Critical Care Bulletin - December 2023

 

The International Cardiac Arrest Research Consortium Electroencephalography Database

 

by Amorim, Edilberto; Zheng, Wei-Long; Ghassemi, Mohammad M.; Aghaeeaval, Mahsa; Kandhare, Pravinkumar; Karukonda, Vishnu; Lee, Jong Woo; Herman, Susan T.; Sivaraju, Adithya; Gaspard, Nicolas; Hofmeijer, Jeannette; van Putten, Michel J. A. M.; Sameni, Reza; Reyna, Matthew A.; Clifford, Gari D.; Westover, M. Brandon 

Critical Care Medicine 51(12):p 1802-1811, December 2023.

 

OBJECTIVES: 

To develop the International Cardiac Arrest Research (I-CARE), a harmonized multicenter clinical and electroencephalography database for acute hypoxic-ischemic brain injury research involving patients with cardiac arrest.

DESIGN: 

Multicenter cohort, partly prospective and partly retrospective.

SETTING: 

Seven academic or teaching hospitals from the United States and Europe.

PATIENTS: 

Individuals 16 years old or older who were comatose after return of spontaneous circulation following a cardiac arrest who had continuous electroencephalography monitoring were included.

INTERVENTIONS: 

Not applicable.

MEASUREMENTS AND MAIN RESULTS: 

Clinical and electroencephalography data were harmonized and stored in a common Waveform Database-compatible format. Automated spike frequency, background continuity, and artifact detection on electroencephalography were calculated with 10-second resolution and summarized hourly. Neurologic outcome was determined at 3–6 months using the best Cerebral Performance Category (CPC) scale. This database includes clinical data and 56,676 hours (3.9 terabytes) of continuous electroencephalography data for 1,020 patients. Most patients died (n = 603, 59%), 48 (5%) had severe neurologic disability (CPC 3 or 4), and 369 (36%) had good functional recovery (CPC 1–2). There is significant variability in mean electroencephalography recording duration depending on the neurologic outcome (range, 53–102 hr for CPC 1 and CPC 4, respectively). Epileptiform activity averaging 1 Hz or more in frequency for at least 1 hour was seen in 258 patients (25%) (19% for CPC 1–2 and 29% for CPC 3–5). Burst suppression was observed for at least 1 hour in 207 (56%) and 635 (97%) patients with CPC 1–2 and CPC 3–5, respectively.

CONCLUSIONS: 

The I-CARE consortium electroencephalography database provides a comprehensive real-world clinical and electroencephalography dataset for neurophysiology research of comatose patients after cardiac arrest. This dataset covers the spectrum of abnormal electroencephalography patterns after cardiac arrest, including epileptiform patterns and those in the ictal-interictal continuum.

 

Inhaled drug delivery: a randomized study in intubated patients with healthy lungs

 

by Jonathan Dugernier, Déborah Le Pennec, Guillaume Maerckx, Laurine Allimonnier, Michel Hesse, Diego Castanares-Zapatero, Virginie Depoortere, Laurent Vecellio, Gregory Reychler, Jean-Bernard Michotte, Pierre Goffette, Marie-Agnes Docquier, Christian Raftopoulos, François Jamar, Pierre-François Laterre, Stephan Ehrmann…

 

Annals of Intensive Care volume 13, Article number: 125 (2023) Published: 11 December 2023

 

Background

The administration technique for inhaled drug delivery during invasive ventilation remains debated. This study aimed to compare in vivo and in vitro the deposition of a radiolabeled aerosol generated through four configurations during invasive ventilation, including setups optimizing drug delivery.

Methods

Thirty-one intubated postoperative neurosurgery patients with healthy lungs were randomly assigned to four configurations of aerosol delivery using a vibrating-mesh nebulizer and specific ventilator settings: (1) a specific circuit for aerosol therapy (SCAT) with the nebulizer placed at 30 cm of the wye, (2) a heated-humidified circuit switched off 30 min before the nebulization or (3) left on with the nebulizer at the inlet of the heated-humidifier, (4) a conventional circuit with the nebulizer placed between the heat and moisture exchanger filter and the endotracheal tube. Aerosol deposition was analyzed using planar scintigraphy.

Results

A two to three times greater lung delivery was measured in the SCAT group, reaching 19.7% (14.0–24.5) of the nominal dose in comparison to the three other groups (p < 0.01). Around 50 to 60% of lung doses reached the outer region of both lungs in all groups. Drug doses in inner and outer lung regions were significantly increased in the SCAT group (p < 0.01), except for the outer right lung region in the fourth group due to preferential drug trickling from the endotracheal tube and the trachea to the right bronchi. Similar lung delivery was observed whether the heated humidifier was switched off or left on. Inhaled doses measured in vitro correlated with lung doses (R = 0.768, p < 0.001).

