Advancing insights in critical COVID-19: unraveling lymphopenia through propensity score matching - Findings from the Multicenter LYMPH-COVID Study.

OBJECTIVE: To elucidate the impact of lymphopenia on critical COVID-19 patient outcomes. METHODS: We conducted a multicenter prospective cohort study across five hospitals in Portugal and Brazil from 2020 to 2021. The study included adult patients admitted to the intensive care unit with SARS-CoV-2 pneumonia. Patients were categorized into two groups based on their lymphocyte counts within 48 hours of intensive care unit admission: the Lymphopenia Group (lymphocyte serum count < 1 × 109/L) and the Nonlymphopenia Group. Multivariate logistic regression, propensity score matching, Kaplan‒Meier survival curve analysis and Cox proportional hazards regression analysis were used. RESULTS: A total of 912 patients were enrolled, with 191 (20.9%) in the Nonlymphopenia Group and 721 (79.1%) in the Lymphopenia Group. Lymphopenia patients displayed significantly elevated disease severity indices, including Sequential Organ Failure Assessment and Simplified Acute Physiology Score 3 scores, at intensive care unit admission (p = 0.001 and p < 0.001, respectively). Additionally, they presented heightened requirements for vasopressor support (p = 0.045) and prolonged intensive care unit and in-hospital stays (both p < 0.001). Multivariate logistic regression analysis after propensity score matching revealed a significant contribution of lymphopenia to mortality, with an odds ratio of 1,621 (95%CI: 1,275 - 2,048; p < 0.001). Interaction models revealed an increase of 8% in mortality for each decade of longevity in patients with concomitant lymphopenia. In the subanalysis utilizing three-group stratification, the Severe Lymphopenia Group had the highest mortality rate, not only in direct comparisons but also in Kaplan‒Meier survival analysis (log-rank test p = 0.0048). CONCLUSION: Lymphopenia in COVID-19 patients is associated with increased disease severity and an increased risk of mortality, underscoring the need for prompt support for critically ill high-risk patients. These findings offer important insights into improving patient care strategies for COVID-19 patients.

Daily Chlorhexidine Bath for Health Care Associated Infection Prevention (CLEAN-IT): protocol for a multicenter cluster randomized crossover open-label trial.

BACKGROUND: Critically ill patients are at increased risk of health care-associated infections due to various devices (central line-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which pose a significant threat to this population. Among several strategies, daily bathing with chlorhexidine digluconate, a water-soluble antiseptic, has been studied as an intervention to decrease the incidence of health care-associated infections in the intensive care unit; however, its ability to reduce all health care-associated infections due to various devices is unclear. We designed the Daily Chlorhexidine Bath for Health Care Associated Infection Prevention (CLEAN-IT) trial to assess whether daily chlorhexidine digluconate bathing reduces the incidence of health care-associated infections in critically ill patients compared with soap and water bathing. METHODS: The CLEAN-IT trial is a multicenter, open-label, cluster randomized crossover clinical trial. All adult patients admitted to the participating intensive care units will be included in the trial. Each cluster (intensive care unit) will be randomized to perform either initial chlorhexidine digluconate bathing or soap and water bathing with crossover for a period of 3 to 6 months, depending on the time of each center's entrance to the study, with a 1-month washout period between chlorhexidine digluconate bathing and soap and water bathing transitions. The primary outcome is the incidence of health care-associated infections due to devices. The secondary outcomes are the incidence of each specific health care-associated infection, rates of microbiological cultures positive for multidrug-resistant pathogens, antibiotic use, intensive care unit and hospital length of stay, and intensive care unit and hospital mortality. CONCLUSION: The CLEAN-IT trial will be used to study feasible and affordable interventions that might reduce the health care-associated infection burden in critically ill patients.

Pharmacokinetic Research in Pediatric Extracorporeal Therapies: Current State and Future Directions.

