[Liver diseases in the intensive care unit]. / Lebererkrankungen auf der Intensivstation.

The frequency of liver diseases in the intensive care unit has increased significantly in recent years and is now observed in up to 20% of critically ill patients. The occurrence of liver disease is associated with significantly increased morbidity and mortality. Two groups of liver diseases in the intensive care unit can be distinguished. First, the group of "primary hepatic dysfunctions", which includes primary acute liver failure as well as acute-on-chronic liver failure in patients with pre-existing liver cirrhosis. The second group of "secondary or acquired liver diseases" includes cholestatic liver diseases, as well as hypoxic liver injury and mixed forms, as well as other rarer liver diseases. Due to the diversity of liver diseases and the very different triggers, sufficient knowledge of the underlying changes (including hemodynamic changes, inflammatory states or drug-related) is essential. Early recognition, diagnosis, and treatment of the underlying disease are essential for all liver dysfunction in critically ill patients in the intensive care unit. This review article aims to take a closer look at liver diseases in the intensive care unit and provides insight into diagnostics and treatment options.

Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial / Eficácia da melatonina na redução da incidência de delirium em pacientes adultos graves: um ensaio clínico randomizado

ABSTRACT Objective: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. Methods: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). Results: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. Conclusion: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

RESUMO Objetivo: Determinar se a melatonina enteral diminui a incidência de delirium em adultos em estado grave. Métodos: Neste estudo controlado e randomizado, os adultos foram admitidos à unidade de terapia intensiva e/ou receberam apenas o padrão de cuidado habitual (Grupo Controle) ou o tratamento combinado com 3mg de melatonina enteral uma vez ao dia às 21h (Grupo Melatonina). A ocultação da alocação foi feita por meio de envelopes selados opacos e numerados sequencialmente. O intensivista que avaliou o delirium e o pesquisador que realizou a análise dos dados foram cegados quanto à alocação do grupo. O desfecho primário foi a incidência de delirium dentro de 24 horas de internação na unidade de terapia intensiva. Os desfechos secundários foram a incidência de delirium nos dias 3 e 7, a mortalidade na unidade de terapia intensiva, a duração da internação na unidade de terapia intensiva, a duração da ventilação mecânica e o escore da escala de desfecho de Glasgow (na alta). Resultados: Foram incluídos 108 pacientes na análise final, com 54 sujeitos em cada grupo. Em 24 horas de internação na unidade de terapia intensiva, a incidência de delirium não foi diferente entre os Grupos Melatonina e Controle (29,6% versus 46,2%; RR = 0,6; IC95% 0,38 - 1,05; p = 0,11). Nenhum desfecho secundário apresentou diferenças estatisticamente significativas. Conclusão: Em adultos em estado grave, 3mg de melatonina enteral não foi mais eficaz que os cuidados padrão na redução da incidência de delirium.

Estimated continuous cardiac output based on pulse wave transit time in critically ill children: a report of two cases.

Cardiac output is an essential determinant of oxygen delivery, although unreliably measured on clinical examination and routine monitoring. Unfortunately, cardiac output monitoring is rarely performed in pediatric critical care medicine, with a limited availability of accurate methods for children. Herein, we report two pediatric cases in which noninvasive pulse-wave transit time-based cardiac output monitoring (esCCO, Nihon Kohden, Tokyo, Japan) was used. The esCCO system calculates cardiac output continuously by using the negative correlation between stroke volume and pulse wave transit time and requires only electrocardiogram monitoring, noninvasive blood pressure, and pulse oximetry signals. Before starting its use, esCCO should be calibrated, which can be done using patient information (gender, age, height, and body weight) or entering cardiac output values obtained by other methods. In both cases, when calibrations were performed using patient information, the agreement between esCCO and echocardiographic measurements was poor. However, after calibration with transthoracic echocardiography, the cardiac output values obtained by both methods remained similar after 2 hours and 18 hours. The results indicate that the esCCO system is suitable for use in children; however, further studies are needed to optimize its algorithm and determine its accuracy, precision, and trend in children.

Post Hospital Discharge Functional Recovery of Critical Illness Survivors. Systematic Review.

Background: Millions of people face critical illnesses and need to be hospitalized in an Intensive Care Unit (ICU) annually worldwide. Despite the fact that survival rates of these patients have increased, they develop various cognitive, psychological and functional impairments. This study aims to investigate the significance of the recovery interventions following intensive care unit discharge, the effectiveness of the rehabilitative protocols and their possible deficits. Methods: MEDLINE (PubMed) and Physiotherapy Evidence Database (PEDro) were searched for studies analyzing the recovery potentials post-ICU among adults, who spent at least 48 hours at the ICU. Methodological quality of the studies was assessed via PEDro Scale. Results: Nine randomized controlled trials were included. These took place mainly at specialized rehabilitation gyms as well as patients home environments. Studies analyses showed that treatment group showed improvement in functional ability in relation to control group. Nevertheless, differences between two groups were not statistically significant (P<0.05). The majority of studies assessed cardiorespiratory endurance and muscular strength. Conclusions: The included rehabilitation programs were determined to be effective. Although they didn't prove any statistically significant difference between groups, quality of life enhancements and stress reduction were reported. Hence, new randomized controlled trials are required in order to provide more accurate data on the potential benefits of rehabilitation strategies among post-ICU patients.