Conclusion

Optimizing the administration technique enables a significant increase in inhaled drug delivery to the lungs, including peripheral airways. Before adapting mechanical ventilation, studies are required to continue this optimization and to assess its impact on drug delivery and patient outcome in comparison to more usual settings.

 

 

 

 

Do critical illness survivors with multimorbidity need a different model of care?

 

by Jonathan Stewart, Judy Bradley, Susan Smith, Joanne McPeake, Timothy Walsh, Kimberley Haines, Nina Leggett, Nigel Hart and Danny McAuley 

 

Critical Care volume 27, Article number: 485 (2023) Published: 08 December 2023

 

Abstract

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person’s existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person’s medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

 

Proenkephalin as a biomarker correlates with acute kidney injury: a systematic review with meta-analysis and trial sequential analysis

 

by Li-Chun Lin, Min-Hsiang Chuan, Jung-Hua Liu, Hung-Wei Liao, Leong L. Ng, Martin Magnusson, Amra Jujic, Heng-Chih Pan, Vin-Cent Wu and Lui G. Forni 

 

Critical Care volume 27, Article number: 481 (2023) Published: 07 December 2023

 

Background

Proenkephalin A 119-159 (PENK) is freely filtered in the glomerulus with plasma levels correlating with glomerular filtration rate. Therefore, PENK has been proposed as an early indicator of acute kidney injury (AKI) although its performance is dependent on the clinical setting. This meta-analysis aimed to investigate the correlation between PENK levels and the development of AKI.

Methods

We conducted a comprehensive search on the PubMed, Embase, Cochrane databases, the website ClinicalTrials.gov and Cnki.net until June 26, 2023. Summary receiver operating characteristic (SROC) curves were used to amalgamate the overall test performance. Diagnostic odds ratio (DOR) was employed to compare the diagnostic accuracy of PENK with other biomarkers. Quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria.

Results

We incorporated 11 observational studies with 3969 patients with an incidence of AKI of 23.4% (929 out of 3969 patients) with the best optimal cutoff value of PENK for early detection of AKI being 57.3 pmol/L. The overall sensitivity and specificity of PENK in identifying AKI were 0.69 (95% CI 0.62–0.75) and 0.76 (95% CI 0.68–0.82), respectively. The combined positive likelihood ratio (LR) stood at 2.83 (95% CI 2.06–3.88), and the negative LR was 0.41 (95% CI 0.33–0.52). The SROC curve showcased pooled diagnostic accuracy of 0.77 (95% CI 0.73–0.81). Interestingly, patients with a history of hypertension or heart failure demonstrated a lower specificity of PENK in correlating the development of AKI.

Conclusion

Our results indicate that PENK possesses significant potential as a biomarker for the early detection of the development of AKI, using a cutoff point of 57.3 pmol/L for PENK.

 

Targeting the host response in sepsis: current approaches and future evidence

 

by Christian Bode, Sebastian Weis, Andrea Sauer, Pedro Wendel-Garcia and Sascha David 

 

Critical Care volume 27, Article number: 478 (2023) Published: 06 December 2023

 

Abstract

Sepsis, a dysregulated host response to infection characterized by organ failure, is one of the leading causes of death worldwide. Disbalances of the immune response play an important role in its pathophysiology. Patients may develop simultaneously or concomitantly states of systemic or local hyperinflammation and immunosuppression. Although a variety of effective immunomodulatory treatments are generally available, attempts to inhibit or stimulate the immune system in sepsis have failed so far to improve patients’ outcome. The underlying reason is likely multifaceted including failure to identify responders to a specific immune intervention and the complex pathophysiology of organ dysfunction that is not exclusively caused by immunopathology but also includes dysfunction of the coagulation system, parenchymal organs, and the endothelium. Increasing evidence suggests that stratification of the heterogeneous population of septic patients with consideration of their host response might led to treatments that are more effective. The purpose of this review is to provide an overview of current studies aimed at optimizing the many facets of host response and to discuss future perspectives for precision medicine approaches in sepsis.

 

Critical illness among patients experiencing homelessness: a retrospective cohort study

 

by K. M. Sauro, C. M. O’Rielly, J. Kersen, A. Soo, S. M. Bagshaw and H. T. Stelfox 

 

Critical Care volume 27, Article number: 477 (2023) Published: 06 December 2023

 

Purpose

To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing.

Methods

This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status.