Extracorporeal life support (ECLS), including extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), are life-saving therapies for critically ill children. Despite this, these modalities carry frustratingly high mortality rates. One driver of mortality may be altered drug disposition due to a combination of underlying illness, patient-circuit interactions, and drug-circuit interactions. Children receiving ECMO and/or CRRT routinely receive 20 or more drugs, and data supporting optimal dosing is lacking for most of these medications. The Pediatric Paracorporeal and Extracorporeal Therapies Summit (PPETS) gathered an international group of experts in the fields of ECMO, CRRT, and other ECLS modalities to discuss the current state of these therapies, disseminate innovative support strategies, share clinical experiences, and foster future collaborations. Here, we summarize the conclusions of PPETS and put forward a pathway to optimize pharmacokinetic (PK) research in this population. We must prioritize specific medications for in-depth study to improve drug use in ECLS and patient outcomes. Based on frequency of use, potential for adverse outcomes if dosed inappropriately, and lack of existing PK data, a list of high priority drugs was compiled for future research. Researchers must additionally reconsider study designs, emphasizing pooling of resources through multi-center studies and the use of innovative PK modeling techniques. Finally, the integration of validated PK models into clinical practice must be streamlined to deliver optimal medication use at the bedside. Focusing on the proposed list of highlighted medications and key methodological considerations will maximize the impact of future research.

The prognostic role of Neurologic Pupil Index in COVID-19 patients: a retrospective study.

BACKGROUND: Neurological complications have been observed in approximately 30% of hospitalized COVID-19 patients. The aim of this study was to evaluate whether early assessment of the Neurological Pupil Index (NPiTM) derived from an automated pupillometry could predict mortality in critically ill COVID-19 patients. METHODS: Retrospective cohort study of adult critically ill COVID-19 patients admitted to the intensive care unit of a University Hospital; patients without NPi measurement were excluded. The worst NPi (i.e. lowest value from one eye) was collected daily and then computed over the first five days of assessment. Mortality was assessed at hospital discharge. The secondary endpoint involved assessing differences in neurological assessments between patients who developed neurological complications and those who did not. RESULTS: A total of 217 patients were included over the study period (median age 61 [50-68] years), 70% were males. A total of 97 patients (45%) died during the hospital stay. Among all patients, 35 (16%) experienced neurological complications. Non-survivors showed significantly a lower overall NPi (3.0 [2.0-4.1] vs. 3.4 [2.7-4.2]; P=0.04) than survivors. At multivariate logistic regression NPi was not significantly associated with in-hospital mortality. Moreover, no differences in different NPi measurements were observed between patients with and without neurological complications. CONCLUSIONS: In this study, NPi values were not independent predictor of mortality and neurological complications in critically ill COVID-19 patients.

Lower gastrointestinal tract dysbiosis in persistent critical illness: a systematic review.

Introduction. The human lower gastrointestinal tract microbiome is complex, dynamic and prone to disruption occurring during critical illness.Hypothesis or gap statement. The characteristics of lower gastrointestinal tract microbiome disruption and its association with clinical outcomes in patients with prolonged intensive care stay remain uncertain.Aim. To systematically review studies describing lower gastrointestinal tract molecular sequencing in patients with prolonged intensive care stay and explore associations with clinical outcomes.Methodology. This systematic review was prospectively registered and follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. OVID MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials databases were searched for eligible studies describing adults and/or children who underwent molecular sequencing of stool or rectal samples taken on or after 10 days of intensive care.Results. There were 13 studies with 177 patients included. The overall certainty of evidence was low, and no studies reported mortality. Reduced alpha diversity was observed in nine out of nine studies but was not associated with clinical outcomes in four out of four studies. Longitudinal alpha diversity decreased in five out of six studies, and inter-individual beta diversity increased in five out of five studies. After approximately one week of intensive care unit admission, rapid fluctuations in dominant taxa stabilized with trajectories of either recovery or deterioration in five studies. Pathogenic enrichment and commensal depletion were reported in all 13 studies and associated with clinical outcomes in two studies.Conclusion. Lower gastrointestinal tract microbiome disruption is highly prevalent and has consistent characteristics in patients with prolonged intensive care stay. Amongst reported metrics, only relative taxon abundance was associated with clinical outcomes.

Association between hair cortisol concentration and acute stress symptoms in family members of critically ill patients: a cross-sectional study.

