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1.
Crit Care ; 28(1): 212, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38956732

RESUMO

BACKGROUND: Vitamin K is essential for numerous physiological processes, including coagulation, bone metabolism, tissue calcification, and antioxidant activity. Deficiency, prevalent in critically ill ICU patients, impacts coagulation and increases the risk of bleeding and other complications. This review aims to elucidate the metabolism of vitamin K in the context of critical illness and identify a potential therapeutic approach. METHODS: In December 2023, a scoping review was conducted using the PRISMA Extension for Scoping Reviews. Literature was searched in PubMed, Embase, and Cochrane databases without restrictions. Inclusion criteria were studies on adult ICU patients discussing vitamin K deficiency and/or supplementation. RESULTS: A total of 1712 articles were screened, and 13 met the inclusion criteria. Vitamin K deficiency in ICU patients is linked to malnutrition, impaired absorption, antibiotic use, increased turnover, and genetic factors. Observational studies show higher PIVKA-II levels in ICU patients, indicating reduced vitamin K status. Risk factors include inadequate intake, disrupted absorption, and increased physiological demands. Supplementation studies suggest vitamin K can improve status but not normalize it completely. Vitamin K deficiency may correlate with prolonged ICU stays, mechanical ventilation, and increased mortality. Factors such as genetic polymorphisms and disrupted microbiomes also contribute to deficiency, underscoring the need for individualized nutritional strategies and further research on optimal supplementation dosages and administration routes. CONCLUSIONS: Addressing vitamin K deficiency in ICU patients is crucial for mitigating risks associated with critical illness, yet optimal management strategies require further investigation. IMPACT RESEARCH: To the best of our knowledge, this review is the first to address the prevalence and progression of vitamin K deficiency in critically ill patients. It guides clinicians in diagnosing and managing vitamin K deficiency in intensive care and suggests practical strategies for supplementing vitamin K in critically ill patients. This review provides a comprehensive overview of the existing literature, and serves as a valuable resource for clinicians, researchers, and policymakers in critical care medicine.


Assuntos
Estado Terminal , Deficiência de Vitamina K , Vitamina K , Humanos , Estado Terminal/terapia , Vitamina K/uso terapêutico , Deficiência de Vitamina K/tratamento farmacológico , Unidades de Terapia Intensiva/organização & administração
2.
Pediatr Crit Care Med ; 25(7 Suppl 1): e78-e89, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38959362

RESUMO

OBJECTIVES: To identify and prioritize research questions for anticoagulation and hemostasis management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus. DATA SOURCES: Systematic review was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial consensus conferences of international, interprofessional experts in the management of ECMO for critically ill neonates and children. STUDY SELECTION: The management of ECMO anticoagulation for critically ill neonates and children. DATA EXTRACTION: Within each of the eight subgroups, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS: Following the systematic review of MEDLINE, EMBASE, and Cochrane Library databases from January 1988 to May 2021, and the consensus process for clinical recommendations and consensus statements, PEACE panel experts constructed research priorities using the Child Health and Nutrition Research Initiative methodology. Twenty research topics were prioritized, falling within five domains (definitions and outcomes, therapeutics, anticoagulant monitoring, protocolized management, and impact of the ECMO circuit and its components on hemostasis). CONCLUSIONS: We present the research priorities identified by the PEACE expert panel after a systematic review of existing evidence informing clinical care of neonates and children managed with ECMO. More research is required within the five identified domains to ultimately inform and improve the care of this vulnerable population.


Assuntos
Anticoagulantes , Oxigenação por Membrana Extracorpórea , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Criança , Recém-Nascido , Estado Terminal/terapia , Pesquisa Biomédica/métodos , Lactente , Pré-Escolar
3.
Pediatr Crit Care Med ; 25(7): 643-675, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38959353

RESUMO

OBJECTIVES: To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES: Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION: The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION: Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS: A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS: The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.