Impact of intravenous vitamin C as a monotherapy on mortality risk in critically ill patients: A meta-analysis of randomized controlled trials with trial sequential analysis.

Background: This meta-analysis aimed at investigating the pooled evidence regarding the effects of intravenous vitamin C (IVVC) on mortality rate in critically ill patients. Methods: Databases including Medline, Embase, and Cochrane Library were searched from inception to October, 2022 to identify RCTs. The primary outcome was the risk of overall mortality. Subgroup analyses were performed based on IVVC dosage (i.e., cut-off value: 100 mg/kg/day or 10000 mg/day). Trial sequential analysis (TSA) was used to examine the robustness of evidence. Results: A total of 12 trials including 1,712 patients were analyzed. Although meta-analysis demonstrated a lower risk of mortality in patients with IVVC treatment compared to those without [risk ratio (RR): 0.76, 95% CI: 0.6 to 0.97, p = 0.02, I 2 = 36%, 1,711 patients), TSA suggested the need for more studies for verification. Moreover, subgroup analyses revealed a reduced mortality risk associated with a low IVVC dosage (RR = 0.72, p = 0.03, 546 patients), while no beneficial effect was noted with high IVVC dosage (RR = 0.74, p = 0.13, I 2 = 60%, 1,165 patients). The durations of vasopressor [mean difference (MD): -37.75 h, 404 patients) and mechanical ventilation (MD: -47.29 h, 388 patients) use were shorter in the IVVC group than those in the controls, while there was no significant difference in other prognostic outcomes (e.g., length of stay in intensive care unit/hospital) between the two groups. Conclusion: Although intravenous vitamin C as a monotherapy reduced pooled mortality, durations of vasopressor use and mechanical ventilation, further research is required to support our findings and to identify the optimal dosage of vitamin C in the critical care setting. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022371090.

Severe community-acquired Streptococcus pneumoniae bacterial meningitis: clinical and prognostic picture from the intensive care unit.

BACKGROUND: Severe community-acquired pneumococcal meningitis is a medical emergency. The aim of the present investigation was to evaluate the epidemiology, management and outcomes of this condition. METHODS: This was a retrospective, observational and multicenter cohort study. Sixteen Spanish intensive care units (ICUs) were included. Demographic, clinical and microbiological variables from patients with Streptococcus pneumoniae meningitis admitted to ICU were evaluated. Clinical response was evaluated at 72 h after antibiotic treatment initiation, and meningitis complications, length of stay and 30-day mortality were also recorded. RESULTS: In total, 255 patients were included. Cerebrospinal fluid (CSF) culture was positive in 89.7%; 25.7% were non-susceptible to penicillin, and 5.2% were non-susceptible to ceftriaxone or cefotaxime. The most frequent empiric antibiotic regimen was third-generation cephalosporin (47.5%) plus vancomycin (27.8%) or linezolid (12.9%). A steroid treatment regimen was administered to 88.6% of the patients. Clinical response was achieved in 65.8% of patients after 72 h of antibiotic treatment. Multivariate analysis identified two factors associated with early treatment failure: invasive mechanical ventilation (OR 10.74; 95% CI 3.04-37.95, p < 0.001) and septic shock (OR 1.18; 95% CI 1.03-1.36, p = 0.017). The 30-day mortality rate was 13.7%. Only three factors were independently associated with 30-day mortality: delay in start of antibiotic treatment (OR 18.69; 95% CI 2.13-163.97, p = 0.008), Sepsis-related Organ Failure Assessment (SOFA) score (OR 1.36; 95% CI 1.12-1.66, p = 0.002) and early treatment failure (OR 21.75 (3.40-139.18), p = 0.001). Neurological complications appeared in 124 patients (48.63%). CONCLUSIONS: Mortality rate in critically ill patients with pneumococcal meningitis is lower than previously reported. Delay in antibiotic treatment following admission is the only amendable factor associated with mortality.

Effect of protein underdosing on the prognosis of patients with severe acute heart failure in the early acute phase: A single-institutional retrospective cohort study.

