Influence of temperature management at 33 °C versus normothermia on survival in patients with vasopressor support after out-of-hospital cardiac arrest: a post hoc analysis of the TTM-2 trial

 

by Joachim Düring, Martin Annborn, Alain Cariou, Michelle S. Chew, Josef Dankiewicz, Hans Friberg, Matthias Haenggi, Zana Haxhija, Janus C. Jakobsen, Halvor Langeland, Fabio Silvio Taccone, Matthew Thomas, Susann Ullén, Matt P. Wise and Niklas Nielsen 

 

Critical Care volume 26, Article number: 231 (2022)  Published: 31 July 2022

 

Background

Targeted temperature management at 33 °C (TTM33) has been employed in effort to mitigate brain injury in unconscious survivors of out-of-hospital cardiac arrest (OHCA). Current guidelines recommend prevention of fever, not excluding TTM33. The main objective of this study was to investigate if TTM33 is associated with mortality in patients with vasopressor support on admission after OHCA.

Methods

We performed a post hoc analysis of patients included in the TTM-2 trial, an international, multicenter trial, investigating outcomes in unconscious adult OHCA patients randomized to TTM33 versus normothermia. Patients were grouped according to level of circulatory support on admission: (1) no-vasopressor support, mean arterial blood pressure (MAP) ≥ 70 mmHg; (2) moderate-vasopressor support MAP < 70 mmHg or any dose of dopamine/dobutamine or noradrenaline/adrenaline dose ≤ 0.25 µg/kg/min; and (3) high-vasopressor support, noradrenaline/adrenaline dose > 0.25 µg/kg/min. Hazard ratios with TTM33 were calculated for all-cause 180-day mortality in these groups.

Results

The TTM-2 trial enrolled 1900 patients. Data on primary outcome were available for 1850 patients, with 662, 896, and 292 patients in the, no-, moderate-, or high-vasopressor support groups, respectively. Hazard ratio for 180-day mortality was 1.04 [98.3% CI 0.78–1.39] in the no-, 1.22 [98.3% CI 0.97–1.53] in the moderate-, and 0.97 [98.3% CI 0.68–1.38] in the high-vasopressor support groups with regard to TTM33. Results were consistent in an imputed, adjusted sensitivity analysis.

Conclusions

In this exploratory analysis, temperature control at 33 °C after OHCA, compared to normothermia, was not associated with higher incidence of death in patients stratified according to vasopressor support on admission.

 

Electrical Impedance Tomography in Acute Respiratory Distress Syndrome Management

 

by Jimenez, Jose Victor; Weirauch, Andrew J.; Culter, Christopher A.; Choi, Philip J.; Hyzy, Robert C.

 

Critical Care Medicine: August 2022 - Volume 50 - Issue 8 - p 1210-1223

 

OBJECTIVE: To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing 

acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum.

DATA SOURCES: We performed an online search in Pubmed to review articles. We searched MEDLINE, Cochrane Central Register, and clinicaltrials.gov for controlled trials databases.

STUDY SELECTION: Selected publications included case series, pilot-physiologic studies, observational cohorts, and randomized controlled trials. To describe the rationale underlying physiologic principles, we included experimental studies.

DATA EXTRACTION: Data from relevant publications were reviewed, analyzed, and its content summarized.

DATA SYNTHESIS: Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined.

CONCLUSIONS: Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.

 

 

 

Long-term cognitive functioning is impaired in ICU-treated COVID-19 patients: a comprehensive controlled neuropsychological study

 

by Henriikka Ollila, Riikka Pihlaja, Sanna Koskinen, Annamari Tuulio-Henriksson, Viljami Salmela, Marjaana Tiainen, Laura Hokkanen and Johanna Hästbacka 

 

Critical Care volume 26, Article number: 223 (2022) Published: 20 July 2022

 

Background

Cognitive impairment has emerged as a common post-acute sequela of coronavirus disease 2019 (COVID-19). We hypothesised that cognitive impairment exists in patients after COVID-19 and that it is most severe in patients admitted to the intensive care unit (ICU).

Methods

This prospective controlled cohort study of 213 participants performed at the Helsinki University Hospital and the University of Helsinki, Finland, comprised three groups of patients—ICU-treated (n = 72), ward-treated (n = 49), and home-isolated (n = 44)—with confirmed COVID-19 between March 13 and December 31, 2020, participating in a comprehensive neuropsychological evaluation six months after the acute phase. Our study included a control group with no history of COVID-19 (n = 48). Medical and demographic data were collected from electronic patient records and interviews carried out four months after the acute phase. Questionnaires filled six months after the acute phase provided information about change in cognitive functioning observed by a close informant, as well as the presence of self-reported depressive and post-traumatic symptoms.

Results

The groups differed (effect size η2p = 0.065, p = 0.004) in the total cognitive score, calculated from neuropsychological measures in three domains (attention, executive functions, and memory). Both ICU-treated (p = 0.011) and ward-treated patients (p = 0.005) performed worse than home-isolated patients. Among those with more than 12 years of education, ICU-treated patients performed worse in the attention domain than ward-treated patients (p = 0.021) or non-COVID controls (p = 0.045); ICU-treated male patients, in particular, were impaired in executive functions (p = 0.037).

Conclusions

ICU-treated COVID-19 patients, compared to patients with less severe acute COVID-19 or non-COVID controls, showed more severe long-term cognitive impairment. Among those with more than 12 years of education, impairment existed particularly in the domains of attention and for men, of executive functions.

 

Improving the intensive care experience from the perspectives of different stakeholders

 

by Jos M. Latour, Nancy Kentish-Barnes, Theresa Jacques, Marc Wysocki, Elie Azoulay and Victoria Metaxa 

 

Critical Care volume 26, Article number: 218 (2022)  Published: 18 July 2022

 

 

The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel’s suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.

 

Hyperglycemia and insulin resistance in COVID-19 versus non-COVID critical illness: Are they really different?

 

by Lies Langouche, Greet Van den Berghe and Jan Gunst 

 

Critical Care volume 25, Article number: 437 (2021) Published: 17 December 2021

 

Hyperglycemia frequently develops in patients with severe COVID-19, regardless of preadmission diabetes status, as in non-COVID critically ill patients. In non-COVID patients, stress hyperglycemia has been attributed to insulin resistance due to elevated counterregulatory hormones, cytokines, and drugs including steroids, although beta-cell dysfunction through prolonged hyperglycemia, poor beta-cell reserve, hypoperfusion and inflammation may co-exist in some patients. As in non-COVID patients, numerous observational studies have associated more severe hyperglycemia and increased glucose variability with poor outcome in COVID-19 patients. However, causality remains unclear, since insulin resistance and resultant hyperglycemia closely relate to illness severity. In this regard, a recent observational study also associated insulin treatment with increased mortality of COVID-19. Evidently, observational studies have an inherent risk of residual confounding, whereby the ideal glucose target can only be derived from adequately powered randomized controlled trials (RCTs)…