Assuntos
Anticoagulantes , Estado Terminal , Oxigenação por Membrana Extracorpórea , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Criança , Estado Terminal/terapia , Recém-Nascido , Lactente , Pré-Escolar
4.
JAMA Netw Open ; 7(7): e2420388, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38949808

RESUMO

Importance: Improving end-of-life care in the intensive care unit (ICU) is a priority, but clinically modifiable factors of quality of dying and death (QODD) are seldom identified. Objectives: To comprehensively identify factors associated with QODD classes of dying ICU patients, emphasizing clinically modifiable factors based on the integrative framework of factors associated with for bereavement outcomes. Design, Setting, and Participants: This observational cohort study was conducted at medical ICUs of 2 Taiwanese medical centers from January 2018 to March 2020 with follow-up through December 2022. Eligible participants included primary family surrogates responsible for decision making for critically ill ICU patients at high risk of death (Acute Physiology and Chronic Health Evaluation II score >20) but who survived more than 3 days after ICU admission. Data analysis was conducted from July to September 2023. Main Outcomes and Measures: QODD was measured by the 23-item ICU-QODD questionnaire. Factors associated with patient membership in 4 previously determined QODD classes (high, moderate, poor to uncertain, and worst) were examined using a 3-step approach for latent class modeling with the high QODD class as the reference category. Results: A total of 309 family surrogates (mean [SD] age, 49.83 [12.55] years; 184 women [59.5%] and 125 men [40.5%]) were included in the study. Of all surrogates, 91 (29.4%) were the patients' spouse and 66 (53.7%) were the patients' adult child. Patient demographics were not associated with QODD class. Two family demographics (age and gender), relationship with the patient (spousal or adult-child), and length of ICU stay were associated with QODD classes. Patients of surrogates perceiving greater social support were less likely to be in the poor to uncertain (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94) and worst (aOR, 0.92; 95% CI, 0.87-0.96) QODD classes. Family meetings were associated with the poor to uncertain QODD class (aOR, 8.61; 95% CI, 2.49-29.74) and worst QODD class (aOR, 7.28; 95% CI, 1.37-38.71). Death with cardiopulmonary resuscitation was associated with the worst QODD class (aOR, 7.51; 95% CI, 1.12-50.25). Family presence at patient death was uniformly negatively associated with the moderate QODD class (aOR, 0.16; 95% CI, 0.05-0.54), poor to uncertain QODD class (aOR, 0.21; 95% CI, 0.05-0.82), and worst QODD class (aOR, 0.08; 95% CI, 0.02-0.38). Higher family satisfaction with ICU care was negatively associated with the poor to uncertain QODD class (aOR, 0.93; 95% CI, 0.87-0.98) and worst QODD class (aOR, 0.86; 95% CI, 0.81-0.92). Conclusions and Relevance: In this cohort study of critically ill patients and their family surrogates, modifiable end-of-life ICU-care characteristics played a more significant role in associations with patient QODD class than did immutable family demographics, preexisting family health conditions, patient demographics, and patient clinical characteristics, thereby illuminating actionable opportunities to improve end-of-life ICU care.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , Assistência Terminal , Humanos , Masculino , Feminino , Estado Terminal/mortalidade , Estado Terminal/psicologia , Pessoa de Meia-Idade , Idoso , Assistência Terminal/psicologia , Família/psicologia , Taiwan , Estudos de Coortes , Inquéritos e Questionários , Adulto , Luto
5.
Sci Rep ; 14(1): 15061, 2024 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-38956245

RESUMO

Neurocritically ill patients frequently exhibit coma, gastroparesis, and intense catabolism, leading to an increased risk of malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) criteria for the diagnosis of malnutrition was created to achieve a consistent malnutrition diagnosis across diverse populations. This study aimed to validate the concurrent and predictive validity of GLIM criteria in patients with neurocritical illnesses. A total of 135 participants were followed from admission to the neurocritical unit (NCU) until discharge. Comparing GLIM criteria to the Subjective Global Assessment (SGA), sensitivity was 0.95 and specificity was 0.69. Predictive validity of GLIM criteria was assessed using a composite adverse clinical outcome, comprising mortality and various major complications. Adjusted hazard ratios for moderate and severe malnutrition were 2.86 (95% CI 1.45-5.67) and 3.88 (95% CI 1.51-9.94), respectively. Changes in indicators of nutritional status, including skeletal muscle mass and abdominal fat mass, within 7 days of admission were obtained for 61 participants to validate the predictive capability of the GLIM criteria for the patients' response of standardized nutritional support. The GLIM criteria have a statistically significant predictive validity on changes in rectus femoris muscle thickness and midarm muscle circumference. In conclusion, the GLIM criteria demonstrate high sensitivity for diagnosing malnutrition in neurocritically ill patients and exhibit good predictive validity.


