Factors associated with extubation failure in an intensive care unit: a case-control study / Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle / Factores asociados al fracaso de la extubación en unidad de cuidados intensivos: estudio de caso y control

Abstract Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher's exact test or the chi-square test; unpaired two-tailed Student's t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure.

Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação.

Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.

Risk factors of prolonged intensive care unit stay following cardiac surgery for infective endocarditis.

INTRODUCTION: Prolonged intensive care unit (ICU) stay is common in serious patients undergoing cardiac surgery. Prolonged ICU stay is associated with increased mortality and worse prognosis. This study was conducted to determine the risk factors for prolonged ICU stay after cardiac surgery for infective endocarditis (IE) and we try to decrease the operative risk of mortality and morbidity of cardiac surgery for IE. METHODS: The retrospective study of patients with IE undergoing cardiac surgery between January 2006 and November 2022 at our hospital was performed. RESULTS: 896 patients undergoing cardiac surgery were divided into group of ICU stay ≤ 3d (n = 416) and group p of ICU stay > 3d (n = 480). There were 48 operative deaths (5.4%). Univariable and multivariable analyses showed that factors are associated with prolonged ICU stay following cardiac surgery for IE, including male (P < .001), age (P < .001), weight (P = .009), vegetation length (P < .001), paravalvular leak (P < .001), aortic cross-clamp time (P < .001), cardiopulmonary bypass (CPB) time (P < .001), mechanical ventilation time (P < .001), hospitalized time postoperative (P = .032), creatinine of serum before surgery (P < .001), creatinine of serum 24h after surgery (P = .005), creatinine of serum 48h after surgery (P < .001), fluid balance on operation day (P < .001), postoperative acute kidney injury (P < .001), left ventricular end diastolic dimension (LVEDD) preoperative (P < .001), LVEDD postoperative (P < .001), chest drainage (P = .032), frozen plasma (P = .016), preoperative aortic insufficiency (P < .001), and packed red cells (P < .001). CONCLUSIONS: In our study, shortness of ICU stay and optimization of pre-, peri-, and postoperative factors that can shorten ICU stay, therefore, contribute to a better postoperative outcome and leads to lower rates of mortality and morbidity.

Is a guideline required to predict the intensive care unit need of patients over 65 years of age during the pre-operative period? A comparison of the American Society of Anesthesiologists, lung ultrasound score, Charlson age-added comorbidity index, surgi.

BACKGROUND: All pre-operative, intra-operative, and post-operative variables of the patients at 65 years of age who had a surgi-cal procedure determine the necessity of post-operative intensive care unit (ICU) monitoring. The indication for post-operative ICU is detected through ideal scoring systems related to the surgery and anesthesia that will be performed easily and fast would prevent the development of morbidity and mortality in high-risk patients. In the present study, we compared the efficacy of the American Society of Anesthesiologists (ASA) score, lung ultrasound score (LUSS), Charlson age-added comorbidity index (CACI), and surgical outcome risk tool (SORT) score of the indication for ICU. The hypothesis of our study is to show that real visual LUSS is superior to the screening test SORT, CACI, and the other score, ASA, for ICU indication determination. METHODS: The study enrolled 101 patients over 65 years of age who will have surgical procedures under elective conditions. De-mographic features, clinical parameters, ICU indications, ASA, LUSS, CACI, and SORTs of the patients were calculated prospectively and recorded. The effects of patients' ASA, LUSS, CACI, and SORT on determining the need for postoperative ICU admission were examined. RESULTS: The age of patients who needed post-operative ICU admission was significantly higher than those who did not need post-operative ICU admission (P<0.001). The groups did not show differences in terms of gender, body mass index, smoking, and type of anesthesia (P>0.05). ASA, LUSS, CACI, and SORT were significantly higher for patients who needed post-operative ICU admission (P<0.001). The proportion of patients who needed post-operative ICU admission was higher for patients with post-operative ICU indication (P<0.001). The number of consultations was significantly higher for patients who needed post-operative ICU admission (P<0.001). SORT was found to be the highest accuracy for predicting the need for post-operative ICU admission. CONCLUSION: It was detected that ASA, LUSS, CACI, and SORT are effective for the determination of the ICU indication in the pre-operative evaluation process of patients over the age of 65 who had elective surgery. However, the efficiency of SORT was found to be superior to the others.