BACKGROUND: The appropriate protein dose during the early acute phase of severe acute heart failure (AHF) remains unknown. We hypothesized that protein underdosing during this period may lead to a poor prognosis. Thus, we investigated the relationship between protein sufficiency rate and prognosis during the early acute phase in patients with severe AHF. METHODS: This retrospective observational study investigated patients with AHF requiring invasive mechanical ventilation who were admitted in the intensive care and cardiac care units between January 2015 and August 2021. These patients were ranked according to the tertile of protein sufficiency rate on intubation day 2. Univariate and multivariate logistic regression analyses were performed to determine whether a low protein sufficiency rate on intubation day 2 was an independent factor for in-hospital mortality. Patients were weighted using the inverse probability of treatment weighting (IPTW) method to determine the differences in baseline characteristics. RESULTS: A total of 118 patients were included in the study and divided into low-protein (n = 40) and non-low-protein (n = 78) groups with protein sufficiency rates of ≤10% and >10%, respectively.In the multivariate analysis of in-hospital mortality, low protein sufficiency on day 2 was identified as an independent factor (odds ratio [OR] = 2.77, 95% confidence interval [CI] = 1.05-7.27, P = 0.039). After adjusting for baseline characteristics using the IPTW method, multiple logistic regression analysis of in-hospital mortality revealed low protein sufficiency on day 2 as an independent factor (OR = 3.32, 95% CI = 1.18-9.32, P = 0.023). CONCLUSION: Protein underdosing in the early acute phase of severe AHF may be associated with increased in-hospital mortality.

Estimated continuous cardiac output based on pulse wave transit time in critically ill children: a report of two cases / Débito cardíaco contínuo estimado baseado no tempo de trânsito da onda de pulso em crianças em estado crítico: relato de dois casos

ABSTRACT Cardiac output is an essential determinant of oxygen delivery, although unreliably measured on clinical examination and routine monitoring. Unfortunately, cardiac output monitoring is rarely performed in pediatric critical care medicine, with a limited availability of accurate methods for children. Herein, we report two pediatric cases in which noninvasive pulse-wave transit time-based cardiac output monitoring (esCCO, Nihon Kohden, Tokyo, Japan) was used. The esCCO system calculates cardiac output continuously by using the negative correlation between stroke volume and pulse wave transit time and requires only electrocardiogram monitoring, noninvasive blood pressure, and pulse oximetry signals. Before starting its use, esCCO should be calibrated, which can be done using patient information (gender, age, height, and body weight) or entering cardiac output values obtained by other methods. In both cases, when calibrations were performed using patient information, the agreement between esCCO and echocardiographic measurements was poor. However, after calibration with transthoracic echocardiography, the cardiac output values obtained by both methods remained similar after 2 hours and 18 hours. The results indicate that the esCCO system is suitable for use in children; however, further studies are needed to optimize its algorithm and determine its accuracy, precision, and trend in children.

RESUMO O débito cardíaco é um determinante importante do fornecimento de oxigênio, embora a sua mensuração seja realizada de forma pouco confiável no exame clínico e no monitoramento de rotina. Infelizmente, o monitoramento do débito cardíaco raramente é realizado na medicina intensiva pediátrica, com disponibilidade limitada de métodos precisos para crianças. Relatamos aqui dois casos pediátricos nos quais utilizouse o monitoramento não invasivo do débito cardíaco por meio da análise do tempo de trânsito de ondas de pulso (esCCO, Nihon Kohden, Tóquio, Japão). O sistema esCCO calcula o débito cardíaco continuamente pela correlação negativa entre o volume sistólico e o tempo de trânsito de ondas de pulso e requer apenas o monitoramento por eletrocardiograma, pressão arterial não invasiva e sinais de oximetria de pulso. Antes de iniciar seu uso, o esCCO deve ser calibrado, o que pode ser feito com informações do paciente (sexo, idade, altura e peso corporal) ou informando os valores do débito cardíaco obtidos mediante outros métodos. Em ambos os casos, quando as calibragens foram realizadas com informações do paciente, a concordância entre o débito cardíaco contínuo estimado e as medidas ecocardiográficas foi insatisfatória. Entretanto, após a calibragem com ecocardiografia transtorácica, os valores do débito cardíaco obtidos pelos dois métodos permaneceram semelhantes após 2 horas e 18 horas. Os resultados indicam que o sistema esCCO pode ser útil em crianças; entretanto, são necessários mais estudos para otimizar seu algoritmo e determinar sua exatidão, precisão e tendência em crianças.

The value of systemic immune inflammation index in predicting the risk of hospital death in critically ill patients / 中华急诊医学杂志