OBJECTIVE: The aim of this study was to investigate whether there is an association between hair cortisol concentrations and acute stress symptoms in family members of critically ill patients. METHODS: A cross-sectional study was conducted in an adult intensive care unit of a tertiary hospital in Porto Alegre, Brazil, from August 2021 to February 2022. Family members of intensive care unit patients admitted for more than 10 days were approached for enrollment. We collected sociodemographic data and assessed resilience, religiosity, and symptoms of acute stress among family members. Samples of family members' hair were collected shortly after the interview to measure the hair cortisol concentration. RESULTS: A total of 110 family members were included in this study. Eighty-eight (80.0%) family members presented with symptoms of acute stress. The median hair cortisol concentration was 2.37pg/mg (1.16 - 5.06pg/mg). There was no significant difference in hair cortisol concentration between family members with and without acute stress symptoms (p = 0.419). According to the multivariate analysis, only the fact that the patient was alert at the time of the family member's interview was significantly associated with the prevalence of acute stress symptoms in the family member. CONCLUSION: We did not find an association between the hair cortisol concentration of family members in hair segments in the months prior to admission to the intensive care unit and the occurrence of acute stress symptoms.

Application of physiological network mapping in the prediction of survival in critically ill patients with acute liver failure.

Reduced functional connectivity of physiological systems is associated with poor prognosis in critically ill patients. However, physiological network analysis is not commonly used in clinical practice and awaits quantitative evidence. Acute liver failure (ALF) is associated with multiorgan failure and mortality. Prognostication in ALF is highly important for clinical management but is currently dependent on models that do not consider the interaction between organ systems. This study aims to examine whether physiological network analysis can predict survival in patients with ALF. Data from 640 adult patients admitted to the ICU for paracetamol-induced ALF were extracted from the MIMIC-III database. Parenclitic network analysis was performed on the routine biomarkers using 28-day survivors as reference population and network clusters were identified for survivors and non-survivors using k-clique percolation method. Network analysis showed that liver function biomarkers were more clustered in survivors than in non-survivors. Arterial pH was also found to cluster with serum creatinine and bicarbonate in survivors compared with non-survivors, where it clustered with respiratory nodes indicating physiologically distinctive compensatory mechanism. Deviation along the pH-bicarbonate and pH-creatinine axes significantly predicts mortality independent of current prognostic indicators. These results demonstrate that network analysis can provide pathophysiologic insight and predict survival in critically ill patients with ALF.

[Critical patients in general hospitalization wards: a descriptive analysis of factors inherent to the transfer to a closed unit] / El paciente crítico en sala de internación general.

Introduction: Unplanned transfers from the General Ward to Critical Care Units occur due to a deterioration in the patient's clinical status. They are of great interest because of their negative impact, associated with longer hospital stays and higher mortality. Objectives: To report the frequency at which these transfers occur, characteristics of these patients and causes of the transfer. Identify shortcomings in the care process that may allow improvement strategies. Methodology: cross-sectional study. Cases were considered those who, during the first 24 hours of hospitalization in the General Ward, required transfer to the ICU between January - December 2022 in a high-complexity hospital in Buenos Aires. Results: Of 8317 admissions, 124 were transferred to the ICU, with a rate of 14 per 1000 and an average of 70 years. The most frequent comorbidities were high blood pressure, heart failure, cancer and overweight-obesity. The main causes of hospitalization were respiratory and gastrointestinal symptoms. 67% had non-alarming results in the NEWS score prior to transfer to the ICU. The most frequent causes were respiratory failure, hemodynamic instability and requirement for monitoring. Average hospital stay was 10 days and in-hospital mortality was 26%. Conclusions: Respiratory decompensation in elderly male patients was the most common cause of transfer to a Closed Unit. One of the shortcomings of the care process seems to be the NEWS score, where in 67% of cases it did not warn about the high requirement of patient monitoring.

