit and children or adults, who were in an intensive care unit because of a critical illness.

Results

After screening the literature, a total of 59 studies were included. Of note, a substantial number of publications consists of case reports, study plans or are lacking a control group. Furthermore, study designs are seldom comparable. However, there have been a variety of use cases for VR and AR that researchers have explored. They can help intensive care unit (ICU) personnel train, plan, and perform difficult procedures such as cardiopulmonary resuscitation, vascular punctures, endotracheal intubation or percutaneous dilatational tracheostomy. Patients might benefit from VR during invasive interventions and ICU stay by alleviating stress or pain. Furthermore, it enables contact with relatives and can also assist patients in their rehabilitation programs.

Conclusion

Both, VR and AR, offer multiple possibilities to improve current care, both from the perspective of the healthcare professional and the patient. It can be assumed that VR and AR will develop further and their application in health care will increase.

 

Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation

 

by Stephan Katzenschlager, Inga K. Kelpanides, Patrick Ristau, Matthias Huck, Stephan Seewald, Sebastian Brenner, Florian Hoffmann, Jan Wnent, Jo Kramer-Johansen, Ingvild B. M. Tjelmeland, Markus A. Weigand, Jan-Thorsten Gräsner and Erik Popp 

 

Critical Care volume 27, Article number: 349 (2023)

 

Aim

This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival.

Methods

Data from the German Resuscitation Registry (GRR) were used, and we included patients registered between 1st January 2007 and 31st December 2021. We included children aged between > 7 days and 17 years, where cardiopulmonary resuscitation (CPR) was started, and treatment was continued by emergency medical services (EMS). Incidences and descriptive analyses are presented for the overall cohort and each age group. Multivariate binary logistic regression was performed on the whole cohort to determine the influence of (1) CPR with/without ventilation started by bystander, (2) OHCA witnessed status and (3) night-time on the outcome hospital admission with return of spontaneous circulation (ROSC).

Results

OHCA in children aged < 1 year had the highest incidence of the same age group, with 23.42 per 100 000. Overall, hypoxia was the leading presumed cause of OHCA, whereas trauma and drowning accounted for a high proportion in children aged > 1 year. Bystander-witnessed OHCA and bystander CPR rate were highest in children aged 1–4 years, with 43.9% and 62.3%, respectively. In reference to EMS-started CPR, bystander CPR with ventilation were associated with an increased odds ratio for ROSC at hospital admission after adjusting for age, sex, year of OHCA and location of OHCA.

Conclusion

This study provides an epidemiological overview of OHCA in children in Germany and identifies bystander CPR with ventilation as one primary factor for survival.

 

Sex and gender differences in intensive care medicine

 

Intensive Care Medicine: Narrative Review: Published: 07 September 2023

 

 

Abstract

Despite significant advancements in critical care medicine, limited attention has been given to sex and gender disparities in management and outcomes of patients admitted to the intensive care unit (ICU). While “sex” pertains to biological and physiological characteristics, such as reproductive organs, chromosomes and sex hormones, “gender” refers more to sociocultural roles and human behavior. Unfortunately, data on gender-related topics in the ICU are lacking. Consequently, data on sex and gender-related differences in admission to the ICU, clinical course, length of stay, mortality, and post-ICU burdens, are often inconsistent. Moreover, when examining specific diagnoses in the ICU, variations can be observed in epidemiology, pathophysiology, presentation, severity, and treatment response due to the distinct impact of sex hormones on the immune and cardiovascular systems. In this narrative review, we highlight the influence of sex and gender on the clinical course, management, and outcomes of the most encountered intensive care conditions, in addition to the potential co-existence of unconscious biases which may also impact critical illness. Diagnoses with a known sex predilection will be discussed within the context of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where clinical improvement is needed. To optimize patient care and outcomes, it is crucial to comprehend and address sex and gender differences in the ICU setting and personalize management accordingly to ensure equitable, patient-centered care. Future research should focus on elucidating the underlying mechanisms driving sex and gender disparities, as well as exploring targeted interventions to mitigate these disparities and improve outcomes for all critically ill patients.