Objective:To explore the predictive value of systemic immune inflammation index (SII) for the risk of hospital death in critically ill patients.Methods:The basic information and clinical data of critically ill patients were extracted from the Medical Information Mart for Intensive Care database-Ⅳ (MIMIC-IV) database, including demographic data, vital signs, blood routine, Logistic organ dysfunction score (Lods), Oxford acute severity of illness score (Oasis), simplified acute physiology score (Saps-Ⅱ), acute physiology score Ⅲ (APS-Ⅲ), sequential organ failure score (SOFA) and outcome. The main outcome was hospital death, and the secondary outcomes were length of hospital stay, continuous renal replacement therapy (CRRT), invasive ventilation and 1-year mortality. Patients were divided into two groups according to in-hospital death, and the differences between the groups were compared. According to the SII tripartite for inter-group comparison, the patients were further divided into three groups for comparison, and Logistic regression model was used to analyze the odd ratio ( OR) of the three groups. Results:A total of 32 450 critically ill patients were included in the study, of which 3765 died in hospital, with a mortality rate of 11.6%. ① Compared with the survival group, the SII in the death group were significantly higher ( P < 0.05). ② The mortality for the SII tripartite grouping (<817; 817~2 151; >2 151) were 8.4%, 10.2% and 16.3%, respectively, and the differences between groups were statistically significant. ③ Further, Logistic regression model analysis showed that the risk of death increased gradually with the increase of groups (the first group was the reference group, OR of the second group was 1.38, 95% CI 1.24-1.54, and OR of the third group was 2.03, 95% CI 1.83-2.24 ( P < 0.05). Conclusions:SII has a certain value in predicting hospital death in critically ill patients. It is easy to obtain and can be used for risk stratification of critically ill patients.

Development and validation of a nomogram to predict in-hospital cardiac arrest in critically ill patients / 中华急诊医学杂志

Objective:To explore the independent risk factors of in-hospital cardiac arrest (IHCA) in critically ill patients and construct a nomogram model to predict the risk of IHCA based on the identified risk factors.Methods:Patients who were admitted to the intensive care units (ICUs) from 2008 to 2019 were retrospectively enrolled from the Medical Information Mart for Intensive Care -Ⅳ database. The patients were excluded if they (1) were younger than 18 years old, (2) had repeated ICU admission records, or (3) had an ICU stay shorter than 24 h. The patients were randomly divided into the training and internal validation cohorts (7 : 3). Univariate and multivariate logistic regression models were used to identify independent risk factors of IHCA, and a nomogram was constructed based on these independent risk factors. Calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used to evaluate the nomogram model. Finally, the nomogram was externally validated using the emergency ICU collaborative research database.Results:A total of 41,951 critically ill patients were enrolled (training cohort, n=29 366; internal validation cohort, n=12 585). Multivariate analysis showed that myocardial infarction, pulmonary heart disease, cardiogenic shock, respiratory failure, acute kidney injury, respiratory rate, glucose, hematocrit, sodium, anion gap, vasoactive drug use, and invasive mechanical ventilation were independent risk factors of IHCA. Based on the above risk factors, a nomogram for predicting IHCA was constructed. The area under the ROC curve (AUC) of the nomogram was 0.817 (95% CI: 0.785–0.847). The calibration curve showed that the predicted and actual probabilities of the nomogram were consistent. Moreover, DCA showed that the nomogram had clinical benefits for predicting IHCA. In the internal validation cohort, the nomogram had a similar predictive value of IHCA (AUC=0.807, 95% CI: 0.760–0.862). In an external validation cohort of 87,626 critically ill patients, the nomogram had stable ability for predicting IHCA (AUC=0.804, 95% CI: 0.786–0.822). In addition, the nomogram also had predictive value for in-hospital mortality (AUC=0.818, 95% CI: 0.802-0.834). Conclusions:The nomogram is constructed based on identified independent risk factors, which has good predictive value for IHCA. Moreover, the performance of the nomogram in the external validation cohort is robust. The study findings may help clinicians to assess the risk of IHCA in critically ill patients.

Application of Machine Learning for Clinical Subphenotype Identification in Sepsis.

INTRODUCTION: Sepsis is a heterogeneous clinical syndrome. Identification of sepsis subphenotypes could lead to allowing more precise therapy. However, there is a lack of models to identify the subphenotypes in such patients. Thus, we aimed to identify possible subphenotypes and compare the clinical outcomes for subphenotypes in a large sepsis cohort. METHODS: This machine learning-based, cluster analysis was performed using the Medical Information Mart in Intensive Care (MIMIC)-IV database. We enrolled all adult (> 18 years old) patients diagnosed with sepsis in the first 24 h after intensive care unit (ICU) admission. K-means cluster analysis was performed to identify the number of classes. Multivariable logistic regression models were used to estimate the association between sepsis subphenotypes and in-hospital mortality. RESULTS: A total of 8817 participants with sepsis were enrolled. The median age was 66.8 (IQR, 55.9-77.1) years, and 38.1% (3361/8817) were female. Two subphenotypes resulted in optimal separation including 11 routinely available clinical variables obtained during the first 24 h after ICU admission. Participants in subphenotype B showed higher levels of lactate, glucose and creatinine, white blood cell count, sodium and heart rate and lower body temperature, platelet count, systolic blood pressure, hemoglobin and PaO2/FiO2 ratio. In addition, the in-hospital mortality in patients with subphenotype B was significantly higher than that in subphenotype A (29.4% vs. 8.5%, P < 0.001). The difference was still significant after adjustment for potential covariates (adjusted OR 2.214; 95% CI 1.780-2.754, P < 0.001). CONCLUSIONS: Two sepsis subphenotypes with different clinical outcomes could be rapidly identified using the K-means clustering analysis based on routinely available clinical data. This finding may help clinicians to identify the subphenotype rapidly at the bedside.