Results

2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0–2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8–2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6–11.6, p < 0.001), compared with those who have stable housing.

Conclusions

Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.

 

Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver

 

by Rui Zhang, Xiaoting Xu, Hui Chen, Jennifer Beck, Christer Sinderby, Haibo Qiu, Yi Yang and Ling Liu 

 

Annals of Intensive Care volume 13, Article number: 122 (2023) Published: 06 December 2023

 

Background

The unsuccessful extubation in patients with traumatic cervical spinal cord injuries (CSCI) may result from impairment diaphragm function and monitoring of diaphragm electrical activity (EAdi) can be informative in guiding extubation. We aimed to evaluate whether the change of EAdi during a single maximal maneuver can predict extubation outcomes in CSCI patients.

Methods

This is a retrospective study of CSCI patients requiring mechanical ventilation in the ICU of a tertiary hospital. A single maximal maneuver was performed by asking each patient to inhale with maximum strength during the first spontaneous breathing trial (SBT). The baseline (during SBT before maximal maneuver), maximum (during the single maximal maneuver), and the increase of EAdi (ΔEAdi, equal to the difference between baseline and maximal) were measured. The primary outcome was extubation success, defined as no reintubation after the first extubation and no tracheostomy before any extubation during the ICU stay.

Results

Among 107 patients enrolled, 50 (46.7%) were extubated successfully at the first SBT. Baseline EAdi, maximum EAdi, and ΔEAdi were significantly higher, and the rapid shallow breathing index was lower in patients who were extubated successfully than in those who failed. By multivariable logistic analysis, ΔEAdi was independently associated with successful extubation (OR 2.03, 95% CI 1.52–3.17). ΔEAdi demonstrated high diagnostic accuracy in predicting extubation success with an AUROC 0.978 (95% CI 0.941–0.995), and the cut-off value was 7.0 μV.

Conclusions

The increase of EAdi from baseline SBT during a single maximal maneuver is associated with successful extubation and can help guide extubation in CSCI patients.

 

 

 

 

 

Prognostic value of capillary refill time in adult patients: a systematic review with meta-analysis

 

by Matthias Jacquet-Lagrèze, Aymeric Pernollet, Eduardo Kattan, Hafid Ait-Oufella, Delphine Chesnel, Martin Ruste, Rémi Schweizer, Bernard Allaouchiche, Glenn Hernandez and Jean-Luc Fellahi 

 

Critical Care volume 27, Article number: 473 (2023) Published: 02 December 2023

 

Purpose

Acute circulatory failure leads to tissue hypoperfusion. Capillary refill time (CRT) has been widely studied, but its predictive value remains debated. We conducted a meta-analysis to assess the ability of CRT to predict death or adverse events in a context at risk or confirmed acute circulatory failure in adults.

Method

MEDLINE, EMBASE, and Google scholar databases were screened for relevant studies. The pooled area under the ROC curve (AUC ROC), sensitivity, specificity, threshold, and diagnostic odds ratio using a random-effects model were determined. The primary analysis was the ability of abnormal CRT to predict death in patients with acute circulatory failure. Secondary analysis included the ability of CRT to predict death or adverse events in patients at risk or with confirmed acute circulatory failure, the comparison with lactate, and the identification of explanatory factors associated with better accuracy.

Results

A total of 60,656 patients in 23 studies were included. Concerning the primary analysis, the pooled AUC ROC of 13 studies was 0.66 (95%CI [0.59; 0.76]), and pooled sensitivity was 54% (95%CI [43; 64]). The pooled specificity was 72% (95%CI [55; 84]). The pooled diagnostic odds ratio was 3.4 (95%CI [1.4; 8.3]). Concerning the secondary analysis, the pooled AUC ROC of 23 studies was 0.69 (95%CI [0.65; 0.74]). The prognostic value of CRT compared to lactate was not significantly different. High-quality CRT was associated with a greater accuracy.

Conclusion

CRT poorly predicted death and adverse events in patients at risk or established acute circulatory failure. Its accuracy is greater when high-quality CRT measurement is performed.

Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials

 

by Jean Baptiste Lascarrou, Cyrielle Ermel, Alain Cariou, Timo Laitio, Hans Kirkegaard, Eldar Søreide, Anders M. Grejs, Matti Reinikainen, Gwenhael Colin, Fabio Silvio Taccone, Amélie Le Gouge and Markus B. Skrifvars 

 

Critical Care volume 27, Article number: 472 (2023) Published: 01 December 2023

 

Purpose

To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest.

Methods

We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135–145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP).

Results

We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15–29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26–0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis.

Conclusions

Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating.