 

Mottling as a prognosis marker in cardiogenic shock

 

by Hamid Merdji, Vincent Bataille, Anais Curtiaud, Laurent Bonello, François Roubille, Bruno Levy, Pascal Lim, Francis Schneider, Hadi Khachab, Jean-Claude Dib, Marie-France Seronde, Guillaume Schurtz, Brahim Harbaoui, Gerald Vanzetto, Severine Marchand, Caroline Eva Gebhard…

 

Annals of Intensive Care volume 13, Article number: 80 (2023)

Aims

Impact of skin mottling has been poorly studied in patients admitted for cardiogenic shock. This study aimed to address this issue and identify determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all etiologies.

Methods and results

FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October, 2016. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 660 had skin mottling assessed at admission (85.5%) with almost 39% of patients in cardiogenic shock presenting mottling. The need for invasive respiratory support was significantly higher in patients with mottling (50.2% vs. 30.1%, p < 0.001) and likewise for the need for renal replacement therapy (19.9% vs. 12.4%, p = 0.09). However, the need for mechanical circulatory support was similar in both groups. Patients with mottling at admission presented a higher length of stay (19 vs. 16 days, p = 0.033), a higher 30-day mortality rate (31% vs. 23.3%, p = 0.031), and also showed significantly higher mortality at 1-year (54% vs. 42%, p = 0.003). The subgroup of patients in whom mottling appeared during the first 24 h after admission had the worst prognosis at 30 days.

Conclusion

Skin mottling at admission in patients with cardiogenic shock was statistically associated with prolonged length of stay and poor outcomes. As a perfusion-targeted resuscitation parameter, mottling is a simple, clinical-based approach and may thus help to improve and guide immediate goal-directed therapy to improve cardiogenic shock patients’ outcomes.

 

Long-term immunosuppressive treatment is not associated with worse outcome in patients hospitalized in the intensive care unit for septic shock: the PACIFIC study

by Julien Vaidie, Edwige Peju, Louise-Marie Jandeaux, Mathieu Lesouhaitier, Jean-Claude Lacherade, Antoine Guillon, Xavier Wittebole, Pierre Asfar, Bruno Evrard, Thomas Daix, Philippe Vignon and Bruno François 

Critical Care volume 27, Article number: 340 (2023) 

 

Background

Except in a few retrospective studies mainly including patients under chemotherapy, information regarding the impact of immunosuppressive therapy on the prognosis of patients admitted to the intensive care unit (ICU) for septic shock is scarce. Accordingly, the PACIFIC study aimed to asses if immunosuppressive therapy is associated with an increased mortality in patients admitted to the ICU for septic shock.

Methods

This was a retrospective epidemiological multicentre study. Eight high enroller centres in septic shock randomised controlled trials (RCTs) participated in the study. Patients in the “exposed” group were selected from the screen failure logs of seven recent RCTs and excluded because of immunosuppressive treatment. The “non-exposed” patients were those included in the placebo arm of the same RCTs. A multivariate logistic regression model was used to estimate the risk of death.

Results

Among the 433 patients enrolled, 103 were included in the “exposed” group and 330 in the “non-exposed” group. Reason for immunosuppressive therapy included organ transplantation (n = 45 [44%]) or systemic disease (n = 58 [56%]). ICU mortality rate was 24% in the “exposed” group and 25% in the “non-exposed” group (p = 0.9). Neither in univariate nor in multivariate analysis immunosuppressive therapy was associated with a higher ICU mortality (OR: 0.95; [95% CI 0.56–1.58]: p =  0.86 and 1.13 [95% CI 0.61–2.05]: p =  0.69, respectively) or 3-month mortality (OR: 1.13; [95% CI 0.69–1.82]: p =  0.62 and OR: 1.36 [95% CI 0.78–2.37]: p =  0.28, respectively).

Conclusions

In this study, long-term immunosuppressive therapy excluding chemotherapy was not associated with significantly higher or lower ICU and 3-month mortality in patients admitted to the ICU for septic shock.

