Central venous oxygen saturation changes as a reliable predictor of the change of CI in septic shock: To explore potential influencing factors.

PURPOSE: Assessing fluid responsiveness relying on central venous oxygen saturation (ScvO2) yields varied outcomes across several studies. This study aimed to determine the ability of the change in ScvO2 (ΔScvO2) to detect fluid responsiveness in ventilated septic shock patients and potential influencing factors. METHODS: In this prospective, single-center study, all patients conducted from February 2023 to January 2024 received fluid challenge. Oxygen consumption was measured by indirect calorimetry, and fluid responsiveness was defined as an increase of cardiac index (CI) ≥ 10% measured by transthoracic echocardiography. Multivariate linear regression analysis was conducted to evaluate the impact of oxygen consumption, arterial oxygen saturation, CI, and hemoglobin on ScvO2 and its change before and after fluid challenge. RESULTS: Among 49 patients (31 men, aged (59 ± 18) years), 27 were responders. The patients had an acute physiology and chronic health evaluation II score of 24 ± 8, a sequential organ failure assessment score of 11 ± 4, and a blood lactate level of (3.2 ± 3.1) mmol/L at enrollment. After the fluid challenge, the ΔScvO2 (mmHg) in the responders was greater than that in the non-responders (4 ± 6 vs. 1 ± 3, p = 0.019). Multivariate linear regression analysis suggested that CI was the only independent influencing factor of ScvO2, with R2 = 0.063, p = 0.008. After the fluid challenge, the change in CI became the only contributing factor to ΔScvO2 (R2 = 0.245, p < 0.001). ΔScvO2 had a good discriminatory ability for the responders and non-responders with a threshold of 4.4% (area under the curve = 0.732, p = 0.006). CONCLUSION: ΔScvO2 served as a reliable surrogate marker for ΔCI and could be utilized to assess fluid responsiveness, given that the change of CI was the sole contributing factor to the ΔScvO2. In stable hemoglobin conditions, the absolute value of ScvO2 could serve as a monitoring indicator for adequate oxygen delivery independent of oxygen consumption.

Comparison of different criteria of metagenomic next-generation sequencing for the diagnosis of invasive pulmonary aspergillosis in critically ill patients.

OBJECTIVE: To compare different criteria of Metagenomic Next-Generation Sequencing (mNGS) in bronchoalveolar lavage fluid (BALF) for diagnosing invasive pulmonary aspergillosis (IPA). METHODS: We compared the diagnostic agreement and performances of six BALF mNGS-derived criteria (SDSMRN>1, SDSMRN≥3, SMRN≥10, SMRN≥50, RPM ratio≥10, and relative abundance of genus>30 %) in pneumonia patients. RESULTS: A total of 115 patients were analyzed, with 28 identified with IPA. Diagnostic agreement among the six mNGS-derived criteria was moderate, with a Cohen's kappa of 0.577(P < 0.001). mNGS-derived criteria had low sensitivity ranging from 21.4 % to 57.1 % and high specificity from 88 % to 92 %. The optimal threshold of SDSMRN, SMRN, RPM ratio, and relative abundance of genus for diagnosing IPA were 5, 0.25, 8, and 20 %, respectively. Although using the optimal threshold, the sensitivity of mNGS is lower than 50 %. CONCLUSIONS: All mNGS-derived criteria had low sensitivity for diagnosing IPA. A combination of mNGS and conventional mycological tests may be the best diagnostic strategy.

Sepsis-induced Coagulopathy: The Different Prognosis in Severe Pneumonia and Bacteremia Infection Patients.

Sepsis-induced coagulopathy (SIC) is a critical condition in sepsis patients, with varying outcomes depending on the type of infection. This study aims to analyze the prognosis of different infections in SIC cohort. A retrospective cohort study was conducted on 525 patients diagnosed with SIC in the intensive care unit from December 2013 to December 2022. These patients were divided into four groups: a non-pneumonia or bacteremia group, a severe pneumonia group, a bacteremia group, and a severe pneumonia concomitant with bacteremia group. The 28-day mortality was 18% (49/271) in the other infections group, 31% (33/106) in the lung infections group, 23% (29/126) in the blood infections group and 36% (8/36) in the lung and blood co-infections group, respectively. Pearson correlation analysis showed that procalcitonin (PCT) correlated strongly with all detected hemostatic markers (p < 0.001). The 28-day mortality rate in Lung infections group was significantly higher (p = 0.019), while Blood infections group had a higher incidence of disseminated intravascular coagulation (p = 0.011). By multivariable model analyses, longer duration of ventilation (p = 0.039) and severe pneumonia (p = 0.040) are risk factors associated with mortality. Different infections, including Lung and Blood infections, indicated different conditions in vivo. Longer duration of ventilation is associated with mortality, while Lung infections indicated higher 28-day mortality rate.