Introducción: Los traslados no programados, de Sala General a Unidades de Cuidados Críticos, se producen debido a un deterioro en el estado clínico del paciente. Son de gran interés debido a su impacto negativo, asociado con estadías hospitalarias más largas y mayor mortalidad. Objetivos: Reportar la frecuencia en la que ocurren estos traslados, las características de estos pacientes y las causas del pase. Identificar falencias del proceso asistencial que permitan generar estrategias de mejora. Metodología: estudio de corte transversal. Se consideraron casos quienes durante las primeras 24 horas de internación en Sala General requirieron traslado a UCI entre Enero - Diciembre 2022 en un hospital de alta complejidad en Buenos Aires. Resultados: De 8317 ingresos 124 fueron trasladados a UCI, con una tasa de 14 por 1000 y una media de 70 años. Las comorbilidades más frecuentes fueron hipertensión arterial, insuficiencia cardíaca, cáncer y sobrepeso-obesidad. Las principales causas de internación fueron cuadros respiratorios y gastrointestinales. Un 67% tuvieron resultados no alarmantes en el score NEWS previo al pase a UCI. Las causas más frecuentes fueron insuficiencia respiratoria, inestabilidad hemodinámica y requerimiento de monitoreo. La estadía hospitalaria media fue de 10 días y la mortalidad intrahospitalaria 26%. Conclusión: Los descompensación respiratoria en pacientes añosos de sexo masculino fue la causa más común de pase a Unidad Cerrada.Una de las falencias del proceso asistencial pareciera ser el score NEWS, donde en un 67% de los casos no alertó sobre el alto requerimiento de monitoreo del paciente.

Impact of sleep disturbances on outcomes in intensive care units.

BACKGROUND: Sleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients. OBJECTIVES: We hypothesized that sleep disturbances may be associated with poor outcomes in ICUs. METHODS: Post-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes. RESULTS: Whereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03). CONCLUSION: Complete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

The supplementation of L-carnitine in critically ill patients with sepsis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: The evidence suggests that L-carnitine may reduce mortality in critically ill patients with sepsis. However, the conclusions of different studies are inconsistent. A meta-analysis was conducted to evaluate the effect of L-carnitine compliance on mortality in patients with sepsis. METHODS: A search of the PubMed, Embase, and Cochrane Library databases was conducted on 1 June 2024. The risk ratio (RR) was pooled with a 95% confidence interval (CI) for dichotomous data. The publications were subjected to a review in accordance with the guidelines set forth in the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). This study has been registered with INPLASY (number INPLASY202460086). RESULTS: A total of 356 patients were included in four randomized controlled trials. The results indicated that L-carnitine supplementation was not associated with 28-day mortality in sepsis patients (RR: 0.65; 95% CI 0.33-1.28; I2 = 70%; P = 0.21). And there was no significant effect on 12-month mortality (RR: 0.72; 95% CI 0.47-1.11; I2 = 0%; P = 0.14) compared to placebo. CONCLUSIONS: The use of L-carnitine was not found to be significantly correlated with 28-day or 12-month mortality in patients with sepsis.

A narrative review on antimicrobial dosing in adult critically ill patients on extracorporeal membrane oxygenation.

The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.

Elevated Triglyceride-Glucose (TyG) Index Predicts Poor Clinical Outcomes in Critically Ill AECOPD Patients: A Retrospective Study.

Purpose: The triglyceride-glucose (TyG) index is a surrogate biomarker of insulin resistance which has been widely used in intensive care unit (ICU) to predict prognosis. However, its role in critically ill acute exacerbation of COPD (AECOPD) patients remains largely unknown. Material and methods: A total of 645 AECOPD patients were induced in this retrospective cohort study, which extracted data from the eICU Collaborative Research Database (eICU-CRD). The TyG index was calculated as Ln (fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2). The primary endpoint includes in-hospital mortality and ICU mortality. The secondary endpoint was sepsis, acute kidney injury (AKI), and acute respiratory failure (ARF). Results: Multivariable Cox regression analysis revealed that the TyG index was independently associated with an increased risk of in-hospital mortality (hazard ratio, HR: 1.45, 95% CI: 1.04-2.01, P = 0.028) and ICU mortality (HR: 2.13, 95% CI: 1.28-3.54, P = 0.004). Moreover, the TyG index was independently associated with an increased risk of sepsis (odds ratio, OR: 1.54, 95% CI: 1.24-1.93, P < 0.001), AKI (OR: 1.57, 95% CI: 1.26-2.02, P < 0.001) and ARF (OR: 1.50, 95% CI: 1.20-1.87, P < 0.001). Kaplan-Meier survival analysis revealed that higher TyG indexes were also related to increased in-hospital mortality and ICU mortality. In addition, the restricted cubic splines regression model demonstrated that the in-hospital mortality and ICU mortality increased linearly with increasing TyG index (P for non-linearity = 0.897, P for non-linearity = 0.897, respectively). Conclusion: Elevated TyG index was independently associated with an increased risk of poor clinical outcomes in critically ill AECOPD patients. A prospective study to define TyG as a biomarker for prognosis prediction in critically ill AECOPD patients is warranted.