 

Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support

 

by Yann Marquet, Guillaume Hékimian, Guillaume Lebreton, Mathieu Kerneis, Philippe Rouvier, Pierre Bay, Alexis Mathian, Nicolas Bréchot, Juliette Chommeloux, Matthieu Petit, Melchior Gautier, Lucie Lefevre, Ouriel Saura, David Levy, Paul Quentric, Quentin Moyon…

 

Annals of Intensive Care volume 13, Article number: 78 (2023)

 

Background

Fulminant myocarditis is a rare and severe disease whose definite and etiological diagnoses rely on pathological examination. Albeit, myocardial biopsy can be associated with significant morbidity and mortality, its therapeutic consequences are unclear. We conducted a study to determine the diagnostic yield, the safety and the therapeutic consequences of myocardial biopsy in patients with fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (MCS).

Methods

Monocenter, retrospective, observational cohort study in a 26-bed French tertiary ICU between January 2002 and February 2019. Inclusion of all fulminant clinically suspected myocarditis patients undergoing in-ICU myocardial biopsy while being on MCS. The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results.

Results

Forty-seven patients (median age 41 [30–47], female 53%) were included: 55% died before hospital discharge, 34% could be bridged-to-recovery and 15% bridged-to-transplant. Myocardial biopsy was endomyocardial or surgical in 36% and 64% cases respectively. Tamponade requiring emergency pericardiocentesis occurred in 29% patients after endomyocardial biopsy. After adding the biopsy results in the Bonaca classification algorithm the percentage of definite myocarditis raised from 13 to 55% (p < 0.0001). The rate of biopsy-related treatments modifications was 13%, leading to patients’ recovery in only 4% patients.

Conclusions

In clinically suspected myocarditis unweanable from MCS, myocardial biopsy increased the rate of definite myocarditis but was associated with a low rate of treatment modification and a significant proportion of adverse events. We believe the benefit/risk ratio of myocardial biopsy should be more carefully weighted in these frail and selected patients than suggested by actual guidelines. Further prospective studies are now needed to determine its value in patients under MCS.

 

Brain tissue oxygen monitoring in traumatic brain injury: part I—To what extent does PbtO2 reflect global cerebral physiology?

 

by Teodor Svedung Wettervik, Erta Beqiri, Stefan Yu Bögli, Michal Placek, Mathew R. Guilfoyle, Adel Helmy, Andrea Lavinio, Ronan O’Leary, Peter J. Hutchinson and Peter Smielewski 

 

Critical Care volume 27, Article number: 339 (2023)

 

Background

The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI).

Methods

A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke’s Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < − 5 mmHg were considered as cerebral insults.

Results

PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < − 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [− 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below − 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation.

Conclusions

PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.

 

Plasma Nitric Oxide Consumption Is Elevated and Associated With Adverse Outcomes in Critically Ill Patients

by Dony, Christina A.; Illipparambil, Lijo C.; Maeda, Tetsuro; Mroczek, Susan K.; Rovitelli, Amy; Wexler, Orren; Malnoske, Michelle; Bice, Tristan; Fe, Alex Z.; Storms, Casey R.; Zhang, Jimmy; Schultz, Rebecca D.; Pietropaoli, Anthony P. 

Critical Care Medicine:  August 18, 2023.

OBJECTIVES: 

Impaired nitric oxide (NO) bioavailability may contribute to microvascular dysfunction in sepsis. Excessive plasma NO consumption has been attributed to scavenging by circulating cell-free hemoglobin. This may be a mechanism for NO deficiency in sepsis and critical illness. We hypothesized that plasma NO consumption is high in critically ill patients, particularly those with sepsis, acute respiratory distress syndrome (ARDS), shock, and in hospital nonsurvivors. We further hypothesized that plasma NO consumption is correlated with plasma cell-free hemoglobin concentration.

DESIGN: 

Retrospective cohort study.

SETTING: 

Adult ICUs of an academic medical center.