[Establishment of a digital remote platform for respiratory support and intelligent early warning in intensive care units].

During the disease progression or treatment of critically ill patients with lung injury, the changes in respiratory mechanics are continuous and dynamic. Establishing a digital platform for respiratory support in the ICU, which enables the continuous recording, dynamic analysis, and real-time alerting of numerical and waveform data from mechanical ventilation, can help intensivists improve their understanding of "dynamic respiratory mechanics", improve respiratory therapy and patient outcomes, as well as reduce workload and increase work efficiency. The construction of a dedicated database for mechanical ventilation, based on ventilator waveforms provides essential data support for projects such as respiratory mechanics data algorithm models. This will facilitate the establishment of an auxiliary decision-making system, enable the realization of intelligent mechanical ventilation, and create a new era of dynamic respiratory mechanics.

Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit.

BACKGROUND: This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES: To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS: We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS: In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.

Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review.

BACKGROUND: Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base. METHODS: We conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map. RESULTS: We identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described. CONCLUSION: The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.

Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma.

BACKGROUND: The trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC). METHODS: All patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant. RESULTS: The study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay. CONCLUSION: Patients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.

Risk factors associated with prolonged intensive care unit stay following surgery for total anomalous pulmonary venous connection: a retrospective study.

BACKGROUND: Prolonged intensive care unit (ICU) stays consume medical resources and increase medical costs. This study identified risk factors associated with prolonged postoperative intensive care unit (ICU) stay in children with total anomalous pulmonary venous connection (TAPVC). METHODS: The medical records of 85 patients who underwent surgical repair of TAPVC were retrospectively analyzed. The patients were divided into prolonged-stay and standard-stay groups. The prolonged stay group included all patients who exceeded the 75th percentile of the ICU stay duration, and the standard stay group included all remaining patients. The effects of patient variables on ICU stay duration were investigated using univariate and logistic regression analyses. RESULTS: Patient median age was 41 (18-103) days, and median weight was 3.80 (3.30-5.35) kg.Postoperative duration of ICU stay was 11-68 days in the prolonged stay group (n = 23) and 2-10 days in the standard stay group (n = 62). Lower preoperative pulse oximetry saturation (SpO2), higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay. Preoperative SpO2 < 88.5%, highest plasma lactate value > 4.15 mmol/L, and postoperative mechanical ventilation duration was longer than 53.5 h, were associated with increased risk of prolonged ICU stay. Young age, low body weight, subcardiac type, need for vasoactive drug support, emergency surgery, long anesthesia time, low SpO2 after anesthesia induction, long cardiopulmonary bypass (CPB) and aortic clamp times, high lactate level, low temperature, large volume of ultrafiltration during CPB, large amounts of chest drainage, large red blood cells (RBCs) and plasma transfusion, and postoperative cardiac dysfunction may be associated with prolonged ICU stay. CONCLUSIONS: Lower preoperative SpO2, higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay in children with TAPVC. When SpO2 was lower than 88.5%, the highest plasma lactate value was more than 4.15 mmol/L, and the postoperative mechanical ventilator duration was longer than 53.5 h, the risk of prolonged ICU stay increased. Improved clinical management, including early diagnosis and timely surgical intervention to reduce hypoxia time and protect intraoperative cardiac function, may reduce ICU stay time.

Correlation between mortality and blood transfusion in patients with major surgery initially admitted to intensive care unit: a retrospective analysis.