Assuntos
Estado Terminal , Desnutrição , Apoio Nutricional , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Desnutrição/diagnóstico , Apoio Nutricional/métodos , Idoso , Estado Nutricional , Adulto , Avaliação Nutricional , Doenças do Sistema Nervoso/diagnóstico , Valor Preditivo dos Testes
6.
Sci Transl Med ; 16(755): eadn9285, 2024 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-38985853

RESUMO

Patients with sepsis experience metabolic and immunologic dysfunction that may be amplified by standard carbohydrate-based nutrition. A ketogenic diet (KD) may offer an immunologically advantageous alternative, although clinical evidence is limited. We conducted a single-center, open-label, randomized controlled trial to assess whether a KD could induce stable ketosis in critically ill patients with sepsis. Secondary outcomes included assessment of feasibility and safety of KD, as well as explorative analysis of clinical and immunological characteristics. Forty critically ill adults were randomized to either a ketogenic or standard high-carbohydrate diet. Stable ketosis was achieved in all KD patients, with significant increases in ß-hydroxybutyrate levels compared with controls [mean difference 1.4 milimoles per liter; 95% confidence interval (CI): 1.0 to 1.8; P < 0.001). No major adverse events or harmful metabolic side effects (acidosis, dysglycemia, or dyslipidemia) were observed. After day 4, none of the patients in the KD group required insulin treatment, whereas in the control group, insulin dependency ranged between 35% and 60% (P = 0.009). There were no differences in 30-day survival, but ventilation-free [incidence rate ratio (IRR) 1.7; 95% CI: 1.5 to 2.1; P < 0.001], vasopressor-free (IRR 1.7; 95% CI: 1.5 to 2.0; P < 0.001), dialysis-free (IRR 1.5; 95% CI: 1.3 to 1.8; P < 0.001), and intensive care unit-free days (IRR 1.7; 95% CI: 1.4 to 2.1; P < 0.001) were higher in the ketogenic group. Next-generation sequencing of CD4+/CD8+ T cells and protein analyses showed reduced immune dysregulation, with decreased gene expression of T-cell activation and signaling markers and lower pro-inflammatory cytokine secretion. This trial demonstrated the safe induction of a stable ketogenic state in sepsis, warranting larger trials to investigate potential benefits in sepsis-related organ dysfunction.


Assuntos
Estado Terminal , Dieta Cetogênica , Sepse , Humanos , Masculino , Sepse/dietoterapia , Sepse/sangue , Feminino , Pessoa de Meia-Idade , Ácido 3-Hidroxibutírico/sangue , Adulto , Idoso , Cetose , Resultado do Tratamento
7.
Front Endocrinol (Lausanne) ; 15: 1411891, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38994011

RESUMO

Background: This study aimed to investigate the association between blood urea nitrogen to serum albumin ratio (BAR) and the risk of in-hospital mortality in patients with diabetic ketoacidosis. Methods: A total of 3,962 diabetic ketoacidosis patients from the eICU Collaborative Research Database were included in this analysis. The primary outcome was in-hospital death. Results: Over a median length of hospital stay of 3.1 days, 86 in-hospital deaths were identified. One unit increase in LnBAR was positively associated with the risk of in-hospital death (hazard ratio [HR], 1.82 [95% CI, 1.42-2.34]). Furthermore, a nonlinear, consistently increasing correlation between elevated BAR and in-hospital mortality was observed (P for trend =0.005 after multiple-adjusted). When BAR was categorized into quartiles, the higher risk of in-hospital death (multiple-adjusted HR, 1.99 [95% CI, (1.1-3.6)]) was found in participants in quartiles 3 to 4 (BAR≥6.28) compared with those in quartiles 1 to 2 (BAR<6.28). In the subgroup analysis, the LnBAR-hospital death association was significantly stronger in participants without kidney insufficiency (yes versus no, P-interaction=0.023). Conclusion: There was a significant and positive association between BAR and the risk of in-hospital death in patients with diabetic ketoacidosis. Notably, the strength of this association was intensified among those without kidney insufficiency.