 

 

The use of checklists in the intensive care unit: a scoping review

 

by Ethan J. Erikson, Daniel A. Edelman, Fiona M. Brewster, Stuart D. Marshall, Maryann C. Turner, Vineet V. Sarode and David J. Brewster 

 

Critical Care volume 27, Article number: 468 (2023) Published: 30 November 2023

 

Background

Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use.

Methods

A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted.

Results

Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative.

Conclusions

Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data.

 

Prognostic differences in sepsis caused by gram-negative bacteria and gram-positive bacteria: a systematic review and meta-analysis

 

by Aling Tang, Yi Shi, Qingqing Dong, Sihui Wang, Yao Ge, Chenyan Wang, Zhimin Gong, Weizhen Zhang and Wei Chen 

 

Critical Care volume 27, Article number: 467 (2023) Published: 30 November 2023

 

Background

Bacteria are the main pathogens that cause sepsis. The pathogenic mechanisms of sepsis caused by gram-negative and gram-positive bacteria are completely different, and their prognostic differences in sepsis remain unclear.

Methods

The PubMed, Web of Science, Cochrane Library, and Embase databases were searched for Chinese and English studies (January 2003 to September 2023). Observational studies involving gram-negative (G (−))/gram-positive (G (+)) bacterial infection and the prognosis of sepsis were included. The stability of the results was evaluated by sensitivity analysis. Funnel plots and Egger tests were used to check whether there was publication bias. A meta-regression analysis was conducted on the results with high heterogeneity to identify the source of heterogeneity. A total of 6949 articles were retrieved from the database, and 45 studies involving 5586 subjects were included after screening according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-seven high-quality studies and 18 moderate-quality studies were identified according to the Newcastle‒Ottawa Scale score. There was no significant difference in the survival rate of sepsis caused by G (−) bacteria and G (+) bacteria (OR 0.95, 95% CI 0.70–1.28). Subgroup analysis according to survival follow-up time showed no significant difference. The serum concentrations of C-reactive protein (CRP) (SMD = 0.39, 95% CI 0.02–0.76), procalcitonin (SMD = 1.95, 95% CI 1.32–2.59) and tumor necrosis factor-alpha (TNF-α) (MD = 0.31, 95% CI 0.25–0.38) in the G (−) bacterial infection group were significantly higher than those in the G (+) bacterial infection group, but there was no significant difference in IL-6 (SMD = 1.33, 95% CI − 0.18–2.84) and WBC count (MD = − 0.15, 95% CI − 0.96–00.66). There were no significant differences between G (−) and G (+) bacteria in D dimer level, activated partial thromboplastin time, thrombin time, international normalized ratio, platelet count, length of stay or length of ICU stay. Sensitivity analysis of the above results indicated that the results were stable.

Conclusion

The incidence of severe sepsis and the concentrations of inflammatory factors (CRP, PCT, TNF-α) in sepsis caused by G (−) bacteria were higher than those caused by G (+) bacteria. The two groups had no significant difference in survival rate, coagulation function, or hospital stay. The study was registered with PROSPERO (registration number: CRD42023465051).

 

 

 

 

 

 

 

 

High-flow nasal cannula oxygen versus conventional oxygen therapy for acute respiratory failure due to COVID-19: a systematic review and meta-analysis

by Sylvain Le Pape, Sigourney Savart, François Arrivé, Jean-Pierre Frat, Stéphanie Ragot, Rémi Coudroy and Arnaud W. Thille 

Annals of Intensive Care volume 13, Article number: 114 (2023) Published: 23 November 2023

Background

The effectiveness of high-flow nasal cannula oxygen therapy (HFNC) in patients with acute respiratory failure due to COVID-19 remains uncertain. We aimed at assessing whether HFNC is associated with reduced risk of intubation or mortality in patients with acute respiratory failure due to COVID-19 compared with conventional oxygen therapy (COT).

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, and CENTRAL databases for randomized controlled trials (RCTs) and observational studies comparing HFNC vs. COT in patients with acute respiratory failure due to COVID-19, published in English from inception to December 2022. Pediatric studies, studies that compared HFNC with a noninvasive respiratory support other than COT and those in which intubation or mortality were not reported were excluded. Two authors independently screened and selected articles for inclusion, extracted data, and assessed the risk of bias. Fixed-effects or random-effects meta-analysis were performed according to statistical heterogeneity. Primary outcomes were risk of intubation and mortality across RCTs. Effect estimates were calculated as risk ratios and 95% confidence interval (RR; 95% CI). Observational studies were used for sensitivity analyses.

