The latest medical research on Critical Care

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about critical care gathered by our medical AI research bot.

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Burn Injury-Induced Extracellular Vesicle Production and Characteristics.

Shock

Extracellular vesicles (EVs) are nano-sized membrane-bound particles containing biologically active cargo molecules. The production and molecular c...

Intracranial Pressure Monitoring in Moderate Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Neurocritical Care

The principal aim of this study was to determine the prevalence of intracranial pressure (ICP) monitoring and intracranial hypertension (IHT) in patients treated for moderate traumatic brain injury (TBI). A secondary objective was to assess factors associated with ICP monitoring.

We conducted a systematic review of the literature to identify studies that assessed ICP monitoring in moderate TBI. The meta-analysis was performed by using a random-effects model.

A total of 13 studies comprising 116,714 patients were pooled to estimate the overall prevalence of ICP monitoring and IHT (one episode or more of ICP > 20 mm Hg) after moderate TBI. The prevalence rate for ICP monitoring was 18.3% (95% confidence interval 8.1-36.1%), whereas the proportion of IHT was 44% (95% confidence interval 33.8-54.7%). Three studies were pooled to estimate the prevalence of ICP monitoring according to Glasgow Coma Scale (GCS) (≤ 10 vs. > 10). ICP monitoring was performed in 32.2% of patients with GCS ≤ 10 versus 15.2% of patients with GCS > 10 (p = 0.59). Both subgroups were highly heterogeneous. We found no other variables associated with ICP monitoring or IHT.

The prevalence of ICP monitoring in moderate TBI is low, but the prevalence of IHT is high among patients undergoing ICP monitoring. Current literature is limited in size and quality and does not identify factors associated with ICP monitoring or IHT. Further research is needed to guide the optimal use of ICP monitoring in moderate TBI.

Historical Redlining Impacts Contemporary Environmental and Asthma-Related Outcomes in Black Adults.

Resp Crit Care Med

Environmental threats and poorly controlled asthma disproportionately burden Black people. Some have attributed this to socioeconomic or biologic factors; however, racism, specifically historical redlining, a US discriminatory mortgage lending practice in existence between the 1930s-1970s, may have actuated and then perpetuated poor asthma-related outcomes.

To link historical redlining (institutional racism) to contemporary environmental quality- and lung health-related racial inequity.

Leveraging a broadly-recruited asthma registry, we geocoded 1,034 registry participants from Pittsburgh/Allegheny County, Pennsylvania, USA to neighborhoods subjected to historical redlining, as defined by a 1930s Home Owner's Loan Corporation (HOLC) map. Individual-level clinical/physiologic data, residential air pollution, demographics, and socioeconomic factors provided detailed characterization. We determined the prevalence of uncontrolled and/or severe asthma and other asthma-related outcomes by HOLC (neighborhood) grade ("A"-"D"). We performed a stratified analysis by self-identified race to assess the distribution of environmental and asthma risk within each HOLC grade.

The registry sampling overall reflected Allegheny County neighborhood populations. The emissions of carbon monoxide, filterable particulate matter <2.5 microns (PM2.5), sulfur dioxide (SO2), and volatile organic compounds (VOCs) increased across HOLC grades (all p≤0.004), with "D" neighborhoods encumbered by the highest levels. The persistent, dispersive socioenvironmental burden peripherally extending from "D" neighborhoods, including racialized access to healthy environments (structural racism), supported a long-term impact of historical/HOLC redlining. The worst asthma-related outcomes, including uncontrolled and/or severe asthma (p<0.001, Z=3.81), and evidence for delivery of sub-optimal asthma care occurred among registry participants from "D" neighborhoods. Furthermore, elevated exposure to filterable PM2.5, SO2, and VOCs emissions (all p<0.050) and risk of uncontrolled and/or severe asthma (relative risk [95% confidence interval] = 2.30 [1.19, 4.43], p=0.009) demonstrated inequitable distributions within "D" neighborhood boundaries, disproportionately burdening Black registry participants.

The racist practice of historical/HOLC redlining profoundly contributes to long-term environmental and asthma-related inequities in Black adults. Acknowledging the role racism has in these outcomes should empower more specific and novel interventions targeted at reversing these structural issues.

The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial.

Resp Crit Care Med

Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 d...

End-Tidal to Arterial PCO2 Ratio as Guide to Weaning from Veno-Venous Extra-Corporeal Membrane Oxygenation.