Assuntos
Nitrogênio da Ureia Sanguínea , Cetoacidose Diabética , Mortalidade Hospitalar , Humanos , Masculino , Cetoacidose Diabética/mortalidade , Cetoacidose Diabética/sangue , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto , Albumina Sérica/análise , Albumina Sérica/metabolismo , Bases de Dados Factuais , Idoso , Estado Terminal/mortalidade
9.
Ren Fail ; 46(2): 2374451, 2024 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38967166

RESUMO

BACKGROUND: The primary objective was to examine the association between the lactate/albumin ratio (LAR) and the prognosis of patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). METHODS: Utilizing the Medical Information Mart for Intensive Care IV (MIMIC-IV, v2.0) database, we categorized 703 adult AKI patients undergoing CRRT into survival and non-survival groups based on 28-day mortality. Patients were further grouped by LAR tertiles: low (< 0.692), moderate (0.692-1.641), and high (> 1.641). Restricted cubic splines (RCS), Least Absolute Shrinkage and Selection Operator (LASSO) regression, inverse probability treatment weighting (IPTW), and Kaplan-Meier curves were employed. RESULTS: In our study, the patients had a mortality rate of 50.07% within 28 days and 62.87% within 360 days. RCS analysis revealed a non-linear correlation between LAR and the risk of mortality at both 28 and 360 days. Cox regression analysis, which was adjusted for nine variables identified by LASSO, confirmed that a high LAR (>1.641) served as an independent predictor of mortality at these specific time points (p < 0.05) in AKI patients who were receiving CRRT. These findings remained consistent even after IPTW adjustment, thereby ensuring a reliable and robust outcome. Kaplan-Meier survival curves exhibited a gradual decline in cumulative survival rates at both 28 and 360 days as the LAR values increased (log-rank test, χ2 = 48.630, p < 0.001; χ2 = 33.530, p < 0.001). CONCLUSION: A high LAR (>1.641) was found to be an autonomous predictor of mortality at both 28 and 360 days in critically ill patients with AKI undergoing CRRT.


Assuntos
Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Estado Terminal , Ácido Láctico , Humanos , Injúria Renal Aguda/sangue , Injúria Renal Aguda/terapia , Injúria Renal Aguda/mortalidade , Feminino , Masculino , Estado Terminal/mortalidade , Pessoa de Meia-Idade , Prognóstico , Idoso , Ácido Láctico/sangue , Estimativa de Kaplan-Meier , Unidades de Terapia Intensiva/estatística & dados numéricos , Estudos Retrospectivos , Modelos de Riscos Proporcionais , Albumina Sérica/análise , Albumina Sérica/metabolismo
10.
Trials ; 25(1): 431, 2024 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-38956664

RESUMO

BACKGROUND: Use of sedatives and analgesics is associated with the occurrence of delirium in critically ill patients receiving mechanical ventilation. Dexmedetomidine reduces the occurrence of delirium but may cause hypotension, bradycardia, and insufficient sedation. This substudy aims to determine whether the combination of esketamine with dexmedetomidine can reduce the side effects and risk of delirium than dexmedetomidine alone in mechanically ventilated patients. METHODS: This single-center, randomized, active-controlled, superiority trial will be conducted at The First Affiliated Hospital of Nanjing Medical University. A total of 134 mechanically ventilated patients will be recruited and randomized to receive either dexmedetomidine alone or esketamine combined with dexmedetomidine, until extubation or for a maximum of 14 days. The primary outcome is the occurrence of delirium, while the second outcomes include the number of delirium-free days; subtype, severity, and duration of delirium; time to first onset of delirium; total dose of vasopressors and antipsychotics; duration of mechanical ventilation; ICU and hospital length of stay (LOS); accidental extubation, re-intubation, re-admission; and mortality in the ICU at 14 and 28 days. DISCUSSION: There is an urgent need for a new combination regimen of dexmedetomidine due to its evident side effects. The combination of esketamine and dexmedetomidine has been applied throughout the perioperative period. However, there is still a lack of evidence on the effects of this regimen on delirium in mechanically ventilated ICU patients. This substudy will evaluate the effects of the combination of esketamine and dexmedetomidine in reducing the risk of delirium for mechanically ventilated patients in ICU, thus providing evidence of this combination to improve the short-term prognosis. The study protocol has obtained approval from the Medical Ethics Committee (ID: 2022-SR-450). TRIAL REGISTRATION: ClinicalTrials.gov: NCT05466708, registered on 20 July 2022.