PURPOSE: Transfusing red blood cells promptly corrects anemia and improves tissue oxygenation in around 40% of patients hospitalized in the intensive care unit (ICU) after major surgical operations. This study's goal is to investigate how blood transfusions affect the mortality rates of patients after major surgery who are hospitalized in the ICU. METHODS: Retrospective research was done on recently hospitalized patients who had major procedures in the ICU between October 2020 and February 2022 at the Huanggang Central Hospital of Yangtze University, China. The patients' prognoses at three months were used to classify them as either survivors or deceased. Patient demographic information, laboratory results, and blood transfusion histories were acquired, and the outcomes of the two groups were compared based on the differences. Univariate and multivariate logistic regression analyses were used to examine the prognosis of surgical disease patients first admitted to the ICU. The receiver operating characteristic (ROC) curve was used to evaluate the predictive power of each risk factor. The relationship between transfusion frequency, transfusion modality, and patient outcome was examined using Spearman's correlation analysis. RESULTS: Data from 384 patients was included in the research; of them, 214 (or 55.7%) died within three months of their first stay in the ICU. The death group had higher scores on the Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) than the survival group did (all P < 0.05); the death group also had lower scores on the Glasgow Coma Scale, systolic blood pressure, hemoglobin, platelet distribution width, and blood transfusion ratio. Multivariate logistic regression analysis revealed an odds ratio (OR) of 1.654 (1.281-1.989), a 95% confidence interval (CI) of 1.440 (1.207-1.701), and a P value of 0.05 for death in patients undergoing major surgery who were hospitalized to the intensive care unit (ICU). Areas under the ROC curve (AUC) of 0.836, 0.799, and 0.871, respectively, and 95% CIs of 0.796-0.875, 0.755-0.842, and 0.837-0.904, respectively, all P0.05, had significant predictive value for patients initially admitted to the ICU and for APACHE II score > = 12 points, SOFA score > = 6, and blood transfusion. When all three indicators were used jointly to predict a patient's prognosis after major surgery, the accuracy increased to 86.4% (sensitivity) and 100% (specificity). There was a negative correlation between the number of blood transfusions a patient had and their outcome (r = 0.605, P < 0.001) and death (r = 0.698, P < 0.001). CONCLUSION: A higher initial ICU APACHE II score, SOFA score, and a number of blood transfusions were associated with improved survival for patients undergoing major surgical operations. Patients' death rates have increased with the increase in the frequency and variety of blood transfusions.

Integration of functional capacity to medically necessary, time-sensitive scoring system: A prospective observational study.

OBJECTIVES: To evaluate 2 new modifications to medically necessary, time-sensitive (MeNTS) scoring systems integrating functional capacity assessment in estimating intensive care unit (ICU) requirements. METHODS: This prospective observational study included patients undergoing elective surgeries between July 2021 and January 2022. The MeNTS scores and our 2 modified scores: MeNTS-METs (integrated Duke activity status index [DASI] as metabolic equivalents [METs]) and MeNTS-DASI-5Q (integrated modified DASI [M-DASI] as 5 questions) were calculated. The patients' ICU requirements (group ICU+ and group ICU-), DASIs, patient-surgery-anesthesia characteristics, hospital stay lengths, rehospitalizations, postoperative complications, and mortality were recorded. RESULTS: This study analyzed 718 patients. The MeNTS, MeNTS-METs, and MeNTS-DASI-5Q scores were higher in group ICU+ than in group ICU- (p<0.001). Group ICU+ had longer operation durations and hospital stay lengths (p<0.001), lower DASI scores (p<0.001), and greater hospital readmissions, postoperative complications, and mortality (p<0.001). The MeNTS-METs and MeNTS-DASI-5Q scores better predicted ICU requirement with areas under the receiver operating characteristic curve (AUC) of 0.806 and 0.804, than the original MeNTS (AUC=0.782). CONCLUSION: The 5-questionnaire M-DASI is easy to calculate and, when added to a triage score, is as reliable as the original DASI for predicting postoperative ICU requirements.

Coinfection and superinfection in ICU critically ill patients with severe COVID-19 pneumonia and influenza pneumonia: are the pictures different?