PATIENTS AND SUBJECTS: 

Three hundred sixty-two critically ill patients and 46 healthy control subjects.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

Plasma NO consumption was measured using reductive chemiluminescence and cell-free hemoglobin was measured with a colorimetric assay. Mean (95% CI) plasma NO consumption (µM) was higher in critically ill patients versus healthy control subjects (3.9 [3.7–4.1] vs 2.1 [1.8–2.5]), septic versus nonseptic patients (4.1 [3.8–4.3] vs 3.6 [3.3–3.8]), ARDS versus non-ARDS patients (4.4 [4.0–4.9] vs 3.7 [3.6–3.9]), shock vs nonshock patients (4.4 [4.0–4.8] vs 3.6 [3.4–3.8]), and hospital nonsurvivors versus survivors (5.3 [4.4–6.4] vs 3.7 [3.6–3.9]). These relationships remained significant in multivariable analyses. Plasma cell-free hemoglobin was weakly correlated with plasma NO consumption.

CONCLUSIONS: 

Plasma NO consumption is elevated in critically ill patients and independently associated with sepsis, ARDS, shock, and hospital death. These data suggest that excessive intravascular NO scavenging characterizes sepsis and adverse outcomes of critical illness.

 

Which severe COVID-19 patients could benefit from high dose dexamethasone? A Bayesian post-hoc reanalysis of the COVIDICUS randomized clinical trial

 

by Chevret Sylvie, Bouadma Lila, Dupuis Claire, Burdet Charles and Timsit Jean-François 

 

Annals of Intensive Care volume 13, Article number: 75 (2023)

 

Background

The respective benefits of high and low doses of dexamethasone (DXM) in patients with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and acute respiratory failure (ARF) are controversial, with two large triple-blind RCTs reaching very important difference in the effect-size. In the COVIDICUS trial, no evidence of additional benefit of high-dose dexamethasone (DXM20) was found. We aimed to explore whether some specific patient phenotypes could benefit from DXM20 compared to the standard of care 6 mg dose of DXM (DXMSoC).

Methods

We performed a post hoc exploratory Bayesian analysis of 473 patients who received either DXMSoc or DXM20 in the COVIDICUS trial. The outcome was the 60 day mortality rate of DXM20 over DXMSoC, with treatment effect measured on the hazard ratio (HR) estimated from Cox model. Bayesian analyses allowed to compute the posterior probability of a more than trivial benefit (HR < 0.95), and that of a potential harm (HR > 1.05). Bayesian measures of interaction then quantified the probability of interaction (Pr Interact) that the HR of death differed across the subsets by 20%. Primary analyses used noninformative priors, centred on HR = 1.00. Sensitivity analyses used sceptical and enthusiastic priors, based on null (HR = 1.00) or benefit (HR = 0.95) effects.

Results

Overall, the posterior probability of a more than trivial benefit and potential harm was 29.0 and 51.1%, respectively. There was some evidence of treatment by subset interaction (i) according to age (Pr Interact, 84%), with a 86.5% probability of benefit in patients aged below 70 compared to 22% in those aged above 70; (ii) according to the time since symptoms onset (Pr Interact, 99%), with a 99.9% probability of a more than trivial benefit when lower than 7 days compared to a < 0.1% probability when delayed by 7 days or more; and (iii) according to use of remdesivir (Pr Interact, 91%), with a 90.1% probability of benefit in patients receiving remdesivir compared to 19.1% in those who did not.

Conclusions

In this exploratory post hoc Bayesian analysis, compared with standard-of-care DXM, high-dose DXM may benefit patients aged less than 70 years with severe ARF that occurred less than 7 days after symptoms onset. The use of remdesivir may also favour the benefit of DXM20. Further analysis is needed to confirm these findings.