Assuntos
Delírio , Dexmedetomidina , Quimioterapia Combinada , Hipnóticos e Sedativos , Unidades de Terapia Intensiva , Ketamina , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Humanos , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Dexmedetomidina/uso terapêutico , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/uso terapêutico , Delírio/prevenção & controle , Resultado do Tratamento , Tempo de Internação , Estado Terminal , China , Fatores de Tempo , Feminino , Masculino
11.
Crit Care Explor ; 6(7): e1115, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38968174

RESUMO

OBJECTIVES: Our study aimed to assess the time to positivity (TTP) of clinically significant blood cultures in critically ill children admitted to the PICU. DESIGN: Retrospective review of positive blood cultures in patients admitted or transferred to the PICU. SETTING: Large tertiary-care medical center with over 90 PICU beds. PATIENTS: Patients 0-20 years old with bacteremia admitted or transferred to the PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the TTP, defined as time from blood culture draw to initial Gram stain result. Secondary endpoints included percentage of cultures reported by elapsed time, as well as the impact of pathogen and host immune status on TTP. Host immune status was classified as previously healthy, standard risk, or immunocompromised. Linear regression for TTP was performed to account for age, blood volume, and Gram stain. Among 164 episodes of clinically significant bacteremia, the median TTP was 13.3 hours (interquartile range, 10.7-16.8 hr). Enterobacterales, Staphylococcus aureus, Streptococcus agalactiae, and Streptococcus pneumoniae were most commonly identified. By 12, 24, 36, and 48 hours, 37%, 89%, 95%, and 97% of positive cultures had resulted positive, respectively. Median TTP stratified by host immune status was 13.2 hours for previously healthy patients, 14.0 hours for those considered standard risk, and 10.6 hours for immunocompromised patients (p = 0.001). Median TTP was found to be independent of blood volume. No difference was seen in TTP for Gram-negative vs. Gram-positive organisms (12.2 vs. 13.9 hr; p = 0.2). CONCLUSIONS: Among critically ill children, 95% of clinically significant blood cultures had an initial positive result within 36 hours, regardless of host immune status. Need for antimicrobial therapy should be frequently reassessed and implementation of a shorter duration of empiric antibiotics should be considered in patients with low suspicion for infection.


Assuntos
Bacteriemia , Hemocultura , Estado Terminal , Unidades de Terapia Intensiva Pediátrica , Humanos , Pré-Escolar , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Estudos Retrospectivos , Criança , Lactente , Bacteriemia/diagnóstico , Bacteriemia/microbiologia , Bacteriemia/sangue , Masculino , Feminino , Adolescente , Fatores de Tempo , Recém-Nascido , Adulto Jovem
12.
Crit Care ; 28(1): 227, 2024 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-38978044