Background: Similar to influenza, coinfections and superinfections are common and might result in poor prognosis. Our study aimed to compare the characteristics and risks of coinfections and superinfections in severe COVID-19 and influenza virus pneumonia. Methods: The data of patients with COVID-19 and influenza admitted to the intensive care unit (ICU) were retrospectively analyzed. The primary outcome was to describe the prevalence and pathogenic distribution of coinfections/ICU-acquired superinfections in the study population. The secondary outcome was to evaluate the independent risk factors for coinfections/ICU-acquired superinfections at ICU admission. Multivariate analysis of survivors and non-survivors was performed to investigate whether coinfections/ICU-acquired superinfections was an independent prognostic factor. Results: In the COVID-19 (n = 123) and influenza (n = 145) cohorts, the incidence of coinfections/ICU-acquired superinfections was 33.3%/43.9 and 35.2%/52.4%, respectively. The most common bacteria identified in coinfection cases were Enterococcus faecium, Pseudomonas aeruginosa, and Acinetobacter baumannii (COVID-19 cohort) and A. baumannii, P. aeruginosa, and Klebsiella pneumoniae (influenza cohort). A significant higher proportion of coinfection events was sustained by Aspergillus spp. [(22/123, 17.9% in COVID-19) and (18/145, 12.4% in influenza)]. The COVID-19 group had more cases of ICU-acquired A. baumannii, Corynebacterium striatum and K. pneumoniae. A. baumannii, P. aeruginosa, and K. pneumoniae were the three most prevalent pathogens in the influenza cases with ICU-acquired superinfections. Patients with APACHE II ≥18, CD8+ T cells ≤90/µL, and 50 < age ≤ 70 years were more susceptible to coinfections; while those with CD8+ T cells ≤90/µL, CRP ≥120 mg/L, IL-8 ≥ 20 pg./mL, blood glucose ≥10 mmol/L, hypertension, and smoking might had a higher risk of ICU-acquired superinfections in the COVID-19 group. ICU-acquired superinfection, corticosteroid administration for COVID-19 treatment before ICU admission, and SOFA score ≥ 7 were independent prognostic factors in patients with COVID-19. Conclusion: Patients with COVID-19 or influenza had a high incidence of coinfections and ICU-acquired superinfections. The represent agents of coinfection in ICU patients were different from those in the general ward. These high-risk patients should be closely monitored and empirically treated with effective antibiotics according to the pathogen.

[Sivelestat sodium for treatment of patients with COVID-19-associated acute respiratory distress syndrome in intensive care unit: a single-center retrospective cohort study].

OBJECTIVE: To investigate the effect of sivelestat sodium on survival, oxygenation index, and serum markers for infection in critically ill patients with COVID-19-associated acute respiratory distress syndrome (ARDS). METHODS: This retrospectively study was performed among the critically ill patients with COVID-19-associated ARDS admitted in the intensive care unit (ICU) at Nanfang Hospital, Southern Medical University. We collected the clinical data of the patients on the first day of ICU admission and on the day of discharge and laboratory tests results of interleukin-6 (IL-6), C-reactive protein (CRP) and procalcitonin (PCT) and oxygenation index on days 1, 3 and 7 following ICU admission. Propensity-score matching was used to match the patients receiving sivelestat sodium to those without the treatment. Cox proportional hazards model and linear regression analysis were used to assess the association of sivelestat sodium treatment with in-hospital mortality and the length of hospital stay. RESULTS: A total of 199 patients with COVID-19-associated ARDS patients were included for data analysis. After propensity-score matching PSM, 35 patients receiving sivelestat sodium were matched to 70 patients without the treatment. Treatment with of sivelestat sodium was not associated with the reduction of in- hospital mortality (P=0.36), prolonged ICU stay (P=0.39), hospital stay (P=0.68) or improved oxygenation index (P>0.05) of the patients. No significant difference was found in serum CRP or PCT levels between the patients with and without sivelestat sodium treatment, but a significant reduction in IL-6 level was found in sivelestat sodium group (P=0.016). CONCLUSION: Sivelestat sodium treatment is not correlated with the reduction of mortality or length of hospital stay, but is associated with reduced serum IL-6 level in patients with COVID-19-associated ARDS.

Improvements in cuirass ventilation for airway surgery: origins in Copenhagen on the 70th anniversary of the first intensive care unit.

The first modern intensive care unit was established in Copenhagen 70 yr ago. This cornerstone of anaesthesia was largely based on experience gained using positive pressure ventilation to save hundreds of patients during the polio epidemic in 1952. Ventilation approaches, monitoring techniques, and pharmacological innovations have developed to such an extent that cuirass ventilation, which proved inadequate during the polio epidemic, might now have novel applications for both anaesthesia and treatment of the critically ill.

Association between clinical and surgical variables with postoperative outcomes in patients treated for intestinal obstruction for non-malignant conditions: a cross-sectional study.