 

Evidence for a personalized early start of norepinephrine in septic shock

by Xavier Monnet, Christopher Lai, Gustavo Ospina-Tascon and Daniel De Backer 

Critical Care volume 27, Article number: 322 (2023) 

Abstract

During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe patients. However, earlier administration of norepinephrine, simultaneously with fluid resuscitation, should be considered in some cases. Duration and depth of hypotension strongly worsen outcomes in septic shock patients. However, the response of arterial pressure to volume expansion is inconstant, delayed, and transitory. In the case of profound, life-threatening hypotension, relying only on fluids to restore blood pressure may unduly prolong hypotension and organ hypoperfusion. Conversely, norepinephrine rapidly increases and better stabilizes arterial pressure. By binding venous adrenergic receptors, it transforms part of the unstressed blood volume into stressed blood volume. It increases the mean systemic filling pressure and increases the fluid-induced increase in mean systemic filling pressure, as observed in septic shock patients. This may improve end-organ perfusion, as shown by some animal studies. Two observational studies comparing early vs. later administration of norepinephrine in septic shock patients using a propensity score showed that early administration reduced the administered fluid volume and day-28 mortality. Conversely, in another propensity score-based study, norepinephrine administration within the first hour following shock diagnosis increased day-28 mortality. The only randomized controlled study that compared the early administration of norepinephrine alone to a placebo showed that the early continuous administration of norepinephrine at a fixed dose of 0.05 µg/kg/min, with norepinephrine added in open label, showed that shock control was achieved more often than in the placebo group. The choice of starting norepinephrine administration early should be adapted to the patient’s condition. Logically, it should first be addressed to patients with profound hypotension, when the arterial tone is very low, as suggested by a low diastolic blood pressure (e.g. ≤ 40 mmHg), or by a high diastolic shock index (heart rate/diastolic blood pressure) (e.g. ≥ 3). Early administration of norepinephrine should also be considered in patients in whom fluid accumulation is likely to occur or in whom fluid accumulation would be particularly deleterious (in case of acute respiratory distress syndrome or intra-abdominal hypertension for example).

 

Critically ill metastatic cancer patients returning home after unplanned ICU stay: an observational, multicentre retrospective study

 

by Frédéric Gonzalez, Rémi Starka, Laurent Ducros, Magali Bisbal, Laurent Chow-Chine, Luca Servan, Jean-Manuel de Guibert, Bruno Pastene, Marion Faucher, Antoine Sannini, Marc Leone and Djamel Mokart 

 

Annals of Intensive Care volume 13, Article number: 73 (2023) 

 

Background

Data about critically ill metastatic cancer patients functional outcome after unplanned admission to the ICU are scarce. The aim of this study was to assess factors associated with 90-day return home and 1-year survival in this population.

Study design and methods

A multicenter retrospective study included all consecutive metastatic cancer patients admitted to the ICU for unplanned reason between 2017 and 2020.

Results

Among 253 included metastatic cancer patients, mainly with lung cancer, 94 patients (37.2%) could return home on day 90. One-year survival rate was 28.5%. Performance status 0 or 1 (OR, 2.18; 95% CI 1.21–3.93; P = 0.010), no malnutrition (OR, 2.90; 95% CI 1.61–5.24; P < 0.001), female gender (OR, 2.39; 95% CI 1.33–4.29; P = 0.004), recent chemotherapy (OR, 2.62; 95% CI 1.40–4.90; P = 0.003), SOFA score ≤ 5 on admission (OR, 2.62; 95% CI 1.41–4.90; P = 0.002) were significantly predictive for 90-day return home. Malnutrition (HR, 1.66; 95% CI 1.18–2.22; P = 0.003), acute respiratory failure (ARF) as reason for admission (HR, 1.40; 95% CI 1.10–1.95; P = 0.043), SAPS II on admission (HR, 1.03; 95% CI 1.02–1.05; P < 0.001) and decisions to forgo life-sustaining therapies (DFLST) (HR, 2.80; 95% CI 2.04–3.84; P < 0.001) were independently associated with 1-year mortality.

Conclusions

More than one out of three metastatic cancer patients could return home within 3 months after an unplanned admission to the ICU. Previous performance and nutritional status, ongoing specific treatment and low severity of the acute illness were found to be predictive for return home. Such encouraging findings should help change the dismal perception of critically ill metastatic cancer patients.