Results

Twenty studies were analyzed, accounting for 8383 patients, including 6 RCTs (2509 patients) and 14 observational studies (5874 patients). By pooling the 6 RCTs, HFNC compared with COT significantly reduced the risk of intubation (RR 0.89, 95% CI 0.80 to 0.98; p = 0.02) and reduced length of stay in hospital. HFNC did not significantly reduce the risk of mortality (RR 0.93, 95% CI 0.77 to 1.11; p = 0.40).

Conclusions

In patients with acute respiratory failure due to COVID-19, HFNC reduced the need for intubation and shortened length of stay in hospital without significant decreased risk of mortality.

Trial registration The study was registered on the International prospective register of systematic reviews (PROSPERO) at https://www.crd.york.ac.uk/prospero/ with the trial registration number CRD42022340035 (06/20/2022).

 

Myocardial dysfunction assessed by speckle-tracking in good-grade subarachnoid hemorrhage patients (WFNS 1–2): a prospective observational study

by Hugues de Courson, Grégoire Chadefaux, Alexandre Loiseau, Delphine Georges and Matthieu Biais 

Critical Care volume 27, Article number: 455 (2023) Published: 21 November 2023

Background

Cardiac complications due to non-traumatic subarachnoid hemorrhage (SAH) are usually described using classical echocardiographic evaluation. Strain imaging appears to have better sensitivity than standard echocardiographic markers for the diagnosis of left ventricular dysfunction. The aim of this study was to determine the prevalence of cardiac dysfunction defined as a Global Longitudinal Strain (GLS) ≥  − 20% in patients with good-grade SAH (WFNS 1 or 2).

Methods

Seventy-six patients with good-grade SAH were prospectively enrolled and analyzed at admission for neurocritical care. Transthoracic echocardiography was performed on days 1, 3, and 7 after hemorrhage. Routine measurements, including left ventricular ejection fraction (LVEF), were performed, and off-line analysis was performed by a blinded examiner, to determine 2-, 3-, and 4-cavity longitudinal strain and left ventricular GLS. GLS was considered altered if it was ≥  − 20%, we also interested the value of ≥  − 17%. LVEF was considered altered if it was < 50%.

Results

On day 1, 60.6% of patients had GLS ≥  − 20% and 21.2% of patient had GLS ≥  − 17%. In comparison, alteration of LVEF was present in only 1.7% of patients. The concordance rate between LVEF < 50% and GLS ≥  − 20% and LVEF ≥ 50% and GLS <  − 20% was 46%.

Conclusion

Strain imaging showed a higher prevalence (60.6%) of left ventricular dysfunction during the acute phase of good-grade SAH (WFNS 1 or 2) than previously described.

 

Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis

 

by Emmanuel Novy, Claire Roger, Jason A. Roberts and Menino Osbert Cotta 

 

Critical Care volume 27, Article number: 449 (2023) Published: 20 November 2023

 

Abstract

Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.

Highlights

·         Intra-abdominal candidiasis presents specific pharmacokinetic (PK) and pharmacodynamic (PD) challenges where suboptimal antifungal concentrations are likely to occur leading to high risk of treatment failure.

·         The intra-abdominal cavity has been highlighted as a hidden reservoir for resistance to antifungals including echinocandins.

·         To date, all antifungal PK/PD studies in intra-abdominal candidiasis have enrolled small cohorts and have only provided post-operative antifungal concentrations analysis.

·         Based on current evidence, high dosing regimens of antifungals should be strongly considered, especially at the onset of infection.

·         The place of new antifungals (rezafungin, ibrexafungerp) requires more robust clinical studies including PK/PD analysis in critically ill patients.

 

A Comparison of High and Usual Protein Dosing in Critically Ill Patients With Obesity: A Post Hoc Analysis of an International, Pragmatic, Single-Blinded, Randomized, Clinical Trial

by Tweel, Lauren E.; Compher, Charlene; Bear, Danielle E.; Gutierrez-Castrellon, Pedro; Leaver, Susannah K.; MacEachern, Kristen; Ortiz-Reyes, Luis; Pooja, Lakhani; León, Angélica; Wedemire, Courtney; Lee, Zheng Yii; Day, Andrew G.; Heyland, Daren K. 

Critical Care Medicine, November 06, 2023. 

Objectives: 

Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein.

Design: 

A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial.

Setting: 

Eighty-five adult ICUs across 16 countries.

Patients: 

Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m2 (n = 425).

Interventions: 

In the primary study, patients were randomized into a high-dose (≥ 2.2 g/kg/d) or usual-dose protein group (≤ 1.2 g/kg/d).

Measurements and Main Results: 

Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m2. After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58–1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, –5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups.

Conclusions: 

In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.