Care Intensity and Palliative Care in Chronically Critically Ill Infants.

CONTEXT: Increasingly, chronically critically ill (CCI) infants survive to discharge from Neonatal Intensive Care Units (NICUs). Little is known about their care intensity and the primary and specialty palliative care families receive at and following discharge. OBJECTIVES: To describe care intensity and primary and specialty palliative care received by NICU CCI infants at discharge and one year. METHODS: Chart abstraction of CCI infants at three academic centers discharged at ≥42 weeks corrected gestational age with medical technology between 2016 and 2019, including demographics, care intensity, and primary and specialty palliative care received at discharge and one year. RESULTS: Among 273 infants, NICU median stays were 45 [IQR 23-92] days. Primary diagnoses included congenital and/or genetic conditions (68.5%), prematurity (28.2%), and birth events (3.3%). At discharge, surgical feeding tubes (75.1%) and tracheostomies (24.5%) were the most common technologies. Infants received a median of 6 [IQR 4-9] medications and were followed by a median of 8 [IQR 7-9] providers. At one year, 91.4% continued with one or more technologies, similar numbers of medications and specialty providers. In the NICU, nearly all families had social work involvement, 78.8% had chaplaincy and 53.8% child life; 19.8% received specialty palliative care consultation. At one year, only 13.2% were followed by palliative care. CONCLUSIONS: CCI infants receive intensive medical care including multiple medical technologies, medications, and specialty follow up at discharge and remain complex at one year of life. Most receive primary interprofessional palliative care in the NICU, however these infants and their families may have limited access to specialty palliative care in the short- and long-term.

Incidência e fatores de risco associados à síndrome pós-cuidados intensivos em uma coorte de pacientes em estado crítico / Incidence and risk factors for postintensive care syndrome in a cohort of critically ill patients

RESUMO Objetivo: Determinar a incidência da síndrome pós-cuidados intensivos em uma coorte de pacientes em estado crítico admitidos à unidade de terapia intensiva e identificar fatores de risco relacionados ao seu desenvolvimento nas áreas de saúde física, cognitiva e mental. Métodos: Este foi um estudo de coorte observacional prospectivo desenvolvido na unidade de terapia intensiva de um hospital universitário. Foram incluídos no estudo pacientes internados em unidade de terapia intensiva a partir de 1 semana e com necessidade de ventilação mecânica por mais de 3 dias, choque ou delirium. Foram registradas variáveis demográficas, motivo da admissão, diagnósticos, sedação, tipo de ventilação mecânica, complicações e tempo de internação. Realizou-se análise univariada para identificar os fatores de risco relacionados à síndrome pós-cuidados intensivos. As escalas utilizadas para a avaliação das diferentes esferas foram Barthel, Pfeiffer, Hospital Anxiety and Depression Scale e Impact of Event Scale-6. As principais variáveis de interesse foram incidência da síndrome pós-cuidados intensivos de modo geral e por domínios. Os fatores de risco foram examinados em cada um dos domínios da saúde (saúde física, cognitiva e mental). Resultados: Participaram 87 pacientes. A Acute Physiology and Chronic Health Evaluation II média foi de 16,5. O número médio de dias na unidade de terapia intensiva foi 17. A incidência geral da síndrome pós-cuidados intensivos foi de 56,3% (n = 49; IC95% 45,8 - 66,2). A incidência da síndrome pós-cuidados intensivos em cada uma das esferas foi de 32,1% (física), 11,5% (cognitiva) e 36,6% (saúde mental). Conclusão: A incidência da síndrome pós-cuidados intensivos foi de 56,3%. A esfera da saúde mental foi a mais frequentemente envolvida. Os fatores de risco diferem, dependendo da área considerada.

ABSTRACT Objective: To determine the incidence of postintensive care syndrome in a cohort of critically ill patients admitted to the intensive care unit and to identify risk factors related to its development in the physical, cognitive and mental health areas. Methods: This was a prospective observational cohort study developed in the intensive care unit of a university hospital. Patients with intensive care unit stays equal to or longer than one week and the need for mechanical ventilation for more than 3 days, shock or delirium were included in the study. Demographic variables, reasons for admission, diagnoses, sedation, type of mechanical ventilation used, complications and length of stay were recorded. A univariate analysis was performed to identify risk factors related to postintensive care syndrome. The scales used for the assessment of the different spheres were Barthel, Pfeiffer, Hospital Anxiety and Depression Scale and Impact of Event Scale-6. The main variables of interest were postintensive care syndrome incidence overall and by domains. Risk factors were examined in each of the health domains (physical, cognitive and mental health). Results: Eighty-seven patients were included. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. The mean number of intensive care unit days was 17. The incidence of global postintensive care syndrome was 56.3% (n = 49, 95%CI 45.8 - 66.2%). The incidence of postintensive care syndrome in each of the spheres was 32.1% (physical), 11.5% (cognitive), and 36.6% (mental health). Conclusions: The incidence of postintensive care syndrome is 56.3%. The mental health sphere is the most frequently involved. The risk factors are different depending on the area considered.