Resp Crit Care Med

Weaning from veno-venous extracorporeal membrane oxygenation (VV-ECMO) is based on oxygenation and not on carbon dioxide elimination.

To predict readiness to wean from VV-ECMO Methods: In this multicenter study of mechanically ventilated adults with severe acute respiratory distress syndrome (ARDS) receiving VV-ECMO, we investigated a variable based on CO2 elimination. The study included a prospective interventional study of a physiological cohort (n=26), and a retrospective clinical cohort (n=638).

Weaning failure in the clinical and physiological cohorts were respectively 37% and 42%. The main cause of failure in the physiological cohort was high inspiratory effort or respiratory rate. All patients exhaled similar amounts of CO2 but in patients who failed the weaning trial minute ventilation was higher to maintain the PaCO2 unchanged. The effort to eliminate one unit-volume of CO2, was double in failing patients [68·9 (42·4-123) vs. 39 (20·1-57) [cmH2O/(L/min)], p=0.007], owing to the higher physiological dead space [68 (58.73) % vs. 54 (41,.64) %; p=0.012]. PetCO2/PaCO2 ratio was a clinical variable strongly associated with weaning outcome at baseline was the, AUC: 0.87 (95%CI 0·71 - one). Similarly, the PetCO2/PaCO2 ratio was associated with weaning outcome in the "clinical cohort" both pre-weaning trial (OR 4·14; 95% CI 1·32 - 12·2; p=0·015), and at a sweep gas flow of zero (OR 13·1; 95% CI 4-44·4; p<0·001).

The primary reason for weaning failure from VV-ECMO is high effort to eliminate CO2. A higher PetCO2/PaCO2 ratio was associated with greater likelihood of weaning from VV-ECMO.

The Contribution of Chest Radiography to the Clinical Management of Children Exposed to Tuberculosis.

Resp Crit Care Med

Although World Health Organization guidelines emphasize contact investigation for tuberculosis-exposed children, data that support chest radiography as a useful tool are lacking.

We evaluated the diagnostic and prognostic information of chest radiography in children exposed to TB and measured the efficacy of isoniazid preventive therapy in those with relevant radiographic abnormalities.

Between September 2009 and August 2012, we enrolled 4,468 TB-exposed children who were screened by tuberculin skin testing, symptom assessment and chest radiography. Those negative for TB disease were followed for one year for the occurrence of new TB diagnoses. We assessed the protective efficacy of isoniazid preventive therapy in children with and without abnormal chest radiographs.

Compared to asymptomatic children with normal chest films, asymptomatic children with abnormal radiographs were 25.1-fold more likely to have co-prevalent TB (95%CIs=1.02-613.76) and 26.7-fold more likely to be diagnosed with incident tuberculosis disease during follow-up (95%CIs=10.44-68.30). Among the 29 symptom-negative/CXR-abnormal child contacts, 20% (3/15) of the isoniazid recipients developed incident TB, compared to 57% (8/14) of those who did not receive isoniazid preventive therapy (82% IPT efficacy).

Our results strongly support the use of chest radiography as a routine screening tool for the evaluation of child TB contacts, where this is readily available. Radiographic abnormalities not usually considered suggestive of TB may indicate incipient or subclinical disease, although TB preventive treatment is adequate in most cases.

Renin-Angiotensin System Pathway Therapeutics Associated With Improved Outcomes in Males Hospitalized With COVID-19.

Critical Care Medicine

To determine whether angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme (ACE) inhibitors are associated with improved outcomes in hospitalized patients with COVID-19 according to sex and to report sex-related differences in renin-angiotensin system (RAS) components.

None.

Males on ARBs before admission had decreased use of ventilation (adjusted odds ratio [aOR] = 0.52; p = 0.007) and vasopressors (aOR = 0.55; p = 0.011) compared with males not on ARBs or ACE inhibitors. No significant effects were observed in females for these outcomes. The test for interaction was significant for use of ventilation (p = 0.006) and vasopressors (p = 0.044) indicating significantly different responses to ARBs according to sex. Males had significantly higher plasma ACE-1 at baseline and angiotensin II at day 7 and 14 than females.

ARBs use was associated with less ventilation and vasopressors in males but not females. Sex-based differences in RAS dysregulation may contribute to sex-based differences in outcomes and responses to ARBs in COVID-19.

Electrical Impedance Tomography in Acute Respiratory Distress Syndrome Management.

Critical Care Medicine

To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum.