Intestinal obstruction is considered a frequent surgical pathology related to previous surgical procedures. Many different factors can lead to different outcomes when surgical management is needed. Therefore, we aim to describe the factors related to morbidity and mortality in surgical management of IO in a single-center experience. Retrospective observational study with a prospective database, in which we described patients who underwent surgical management due to intestinal obstruction between 2004 and 2015. Demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. 366 patients were included. Female were 54.6%. Mean age was 61.26. Laparoscopic approach was done in 21.8% and the conversion rate was 17.2%. Intestinal resection was performed in 37.9% of the cases. Postoperative complications were observed in 18.85%. Reintervention and mortality were 9.5% and 4.1% respectively. Laparoscopic approach shows lesser time of intestinal transit (mean 28.67 vs. mean 41.95 h), and restart of oral intake after surgery (mean 96.06 vs. mean 119.65) compared with open approach. Increased heart rate and intensive care unit length of stay were related with mortality (p 0.01 and 0.000 respectively). For morbidity, laparotomy and need and duration of ICU stay were related with any complication statistically significant (p 0.02, 0.008, 0.000 respectively). Patients with increased heart rate in the emergency room, decreased amount of intravenous fluids, need and higher length of stay in the intensive care unit, and delay in resuming oral intake after surgery appear to have poor outcomes. Laparoscopic approach seems to be a safe and feasible approach for intestinal obstruction in selected patients.

[Treatment of hemophagocytic lymphohistiocytosis in patients in the intensive care unit]. / Behandlung der hämophagozytischen Lymphohistiozytose bei Patienten auf der Intensivstation.

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by hyperferritinemia. A differentiation is made between hereditary and acquired forms. In contrast to children, almost all cases in adult patients consist of acquired secondary HLH. Infections, malignancies and autoimmune diseases are frequent triggers of secondary HLH. More recently, cases of HLH have also been described in association with immunotherapy, e.g., when using chimeric antigen receptor (CAR) T­cell treatment. In critically ill patients in the intensive care unit (ICU), sepsis represents the major differential diagnosis of HLH due to the frequently similar clinical presentation. Sometimes both sepsis and HLH are present at the same time. An early diagnosis and timely initiation of immunosuppressive treatment are essential for the further course and prognosis of HLH. Therefore, HLH should be considered as a possible diagnosis in critically ill patients with persistent fever and additional compatible symptoms (e.g., splenomegaly, neurological symptoms) or laboratory parameters (e.g., hyperferritinemia, cytopenia of two or three cell lines, increased transaminases). The diagnosis of HLH is made on the basis of the HLH-2004 criteria. The HScore can be used to estimate the probability of the presence of HLH. Corticosteroids given at high doses are the cornerstone of HLH treatment. Furthermore, immunoglobulins, etoposide, anakinra or ruxolitinib can complement treatment depending on the HLH trigger. The course of HLH depends on the timely initiation of treatment, the underlying trigger and the response to treatment. Despite progress in terms of diagnostics and targeted treatment, the prognosis of critically ill HLH patients is still poor.

Supine transfer test-induced changes in cardiac index predict fluid responsiveness in patients without intra-abdominal hypertension.

BACKGROUND: The reversible maneuver that mimics the fluid challenge is a widely used test for evaluating volume responsiveness. However, passive leg raising (PLR) does have certain limitations. The aim of the study is to determine whether the supine transfer test could predict fluid responsiveness in adult patients with acute circulatory failure who do not have intra-abdominal hypertension, by measuring changes in cardiac index (CI). METHODS: Single-center, prospective clinical study in a 25-bed surgery intensive care unit at the Fudan University Shanghai Cancer Center. Thirty-four patients who presented with acute circulatory failure and were scheduled for fluid therapy. Every patient underwent supine transfer test and fluid challenge with 500 mL saline for 15-30 min. There were four sequential steps in the protocol: (1) baseline-1: a semi-recumbent position with the head of the bed raised to 45°; (2) supine transfer test: patients were transferred from the 45° semi-recumbent position to the strict supine position; (3) baseline-2: return to baseline-1 position; and (4) fluid challenge: administration of 500 mL saline for 15-30 min. Hemodynamic parameters were recorded at each step with arterial pulse contour analysis (ProAQT/Pulsioflex). A fluid responder was defined as an increase in CI ≥ 15% after fluid challenge. The receiver operating characteristic curve and gray zone were defined for CI. RESULTS: Seventeen patients were fluid challenge. The r value of the linear correlations was 0.73 between the supine transfer test- and fluid challenge-induced relative CI changes. The relative changes in CI induced by supine transfer in predicting fluid responsiveness had an area under the receiver operating characteristic curve of 0.88 (95% confidence interval 0.72-0.97) and predicted a fluid responder with 76.5% (95% confidence interval 50.1-93.2) sensitivity and 88.2% (95% confidence interval 63.6-98.5) specificity, at a best threshold of 5.5%. Nineteen (55%) patients were in the gray zone (CI ranging from -3 and 8 L/min/m2). CONCLUSION: The supine transfer test can potentially assist in detecting fluid responsiveness in patients with acute circulatory failure without intra-abdominal hypertension. Nevertheless, the small threshold and the 55% gray zone were noteworthy limitation. TRIAL REGISTRATION: Predicting fluid responsiveness with supine transition test (ChiCTR2200058264). Registered 2022-04-04 and last refreshed on 2023-03-26, https://www.chictr.org.cn/showproj.html?proj=166175 .