Severe Thrombocytopenia Caused by Vancomycin in the Intensive Care Unit: A Case Report.

Thrombocytopenia can cause substantial morbidity and mortality in critically ill patients. There are multiple etiology factors and various mechanisms associated with thrombocytopenia, of which drug-induced thrombocytopenia (DITP) deserves attention. Herein, we describe a case of severe thrombocytopenia during intensive care unit (ICU) hospitalization that was likely to be associated with vancomycin. By revealing the process of identifying this case of DITP and reviewing relevant clinical studies, a risk alert of vancomycin-related severe hematotoxicity should be considered.

Application of interpretable machine learning for early prediction of prognosis in acute kidney injury.

Background: This study aimed to develop an algorithm using the explainable artificial intelligence (XAI) approaches for the early prediction of mortality in intensive care unit (ICU) patients with acute kidney injury (AKI). Methods: This study gathered clinical data with AKI patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) in the US between 2008 and 2019. All the data were further randomly divided into a training cohort and a validation cohort. Seven machine learning methods were used to develop the models for assessing in-hospital mortality. The optimal model was selected based on its accuracy and area under the curve (AUC). The SHapley Additive exPlanation (SHAP) values and Local Interpretable Model-Agnostic Explanations (LIME) algorithm were utilized to interpret the optimal model. Results: A total of 22,360 patients with AKI were finally enrolled in this study (median age, 69.5 years; female, 42.8%). They were randomly split into a training cohort (16770, 75%) and a validation cohort (5590, 25%). The eXtreme Gradient Boosting (XGBoost) model achieved the best performance with an AUC of 0.890. The SHAP values showed that Glasgow Coma Scale (GCS), blood urea nitrogen, cumulative urine output on Day 1 and age were the top 4 most important variables contributing to the XGBoost model. The LIME algorithm was used to explain the individualized predictions. Conclusions: Machine-learning models based on clinical features were developed and validated with great performance for the early prediction of a high risk of death in patients with AKI.

É possível estimar a saturação venosa de oxigênio central a partir da saturação tecidual de oxigênio durante o teste de oclusão venosa? / Can central-venous oxygen saturation be estimated from tissue oxygen saturation during a venous occlusion test?

RESUMO Objetivo: Testar se, após um teste de oclusão venosa, a taxa de saturação tecidual de oxigênio é capaz de estimar a taxa de saturação venosa de oxigênio central. Métodos: Realizou-se estudo observacional em pacientes de unidade de terapia intensiva. A taxa de saturação tecidual de oxigênio foi monitorada a partir de um espectrômetro tecidual (InSpectra modelo 650, Hutchinson Technology Inc., MN, Estados Unidos) com uma sonda múltipla de 15mm e 25mm na posição tenar. Aplicou-se um teste de oclusão venosa no braço superior de voluntários para testar a tolerabilidade e o padrão de mudanças na taxa de saturação tecidual de oxigênio durante a realização do teste de oclusão venosa. Inflou-se um manguito de esfigmomanômetro a uma pressão 30mmHg maior que a pressão diastólica até que a taxa de saturação tecidual de oxigênio alcançasse um platô e o manguito fosse desinflado a 0mmHg. Os parâmetros da taxa de saturação tecidual de oxigênio foram classificados como em repouso e mínima ao final do teste de oclusão venosa. Nos pacientes, o manguito foi inflado a uma pressão 30mmHg maior que a pressão diastólica durante 5 minutos, que foi o tempo derivado dos voluntários, ou até que a taxa de saturação tecidual de oxigênio atingisse um platô. Os parâmetros da taxa de saturação tecidual de oxigênio foram classificados como em repouso e mínima, e o tempo médio que a taxa de saturação tecidual de oxigênio se igualou à de saturação venosa de oxigênio central. A taxa de saturação tecidual de oxigênio no tempo médio foi comparada à de saturação venosa de oxigênio central. Resultados: Todos os nove voluntários toleraram bem o teste de oclusão venosa. O tempo de tolerabilidade ou o platô da taxa de saturação tecidual de oxigênio foi de 7 ± 1 minutos. Estudamos 22 pacientes. O tempo médio para a equalização da taxa de saturação tecidual de oxigênio à de saturação venosa de oxigênio central foi de 100 segundos e 95 segundos, utilizando sondas de 15 e 25mm, respectivamente. A taxa de saturação tecidual de oxigênio em 100 segundos foi de 74% ± 7%, utilizando sonda de 15mm, e de 74% ± 6%, utilizando sonda de 25mm. Então, as taxas foram comparadas à taxa de saturação venosa de oxigênio central, que apresentou 75% ± 6%. A taxa de saturação tecidual de oxigênio em 100 segundos correlacionou-se com a de saturação venosa de oxigênio central (15mm: R2 = 0,63; 25mm: R2 = 0,67; p < 0,01) sem discrepância (Bland-Altman). Conclusão: A taxa de saturação venosa de oxigênio central pode ser estimada a partir da taxa de saturação tecidual de oxigênio, a partir de um teste de oclusão venosa.