RESUMO

BACKGROUND: Acute kidney injury (AKI) is common in hospitalized patients and results in significant morbidity and mortality. The objective of the study was to explore the systemic immune response of intensive care unit patients presenting with AKI, especially the association between immune profiles and persistent AKI during the first week after admission following various types of injuries (sepsis, trauma, surgery, and burns). METHODS: REALAKI is an ancillary analysis of the REAnimation Low Immune Status Marker (REALISM) cohort study, in which 359 critically ill patients were enrolled in three different intensive care units. Patients with end-stage renal disease were excluded from the REALAKI study. Clinical samples and data were collected three times after admission: at day 1 or 2 (D1-2), day 3 or 4 (D3-4) and day 5, 6 or 7 (D5-7). Immune profiles were compared between patients presenting with or without AKI. Patients with AKI at both D1-2 and D5-7 were defined as persistent AKI. A multivariable logistic regression model was performed to determine the independent association between AKI and patients' immunological parameters. RESULTS: Three hundred and fifty-nine patients were included in this analysis. Among them, 137 (38%) were trauma patients, 103 (29%) post-surgery patients, 95 (26%) sepsis patients, and 24 (7%) were burn patients. One hundred and thirty-nine (39%) patients presented with AKI at D1-2 and 61 (20%) at D5-7. Overall, 94% presented with persistent AKI at D5-7. Patients with AKI presented with increased pro and anti-inflammatory cytokines and altered innate and adaptive immune responses. The modifications observed in the immune profiles tended to be more pronounced with increasing KDIGO stages. In the logistic regression model, a statistically significant association was observed at D1-2 between AKI and CD10lowCD16low immature neutrophils (OR 3.03 [1.7-5.5]-p < 0.001). At D5-7, increased interleukin-10 (IL-10) levels and reduced ex vivo TNF-α production after LPS stimulation were significantly associated with the presence of AKI (OR 1.38 [1.12-1.71]-p = 0.001 and 0.51 [0.27-0.91]-p = 0.03, respectively). Patients who recovered from AKI between D1-2 and D5-7 compared to patients with persistent AKI at D5-7, tended to correct these alterations. CONCLUSION: Following various types of severe injuries, early AKI is associated with the initial inflammatory response. Presence of AKI at the end of the first week after injury is associated with injury-induced immunosuppression.


Assuntos
Injúria Renal Aguda , Estado Terminal , Humanos , Masculino , Injúria Renal Aguda/imunologia , Injúria Renal Aguda/etiologia , Feminino , Pessoa de Meia-Idade , Idoso , Adulto , Estudos de Coortes , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Ferimentos e Lesões/complicações , Ferimentos e Lesões/imunologia , Estudos Prospectivos , Fatores de Tempo , Biomarcadores/sangue , Biomarcadores/análise , Sepse/complicações , Sepse/imunologia
13.
Respir Res ; 25(1): 268, 2024 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-38978068

RESUMO

BACKGROUND: Lung ultrasound (LUS) in an emerging technique used in the intensive care unit (ICU). The derivative LUS aeration score has been shown to have associations with mortality in invasively ventilated patients. This study assessed the predictive value of baseline and early changes in LUS aeration scores in critically ill invasively ventilated patients with and without ARDS (Acute Respiratory Distress Syndrome) on 30- and 90-day mortality. METHODS: This is a post hoc analysis of a multicenter prospective observational cohort study, which included patients admitted to the ICU with an expected duration of ventilation for at least 24 h. We restricted participation to patients who underwent a 12-region LUS exam at baseline and had the primary endpoint (30-day mortality) available. Logistic regression was used to analyze the primary and secondary endpoints. The analysis was performed for the complete patient cohort and for predefined subgroups (ARDS and no ARDS). RESULTS: A total of 442 patients were included, of whom 245 had a second LUS exam. The baseline LUS aeration score was not associated with mortality (1.02 (95% CI: 0.99 - 1.06), p = 0.143). This finding was not different in patients with and in patients without ARDS. Early deterioration of the LUS score was associated with mortality (2.09 (95% CI: 1.01 - 4.3), p = 0.046) in patients without ARDS, but not in patients with ARDS or in the complete patient cohort. CONCLUSION: In this cohort of critically ill invasively ventilated patients, the baseline LUS aeration score was not associated with 30- and 90-day mortality. An early change in the LUS aeration score was associated with mortality, but only in patients without ARDS. TRIAL REGISTRATION: ClinicalTrials.gov, ID NCT04482621.


Assuntos
Pulmão , Respiração Artificial , Síndrome do Desconforto Respiratório , Ultrassonografia , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Estudos Prospectivos , Pulmão/diagnóstico por imagem , Ultrassonografia/métodos , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/terapia , Estudos de Coortes , Estado Terminal/mortalidade , Fatores de Tempo , Unidades de Terapia Intensiva
14.
Crit Care Explor ; 6(7): e1126, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38980049

RESUMO

OBJECTIVES: To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome. DESIGN: Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components). SETTING: All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period. PATIENTS: One hundred thirty critically ill patients with confirmed leptospirosis were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters-"Weil's Disease" (48%), "neurological leptospirosis" (20%), and "multiple organ failure" (32%)-with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy. CONCLUSIONS AND RELEVANCE: Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , Leptospirose , Humanos , Masculino , Leptospirose/mortalidade , Leptospirose/epidemiologia , Feminino , Estado Terminal/mortalidade , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto , Insuficiência de Múltiplos Órgãos/mortalidade , Guadalupe/epidemiologia , Idoso , Análise por Conglomerados
15.
BMC Anesthesiol ; 24(1): 227, 2024 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-38982350

RESUMO

PURPOSE: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. METHODS: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. RESULTS: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. CONCLUSION: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.