Nucleated red blood cell distribution in critically ill patients with acute pancreatitis: a retrospective cohort study.

OBJECTIVES: This study examined the potential association between nucleated red blood cell (NRBC) levels and mortality in critically ill patients with acute pancreatitis (AP) in the intensive care unit, due to limited existing research on this correlation. METHODS: This retrospective cohort study utilized data from the MIMIC-IV v2.0 and MIMIC-III v1.4 databases to investigate the potential relationship between NRBC levels and patient outcomes. The study employed restricted cubic splines (RCS) regression analysis to explore non-linear associations. The impact of NRBC on prognosis was assessed using a generalized linear model (GLM) with a logit link, adjusted for potential confounders. Furthermore, four machine learning models, including Gradient Boosting Classifier (GBC), Random Forest, Gaussian Naive Bayes, and Decision Tree Classifier model, were constructed using NRBC data to generate risk scores and evaluate the potential of NRBC in predicting patient prognosis. RESULTS: A total of 354 patients were enrolled in the study, with 162 (45.8%) individuals aged 60 years or older and 204 (57.6%) males. RCS regression analysis demonstrated a non-linear relationship between NRBC levels and 90-day mortality. Receiver Operating Characteristic (ROC) analysis identified a 1.7% NRBC cutoff to distinguish survivor from non-survivor patients for 90-day mortality, yielding an Area Under the Curve (AUC) of 0.599, with a sensitivity of 0.475 and specificity of 0.711. Elevated NRBC levels were associated with increased risks of 90-day mortality in both unadjusted and adjusted models (all Odds Ratios > 1, P < 0.05). Assessment of various machine learning models with nine variables, including NRBC, Sex, Age, Simplified Acute Physiology Score II, Acute Physiology Score III, Congestive Heart Failure, Vasopressin, Norepinephrine, and Mean Arterial Pressure, indicated that the GBC model displayed the highest predictive accuracy for 90-day mortality, with an AUC of 0.982 (95% CI 0.970-0.994). Post hoc power analysis showed a statistical power of 0.880 in the study. CONCLUSIONS: Elevated levels of NRBC are linked to an increased mortality risk in critically ill patients with AP, suggesting its potential for predicting mortality.

Presence of cholestasis and its impact on survival in SARS-CoV-2 associated acute respiratory distress syndrome.

Data on cholestasis and biliary injury in patients with COVID-19 are scarce. The primary aim of this study was to evaluate the prevalence of cholestasis and factors associated with its development and outcome in critically ill patients with COVID-19 associated acute respiratory distress syndrome (ARDS). In this retrospective exploratory study, COVID-19 patients with ARDS admitted to an intensive care unit (ICU) at the Medical University of Vienna were evaluated for the development of cholestasis defined as an alkaline phosphatase level of 1.67x upper limit of normal for at least three consecutive days. Simple and multiple logistic regression analysis was used to evaluate parameters associated with development of cholestasis and survival. Of 225 included patients 119 (53%) developed cholestasis during ICU stay. Patients with cholestasis had higher peak levels of alkaline phosphatase, gamma-glutamyl transferase, bilirubin and inflammation parameters. Factors independently associated with cholestasis were extracorporeal membrane oxygenation support, ketamine use, high levels of inflammation parameters and disease severity. Presence of cholestasis and peak ALP levels were independently associated with worse ICU and 6-month survival. Development of cholestasis is a common complication in critically ill COVID-19 patients and represents a negative prognostic marker for survival. It is associated with disease severity and specific treatment modalities of intensive care.

Short- and long-term outcomes in critically ill patients with primary glomerular disease: a case‒control study.