ABSTRACT Objective: To test whether tissue oxygen saturation (StO2) after a venous occlusion test estimates central venous oxygen saturation (ScvO2). Methods: Observational study in intensive care unit patients. Tissue oxygen saturation was monitored (InSpectra Tissue Spectrometer Model 650, Hutchinson Technology Inc., MN, USA) with a multiprobe (15/25mm) in the thenar position. A venous occlusion test in volunteers was applied in the upper arm to test the tolerability and pattern of StO2 changes during the venous occlusion test. A sphygmomanometer cuff was inflated to a pressure 30mmHg above diastolic pressure until StO2 reached a plateau and deflated to 0mmHg. Tissue oxygen saturation parameters were divided into resting StO2 (r-StO2) and minimal StO2 (m-StO2) at the end of the venous occlusion test. In patients, the cuff was inflated to a pressure 30mmHg above diastolic pressure for 5 min (volunteers' time derived) or until a StO2 plateau was reached. Tissue oxygen saturation parameters were divided into r-StO2, m-StO2, and the mean time that StO2 reached ScvO2. The StO2 value at the mean time was compared to ScvO2. Results: All 9 volunteers tolerated the venous occlusion test. The time for tolerability or the StO2 plateau was 7 ± 1 minutes. We studied 22 patients. The mean time for StO2 equalized ScvO2 was 100 sec and 95 sec (15/25mm probes). The StO2 value at 100 sec ([100-StO2] 15mm: 74 ± 7%; 25mm: 74 ± 6%) was then compared with ScvO2 (75 ± 6%). The StO2 value at 100 sec correlated with ScvO2 (15 mm: R2 = 0.63, 25mm: R2 = 0.67, p < 0.01) without discrepancy (Bland Altman). Conclusion: Central venous oxygen saturation can be estimated from StO2 during a venous occlusion test.

Acute kidney injury in ventilated patients with coronavirus disease-2019 pneumonia: A single-center retrospective study.

BACKGROUND: Acute kidney injury (AKI) is repeatedly observed in ventilated critically ill patients with coronavirus disease-2019 (COVID-19) pneumonia. This study aimed to determine the incidence, risk factors, and consequences of AKI in the ventilated critically ill adult patients with COVID-19 pneumonia. METHODS: This retrospective study included all the ventilated critically ill adult patients with COVID-19 pneumonia from March 1, 2020, to June 1, 2020. Data were collected from the electronic medical system. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice definition. Patients were followed 90 days from the intensive care unit (ICU) admission time or to the date when they were discharged from the hospital. RESULTS: AKI occurred in 65.1% of patients, with 26.6% of these started on continuous renal replacement therapy (CRRT). Patients with AKI had higher comorbidity and illness severity scores (P < 0.001). Age and the vasopressor requirements were predictors of AKI (P= 0.016 and P = 0.041) and hypertension predicted AKI (P = 0.099) and its progression (P = 0.05). The renal recovery rate was 86.7% and was associated with the mean arterial pressure on ICU admission in the no-CRRT group (P = 0.014) and the hypoxic index in the CRRT group (P = 0.019). AKI was associated with higher mortality (P = 0.017) and significantly longer ICU length-of-stay (P = 0.001). Additionally, AKI patients were more often discharged to a long-term skilled nursing facility (P = 0.005). CONCLUSION: COVID-19-associated AKI was common and associated with poor outcome, with the specific mechanisms being the main driving factors.

Evaluation of Nociception Using Quantitative Pupillometry and Skin Conductance in Critically Ill Unconscious Patients: A Pilot Study.