[With a tumor diagnosis in the intensive care unit]. / Mit einer Tumordiagnose auf der Intensivstation.

Tumor patients nowadays show significantly improved survival rates due to advancements in modern intensive care medicine, particularly in the case of organ failure. The previous reluctance towards implementing intensive medical care measures in patients with a tumorous disease is no longer justified. For successful intensive care treatment, the timing and the mode of admission along with the specific intensive care measures and underlying organ dysfunction(s) are crucial factors for the prognosis. To ensure appropriate treatment in clinical practice and to balance between overly restrictive admission criteria and overtreatment, a triage system could be beneficial. This would consider the prognosis of the underlying malignant disease, the performance status of the patient, available treatment options and a dynamic assessment of the course of the intensive medical care. Long-term results of tumor patients show that around 80% of tumor patients who have been in the intensive care unit present physical and mental health similar to those who were never admitted. Even the majority of patients who needed ongoing cancer treatment due to tumor stage did not show any differences in treatment intensity and their remission status after 6 months. A successful intensive care medicine, the individualized definition of aims, as well as adjustment of the treatment goals, require close collaboration between hematologists, oncologists, and intensive care physicians.

Evaluation of factors associated with survival in allogeneic stem cell-transplanted patients admitted to the intensive care unit (ICU).

INTRODUCTION: There are conflicting results concerning the outcome of patients after an allogeneic hematopoietic stem cell transplantation (allo-HSCT) who required treatment in the intensive care unit (ICU). The aim of this study was to evaluate the outcome and prognostic parameters in terms of patient survival after allo-HSCT and admission to the ICU within the first 30 days after transplantation. METHODS: Patients after allo-HSCT, who were ≥18 years and admitted to the ICU after the initiation of conditioning therapy and within the first 30 days after allo-HSCT at the University Hospital of Bonn between January 2017 and April 2021, were analysed retrospectively. Baseline data, laboratory parameters, established scoring systems, vital parameters, and outcome were collected. RESULTS: 44 patients (median age of 63 years) were analysed. The 90-day survival rate was 50% (N = 22) and the 1-year survival rate was 27% (N = 12). The 90-day and 1-year survival rates of patients who required MV were 38% (N = 13) and 18% (N = 6). There was a significant correlation between increased mortality and an APACHE-Score ≥20 (p = 0.03), a SAPS-II-Score ≥60 (p = 0.04) and a SOFA-Score ≥9 (p = 0.03). Invasive mechanical ventilation (p = 0.05) and vasopressor support (p = 0.03) showed a negative correlation with the outcome. CONCLUSION: This study found several parameters (APACHE-II-Score, SAPS-II-Score, SOFA-Score, MV and vasopressor support) associated with increased mortality after allo-HSCT and admission to the ICU. The outcome of allo-HSCT patients admitted to the ICU is not as poor as previously reported. Even older patients under long-term ventilation may benefit from intensive care therapy.

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

BACKGROUND: Independent second-checking of medication is part of everyday practice across many parts of the NHS. A robust, independent second check is built into medication administration protocols to reduce the risk of drug errors affecting patients. AIM: This work aims to determine the barriers and facilitators regarding a robust independent second check of medication before administration to patients within adult critical care. METHOD: Nurses in adult critical care were invited to participate in focus groups. They were asked to discuss factors that they felt enabled or prevented a robust second check of medication. Thematic analysis was undertaken by three critical care pharmacists. FINDINGS: The major themes identified as barriers to an independent second check were: geography of the critical care unit; IT; routine; complex process; and personnel. CONCLUSION: There are complex barriers to undertaking a robust second check and addressing some of these could improve patient safety.