Assuntos
Estado Terminal , Intubação Intratraqueal , Índice de Perfusão , Humanos , Masculino , Feminino , Estudos Prospectivos , Pessoa de Meia-Idade , Intubação Intratraqueal/métodos , Idoso , Extubação/métodos , Frequência Cardíaca/fisiologia , Saturação de Oxigênio/fisiologia , Respiração Artificial/métodos , Taxa Respiratória/fisiologia , Valor Preditivo dos Testes , Adulto
16.
Saudi Med J ; 45(7): 653-657, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38955453

RESUMO

The validity of the traditional nutritional assessment tools in intensive care settings might be compromised when the patient has conditions such as oedema and inflammation. Ultrasound (US) is considered a non-invasive, bedside tool that can be utilized to assess changes in muscle mass. Hence, US could guide healthcare practitioners in identifying the varying degrees of malnutrition and adjusting the nutritional prescription accordingly. This review discusses the currently available data regarding the feasibility and practicality of using US measurements in intensive care settings. Overall, the data suggest that using US as part of the standard anthropometric assessment for critically ill patients is a promising tool to track variations in muscle mass. This has the potential to enhance nutritional prescription and tailor the provision of protein and energy to critically ill patients based on their lean body mass measurements. Therefore, it is recommended to train dietitians on utilizing US for body composition measurements.


Assuntos
Cuidados Críticos , Estado Terminal , Nutrição Enteral , Avaliação Nutricional , Nutrição Parenteral , Ultrassonografia , Humanos , Ultrassonografia/métodos , Nutrição Enteral/métodos , Nutrição Parenteral/métodos , Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Composição Corporal , Desnutrição
17.
Sci Rep ; 14(1): 15900, 2024 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-38987379

RESUMO

This study aimed to investigate the association between serum chloride levels and all-cause mortality in critically ill patients with chronic obstructive pulmonary disease (COPD). Data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were extracted for analysis. Demographic information, laboratory results, medical histories, vital signs, and prognosis-related data were collected. Cox proportional hazard models were used to assess the relationship between serum chloride levels and 90-day and 365-day mortality. Subgroup analyses were conducted to explore potential interactions between serum chloride levels and various factors. The study included patients with a median age of 72.00 years, of whom 52.39% were male. Higher quartiles of serum chloride levels were associated with significantly lower levels of weight, RBC, platelet, hemoglobin, and other variables (P < 0.05), accompanied by lower 90-day and 365-day mortality (P < 0.05). Cox proportional hazard model indicated that the risk of death was significantly lower in the fourth quartile of serum chloride levels compared with the first quartile after adjusting for confounders (90-day HR = 0.54, 365-day HR = 0.52, both P < 0.05). An L-shape relationship was observed, with risks of death decreasing as serum chloride levels increased, although the magnitude decreased when levels reached 102 mmol/L. This study demonstrated an independent L-shaped association between serum chloride levels and all-cause mortality in critically ill patients with COPD. This finding helps us to understand the prognostic value of serum chloride levels in critically ill patients with COPD.


Assuntos
Cloretos , Estado Terminal , Doença Pulmonar Obstrutiva Crônica , Humanos , Masculino , Feminino , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/mortalidade , Estado Terminal/mortalidade , Idoso , Estudos Retrospectivos , Cloretos/sangue , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Idoso de 80 Anos ou mais
18.
Crit Care ; 28(1): 230, 2024 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-38987802