INTRODUCTION: Glomerular diseases, encompassing primary and secondary forms, pose significant morbidity and mortality risks. Despite their impact, little is known about critically ill patients with primary glomerulopathy admitted to the intensive care unit (ICU). METHODS: We conducted a case‒control study of patients with primary glomerulopathy using the Medical Information Mart for Intensive Care IV database. Demographic, clinical, and outcome data were collected. Logistic regression and mediation analysis were performed to identify predictors of hospital and long-term mortality. RESULTS: Among 50,920 patients, 307 with primary glomerulopathy were included. Infectious and cardiovascular-related causes were the main reasons for ICU admission, with sepsis being diagnosed in more than half of the patients during their ICU stay. The hospital mortality rate was similar to that of the control group, with a long-term mortality rate of 29.0% three years post-ICU discharge. Reduced urine output and serum albumin were identified as independent predictors of hospital mortality, while serum albumin and the Charlson comorbidity index were significantly associated with long-term mortality. Notably, although acute kidney injury was frequent, it was not significantly associated with mortality. Additionally, reduced urine output mediates nearly 25% of the association between serum albumin and hospital mortality. CONCLUSION: Critically ill patients with primary glomerulopathy exhibit unique characteristics and outcomes. Although hospital mortality was comparable to that of the control group, long-term mortality remained high. The serum albumin concentration and Charlson Comorbidity Index score emerged as robust predictors of long-term mortality, highlighting the importance of comprehensive risk assessment in this population. The lack of an association between acute kidney injury and mortality suggests the need for further research to understand the complex interplay of factors influencing outcomes in this patient population.

Impact of mechanical power on ICU mortality in ventilated critically ill patients: a retrospective study with continuous real-life data.

BACKGROUND: Over the past decade, numerous studies on potential factors contributing to ventilation-induced lung injury have been carried out. Mechanical power has been pointed out as the parameter that encloses all ventilation-induced lung injury-contributing factors. However, studies conducted to date provide data regarding mechanical power during the early hours of mechanical ventilation that may not accurately reflect the impact of power throughout the period of mechanical ventilatory support on intensive care unit mortality. METHODS: Retrospective observational study conducted at a single center in Spain. Patients admitted to the intensive care unit, > o = 18 years of age, and ventilated for over 24 h were included. We extracted the mechanical power values throughout the entire mechanical ventilation in controlled modes period from the clinical information system every 2 min. First, we calculate the cutoff-point for mechanical power beyond which there was a greater change in the probability of death. After, the sum of time values above the safe cut-off point was calculated to obtain the value in hours. We analyzed if the number of hours the patient was under ventilation with a mechanical power above the safe threshold was associated with intensive care unit mortality, invasive mechanical ventilation days, and intensive care unit length of stay. We repeated the analysis in different subgroups based on the degree of hypoxemia and in patients with SARS CoV-2 pneumonia. RESULTS: The cut-off point of mechanical power at with there is a higher increase in intensive care unit mortality was 18 J/min. The greater the number of hours patients were under mechanical power > 18 J/min the higher the intensive care unit mortality in all the study population, in patients with SARS CoV-2 pneumonia and in mild to moderate hypoxemic respiratory failure. The risk of death in the intensive care unit increases 0.1% for each hour with mechanical power exceeding 18 J/min. The number of hours with mechanical power > 18 J/min also affected the days of invasive mechanical ventilation and intensive care unit length of stay. CONCLUSIONS: The number of hours with mechanical power > 18 J/min is associated with mortality in the intensive care unit in critically ill patients. Continuous monitoring of mechanical power in controlled modes using an automated clinical information system could alert the clinician to this risk.

Candidemia Following Severe COVID-19 in Hospitalised and Critical Ill Patients: A Systematic Review and Meta-Analysis.

RATIONALE: The epidemiology and clinical impact of COVID-19-associated candidemia (CAC) remained uncertain, leaving gaps in understanding its prevalence, risk factors and outcomes. METHODS: A systematic review and meta-analysis were conducted by searching PubMed, Embase and Scopus for reports of CAC prevalence, risk factors and clinical outcomes up to June 18, 2024. The generalised linear mixed model was employed to determine the prevalence and 95% confidence intervals (CIs). The risk factors and clinical outcomes were compared between patients with and without CAC using the inverse variance method. RESULTS: From 81 studies encompassing 29 countries and involving 351,268 patients, the global prevalence of CAC was 4.33% (95% Cl, 3.16%-5.90%) in intensive care unit (ICU) patients. In ICUs, the pooled prevalence of CAC in high-income countries was significantly higher than that of lower-middle-income countries (5.99% [95% Cl, 4.24%-8.40%] vs. 2.23% [95% Cl, 1.06%-4.61%], p = 0.02). Resistant Candida species, including C. auris, C. glabrata (Nakaseomyces glabratus) and C. krusei (Pichia kudriavzveii), constituted 2% of ICU cases. The mortality rate for CAC was 68.40% (95% Cl, 61.86%-74.28%) among ICU patients. Several risk factors were associated with CAC, including antibiotic use, central venous catheter placement, dialysis, mechanical ventilation, tocilizumab, extracorporeal membrane oxygenation and total parenteral nutrition. Notably, the pooled odds ratio of tocilizumab was 2.59 (95% CI, 1.44-4.65). CONCLUSIONS: The prevalence of CAC is substantial in the ICU setting, particularly in high-income countries. Several risk factors associated with CAC were identified, including several that are modifiable, offering the opportunity to mitigate the risk of CAC.