Prevalence and mortality risk of low skeletal muscle mass in critically ill patients: an updated systematic review and meta-analysis.

Background: Patients with critical illness often develop low skeletal muscle mass (LSMM) for multiple reasons. Numerous studies have explored the association between LSMM and mortality. The prevalence of LSMM and its association with mortality are unclear. This systematic review and meta-analysis was performed to examine the prevalence and mortality risk of LSMM among critically ill patients. Methods: Three internet databases (Embase, PubMed, and Web of Science) were searched by two independent investigators to identify relevant studies. A random-effects model was used to pool the prevalence of LSMM and its association with mortality. The GRADE assessment tool was used to assess the overall quality of evidence. Results: In total, 1,582 records were initially identified in our search, and 38 studies involving 6,891 patients were included in the final quantitative analysis. The pooled prevalence of LSMM was 51.0% [95% confidence interval (CI), 44.5-57.5%]. The subgroup analysis showed that the prevalence of LSMM in patients with and without mechanical ventilation was 53.4% (95% CI, 43.2-63.6%) and 48.9% (95% CI, 39.7-58.1%), respectively (P-value for difference = 0.44). The pooled results showed that critically ill patients with LSMM had a higher risk of mortality than those without LSMM, with a pooled odds ratio of 2.35 (95% CI, 1.91-2.89). The subgroup analysis based on the muscle mass assessment tool showed that critically ill patients with LSMM had a higher risk of mortality than those with normal skeletal muscle mass regardless of the different assessment tools used. In addition, the association between LSMM and mortality was statistically significant, independent of the different types of mortality. Conclusion: Our study revealed that critically ill patients had a high prevalence of LSMM and that critically ill patients with LSMM had a higher risk of mortality than those without LSMM. However, large-scale and high-quality prospective cohort studies, especially those based on muscle ultrasound, are required to validate these findings. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022379200.

Tissue oxygen saturation is predictive of lactate clearance in patients with circulatory shock.

BACKGROUND: Tissue oxygen saturation (StO2) decrease could appear earlier than lactate alteration. However, the correlation between StO2 and lactate clearance was unknown. METHODS: This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO2 was calculated from four sites of StO2 (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO2 × 9% + (deltoid StO2 + thenar StO2) × (18% + 27%)/ 2 + knee StO2 × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO2 on 6-hour lactate clearance > 10% since StO2 initially monitored was assessed. RESULTS: A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO2 in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO2 for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO2 of masseter (0.65, 95% CI 0.45-0.84; p < 0.01), deltoid (0.77, 95% CI 0.60-0.94; p = 0.04), thenar (0.72, 95% CI 0.55-0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO2 (0.85, 0.73-0.98; p = 0.09). Additionally, BSA-weighted StO2 model had continuous net reclassification improvement (NRI) over the knee StO2 and mean StO2 model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO2 was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose. CONCLUSIONS: Our results suggested that BSA-weighted StO2 was a strong predictor of 6-hour lactate clearance in patients with shock.

A Comparison of Diagnostic Criteria for Invasive Pulmonary Aspergillosis in Critically Ill Patients.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is a common infection in intensive care units (ICUs). There are no consensus criteria for defining IPA in the ICU. We aimed to compare the diagnosis and prognosis performances of three criteria (the 2020 EORTC/MSG criteria, the 2021 EORTC/MSG ICU criteria, the modified AspICU criteria (M-AspICU)) for IPA in the ICU. METHODS: In this retrospective study from our single center, we applied the three different criteria for IPA in patients with suspected pneumonia and undergoing at least one mycological test between November 10, 2016 and November 10, 2021. We compared the diagnosis agreement and prognosis performances of these three criteria in the ICU. RESULTS: Overall, 2403 patients were included. The rates of IPA according to the 2020 EORTC/MSG, 2021 EORTC/MSG ICU, and M-AspICU were 3.37%, 6.53%, and 23.10%, respectively. Diagnostic agreement among these criteria was poor (Cohen's kappa 0.208-0.666). IPA diagnosed by either the 2020 EORTC/MSG (odds ratio = 2.709, P < 0.001) or the 2021 EORTC/MSG ICU (odds ratio = 2.086, P = 0.001) criteria was independently associated with 28-day mortality. IPA diagnosed by M-AspICU is an independent risk factor of 28-day mortality (odds ratio = 1.431, P = 0.031) when excluding patients who fulfilled neither host criteria nor radiological factors of 2021 EORTC/MSG ICU. CONCLUSIONS: Although M-AspICU criteria have the highest "sensitivity", IPA diagnosed by M-AspICU was not an independent risk factor of 28-day mortality. Caution is required when using the M-AspICU criteria in ICU, especially in patients with non-specific infiltration and non-classical host factors.