RESUMO

BACKGROUND: Impaired microcirculation is a cornerstone of sepsis development and leads to reduced tissue oxygenation, influenced by fluid and catecholamine administration during treatment. Hyperspectral imaging (HSI) is a non-invasive bedside technology for visualizing physicochemical tissue characteristics. Machine learning (ML) for skin HSI might offer an automated approach for bedside microcirculation assessment, providing an individualized tissue fingerprint of critically ill patients in intensive care. The study aimed to determine if machine learning could be utilized to automatically identify regions of interest (ROIs) in the hand, thereby distinguishing between healthy individuals and critically ill patients with sepsis using HSI. METHODS: HSI raw data from 75 critically ill sepsis patients and from 30 healthy controls were recorded using TIVITA® Tissue System and analyzed using an automated ML approach. Additionally, patients were divided into two groups based on their SOFA scores for further subanalysis: less severely ill (SOFA ≤ 5) and severely ill (SOFA > 5). The analysis of the HSI raw data was fully-automated using MediaPipe for ROI detection (palm and fingertips) and feature extraction. HSI Features were statistically analyzed to highlight relevant wavelength combinations using Mann-Whitney-U test and Benjamini, Krieger, and Yekutieli (BKY) correction. In addition, Random Forest models were trained using bootstrapping, and feature importances were determined to gain insights regarding the wavelength importance for a model decision. RESULTS: An automated pipeline for generating ROIs and HSI feature extraction was successfully established. HSI raw data analysis accurately distinguished healthy controls from sepsis patients. Wavelengths at the fingertips differed in the ranges of 575-695 nm and 840-1000 nm. For the palm, significant differences were observed in the range of 925-1000 nm. Feature importance plots indicated relevant information in the same wavelength ranges. Combining palm and fingertip analysis provided the highest reliability, with an AUC of 0.92 to distinguish between sepsis patients and healthy controls. CONCLUSION: Based on this proof of concept, the integration of automated and standardized ROIs along with automated skin HSI analyzes, was able to differentiate between healthy individuals and patients with sepsis. This approach offers a reliable and objective assessment of skin microcirculation, facilitating the rapid identification of critically ill patients.


Assuntos
Estado Terminal , Imageamento Hiperespectral , Aprendizado de Máquina , Microcirculação , Humanos , Aprendizado de Máquina/normas , Masculino , Feminino , Microcirculação/fisiologia , Pessoa de Meia-Idade , Idoso , Imageamento Hiperespectral/métodos , Sepse/fisiopatologia , Sepse/diagnóstico , Adulto , Estudo de Prova de Conceito , Monitorização Fisiológica/métodos , Monitorização Fisiológica/instrumentação
20.
Crit Care Sci ; 36: e20240253en, 2024.
Artigo em Inglês, Português | MEDLINE | ID: mdl-38985049

RESUMO

OBJECTIVE: To identify the influence of obesity on mortality, time to weaning from mechanical ventilation and mobility at intensive care unit discharge in patients with COVID-19. METHODS: This retrospective cohort study was carried out between March and August 2020. All adult patients admitted to the intensive care unit in need of ventilatory support and confirmed to have COVID-19 were included. The outcomes included mortality, time on mechanical ventilation, and mobility at intensive care unit discharge. RESULTS: Four hundred and twenty-nine patients were included, 36.6% of whom were overweight and 43.8% of whom were obese. Compared with normal body mass index patients, overweight and obese patients had lower mortality (p = 0.002) and longer intensive care unit survival (log-rank p < 0.001). Compared with patients with a normal body mass index, overweight patients had a 36% lower risk of death (p = 0.04), while patients with obesity presented a 23% lower risk (p < 0.001). There was no association between obesity and time on mechanical ventilation. The level of mobility at intensive care unit discharge did not differ between groups and showed a moderate inverse correlation with length of stay in the intensive care unit (r = -0.461; p < 0.001). CONCLUSION: Overweight and obese patients had lower mortality and higher intensive care unit survival rates. The duration of mechanical ventilation and mobility level at intensive care unit discharge did not differ between the groups.


Assuntos
COVID-19 , Unidades de Terapia Intensiva , Obesidade , Respiração Artificial , Humanos , COVID-19/mortalidade , COVID-19/terapia , Obesidade/mortalidade , Obesidade/complicações , Masculino , Estudos Retrospectivos , Feminino , Pessoa de Meia-Idade , Idoso , Índice de Massa Corporal , Tempo de Internação/estatística & dados numéricos , Fatores de Tempo , Desmame do Respirador , Estado Terminal/mortalidade , SARS-CoV-2
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