[Therapeutic effects of high monounsaturated fatty acid and low carbohydrate formula on blood glucose levels and diarrhea in critically ill neurological patients].

OBJECTIVE: To investigate the effects of using a high monounsaturated fatty acid (MUFA) and low carbohydrate formula on blood glucose levels and diarrhea treatment effects in critically ill neurological patients. METHODS: A self-controlled before-and-after study design was employed, with 13 patients admitted to the neurology intensive care unit (ICU) of the First Affiliated Hospital of Sun Yat-sen University from November to December 2023, who were treated with a high MUFA and low carbohydrate formula [Glucerna enteral nutrition (EN) preparation]. Changes in blood glucose parameters within 7 days before and after the use of Glucerna EN preparation were analyzed, including standard deviation (SD) of blood glucose, mean blood glucose (MG), median blood glucose, mean amplitude of glycemic excursions (MAGE), largest amplitude of glycemic excursions (LAGE), coefficient of variation (CV) of blood glucose, the incidence of hyperglycemia (> 7.8 mmol/L) and severe hyperglycemia (> 13.9 mmol/L), and daily insulin dose. Changes in total protein (TP), albumin (ALB), hemoglobin (Hb), C-reactive protein (CRP), and white blood cell count (WBC) were observed before and after intervention. Improvement in diarrhea symptoms, Hart diarrhea score, Bristol Stool classification score, and incontinence dermatitis classification were also analyzed before and after the use of Glucerna EN preparation. RESULTS: A total of 13 critically ill neurological patients were enrolled, among whom 9 patients had a history of hyperglycemia and 8 patients had diarrhea symptoms. After intervention with Glucerna, the patients' SD of blood glucose, MG, median blood glucose, MAGE, LAGE, CV of blood glucose, incidence of hyperglycemia, incidence of severe hyperglycemia, and daily insulin dose were all lower than those before the intervention [SD of blood glucose (mmol/L): 1.83±1.11 vs. 2.10±1.13, MG (mmol/L): 8.87±2.03 vs. 9.75±1.37, median blood glucose (mmol/L): 9.12±1.67 vs. 10.17±0.48, MAGE (mmol/L): 0.66±0.31 vs. 0.78±0.32, LAGE (mmol/L): 4.95±3.64 vs. 5.58±3.10, CV of blood glucose: 16.00% (11.00%, 28.50%) vs. 18.00% (12.50%, 27.50%), hyperglycemia incidence: 47.31% vs. 74.66%, severe hyperglycemia incidence: 6.08% vs. 6.71%, daily insulin dose (U): 5.25 (0.00, 32.59) vs. 20.76 (0.00, 66.88)], with a significant decrease in daily insulin dose after the intervention (P < 0.05); TP, ALB, Hb, CRP and WBC showed no significant changes before and after the intervention with Glucerna EN preparation. The improvement time of diarrhea symptoms after intervention was (3.50±1.41) days, and the Hart diarrhea score on the seventh day after intervention (4.88±3.48 vs. 10.00±3.38) and the Bristol Stool classification score on the third and seventh days after intervention (5.87±0.35, 5.50±0.53 vs. 6.50±0.53) were significantly lower than before the intervention (all P < 0.05). Before the intervention with Glucerna EN preparation, the classification of incontinence dermatitis was mainly classified as Grade 2 severity (71.43%); after the intervention, it significantly improved by the seventh day, with Grade 1 being the main classification (57.14%). CONCLUSIONS: The high MUFA and low carbohydrate formula has a positive effect on blood glucose control and diarrhea treatment in critically ill neurological patients.