BACKGROUND: Pain assessment is a challenge in critically ill patients, in particular those who are unable to express movements in reaction to noxious stimuli. The purpose of the study was to compare the pupillary response and skin conductance to pain stimulation in critically ill unconscious patients. METHODS: This observational study included adult patients admitted to the intensive care unit (ICU) with acute brain injury (Glasgow Coma Scale < 9 with a motor response < 5) and/or requirements for deep level of sedation. Automated pupillometry (Algiscan, ID-MED, Marseille, France) was used to determine pupillary reflex dilation during tetanic stimulation. The maximum intensity of the stimulation value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception): a pupillary pain index (PPI) score of ≤4 was used to reflect adequate pain control. For skin conductance (SC), the number of SC peaks per second (NSCF) was collected concomitantly to tetanic stimulation. An NSCF of ≤0.07 peak/second was used to reflect adequate pain control. RESULTS: Of the 51 included patients, there were 32 with brain injury and 19 receiving deep sedation. Mean PPI score was 5 (Interquartile Range= 2-7); a total of 28 (55%) patients showed inadequate control of the nociceptive stimulation according to the PPI assessment. Only 15 (29%) patients showed a detectable skin conductance, with NSCF values from 0.07 to 0.47/s. No correlation was found between skin conductance algesimeter (SCA)-derived variables and PPI score or pupillary dilation to pain. CONCLUSIONS: Detection of inadequate pain control might vary according to the method used to assess nociception in ICU patients. A poor agreement between quantitative pupillometry and skin conductance was observed.

A retrospective evaluation of a multiplex polymerase chain reaction test directly applied to blood for the management of sepsis in the critically ill.

Background: Blood culture (BC) is the established gold standard for microbiological diagnosis of bloodstream infection (BSI); however, its sensitivity is poor. Objectives: The primary objective was to determine the sensitivity and specificity of the Magicplex Sepsis Real-time Test, a multiplex polymerase chain reaction test (mPCR), and BC to detect BSIs. Secondary outcomes included determining the prevalence of BSIs. Methods: A retrospective review of a technical evaluation of the mPCR. Patients requiring BC had a blood sample collected for mPCR. Results: The respective sensitivity and specificity of mPCR for the detection of BSI were 50% (n=7/14) and 58% (n=18/31), while the sensitivity and specificity using BC were 36% (n=5/14) and 68% (n=21/31), respectively. The addition of mPCR to BC increased BSI detection during sepsis from 36% to 64%. Conclusion: The use of mPCR directly applied to blood may increase the detection of micro-organisms associated with BSIs in critically ill patients requiring BC investigation. Contributions of the study: Our data add to a growing body of evidence indicating that mPCR applied directly to blood prior to incubation increases the detection of pathogenic bacteria among hospitalised patients for whom blood cultures are performed for suspected infection. Our study was performed in a low-to-middle income country with a higher sepsis prevalence, a greater burden of multidrug-resistant organisms and clinically defined sepsis. This strengthens the robustness and generalisability of this body of evidence.

Antioxidant micronutrient supplementation in critically ill adults: A systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: The role of antioxidant micronutrient (AxM) supplementation in the critically ill patients has been controversial, and recent trials have suggested a tendency to harm. Therefore, we performed a systematic review with meta-analysis and trial sequential analysis (TSA) of randomized controlled trials (RCT) to examine the effect of AxM supplementation on clinical outcomes among critically ill adults. METHODS: PubMed, EMBASE, Cochrane, CINAHL, LILACS, DARE, SCOPUS, and Web of sciences databases were searched from inception to March 2019. RCTs that compared AxM supplements with placebo in adult critically ill patients and reporting mortality as an outcomes were included. Trial quality was assessed using updated cochrane risk of bias (RoB-II) tool. Primary outcome was all-cause mortality. Secondary outcomes were 28-day mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilator days and infection between the two groups. Outcomes were summarised using random-effects estimators. Quality of evidence (QOE) was rated using Grading of Recommendations, Assessment, Development and Evaluation. Prior to final analysis, we repeated the search through September 2019. R version 3.6.2 and STATA version 13 were used for all statistical analyses. RESULTS: Pooled analysis of 34 trials with 4678 patients revealed that AxM supplementation was associated with possible reduction in all-cause mortality (relative risk [RR], 0.89 [95%CI 0.79 to 0.99], TSA adjusted CI 0.77 to 1.03; Low QOE). Fragility index and number needed to treat were 1 and 41, respectively. Eight studies with low RoB (RR, 1.08; 95%CI 0.95 to 1.23; TSA CI, 0.64 to 1.82; moderate QOE) did not show mortality reduction with AxM supplementation. SECONDARY OUTCOMES: ICU LOS (weighted mean difference [WMD], -0.84; 95%CI -1.50 to -0.18; moderate QOE), hospitalization days (WMD, -2.83; 95%CI -3.91to -1.75; low QOE) and ventilator days (WMD, -1.87; 95%CI -3.60 to -0.14; very low QOE) showed a statistically significant benefit with AxM supplementation. In meta-regression analysis, neither the duration of AxM therapy nor the dosage of selenium, which was the most widely studied AxM, reported an association with mortality. CONCLUSION: Although AxM supplementation was associated with possible reduction in all-cause mortality, results from the TSA and studies with low RoB showing null effect suggest that the evidence of benefit is questionable. Secondary outcomes attained statistically significant benefit with AxM supplements, but the certainity of evidence was low. To summarize, current evidence does not justify administration of AxM in critically ill patients. REGISTRATION: PROSPERO, CRD42019125898.