Data from relevant publications were reviewed, analyzed, and its content summarized.

Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined.

Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.

Tracheostomy Practices and Outcomes in Patients With COVID-19 Supported by Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry.

Critical Care Medicine

The use of extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 has been supported by major healthcare organizations, yet the role of specific management strategies during ECMO requires further study. We sought to characterize tracheostomy practices, complications, and outcomes in ECMO-supported patients with acute respiratory failure related to COVID-19.

None.

We identified 7,047 patients who received ECMO support for acute respiratory failure related to COVID-19. A total of 32% of patients were recorded as having a tracheostomy procedure during ECMO, and 51% had a tracheostomy at some point during hospitalization. The frequency of tracheostomy was similar in pre-COVID-19 viral pneumonia, but tracheostomies were performed 3 days earlier compared with patients with COVID-19 (median 6.7 d [interquartile range [IQR], 3.0-12.0 d] vs 10.0 d [IQR, 5.0-16.5 d]; p < 0.001). More patients were mobilized with pre-COVID-19 viral pneumonia, but receipt of a tracheostomy during ECMO was associated with increased mobilization in both cohorts. More bleeding complications occurred in patients who received a tracheostomy, with 9% of patients with COVID-19 who received a tracheostomy reported as having surgical site bleeding.

Tracheostomies are performed in COVID-19 patients receiving ECMO at rates similar to practices in pre-COVID-19 viral pneumonia, although later during the course of ECMO. Receipt of a tracheostomy was associated with increased patient mobilization. Overall mortality was similar between those who did and did not receive a tracheostomy.

Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial.

Critical Care Medicine

To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients.

Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day.

Participants completed surveys at three time points during the ICU stay: enrollment (n = 252), 1 week (n = 229), and 2 weeks (n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment (p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2-16.0) versus 16.4, (95% CI, 15.5-17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03-0.82; p = 0.03); 0.15 (95% CI, 0.01-1.87; p = 0.14); and 0.27 (95% CI, 0.06-1.27; p = 0.10), respectively.

Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.

Probiotics in Critical Illness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Critical Care Medicine

To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

Independent reviewers extracted data in duplicate. A random-effects model was used to pool data. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

Sixty-five RCTs enrolled 8,483 patients. Probiotics may reduce ventilator-associated pneumonia (VAP) (relative risk [RR], 0.72; 95% CI, 0.59 to 0.89 and risk difference [RD], 6.9% reduction; 95% CI, 2.7-10.2% fewer; low certainty), healthcare-associated pneumonia (HAP) (RR, 0.70; 95% CI, 0.55-0.89; RD, 5.5% reduction; 95% CI, 8.2-2.0% fewer; low certainty), ICU length of stay (LOS) (mean difference [MD], 1.38 days fewer; 95% CI, 0.57-2.19 d fewer; low certainty), hospital LOS (MD, 2.21 d fewer; 95% CI, 1.18-3.24 d fewer; low certainty), and duration of invasive mechanical ventilation (MD, 2.53 d fewer; 95% CI, 1.31-3.74 d fewer; low certainty). Probiotics probably have no effect on mortality (RR, 0.95; 95% CI, 0.87-1.04 and RD, 1.1% reduction; 95% CI, 2.8% reduction to 0.8% increase; moderate certainty). Post hoc sensitivity analyses without high risk of bias studies negated the effect of probiotics on VAP, HAP, and hospital LOS.

Low certainty RCT evidence suggests that probiotics or synbiotics during critical illness may reduce VAP, HAP, ICU and hospital LOS but probably have no effect on mortality.

Blood Pressure Variability Indices for Outcome Prediction After Thrombectomy in Stroke by Using High-Resolution Data.

Neurocritical Care

Blood pressure variability (BPV) is associated with outcome after endovascular thrombectomy in acute large vessel occlusion stroke. We aimed to provide the optimal sampling frequency and BPV index for outcome prediction by using high-resolution blood pressure (BP) data.

Patient characteristics, 3-month outcome, and BP values measured intraarterially at 1 Hz for up to 24 h were extracted from 34 patients treated at a tertiary care center neurocritical care unit. Outcome was dichotomized (modified Rankin Scale 0-2, favorable, and 3-6, unfavorable) and associated with systolic BPV (as calculated by using standard deviation, coefficient of variation, averaged real variability, successive variation, number of trend changes, and a spectral approach using the power of specific BP frequencies). BP values were downsampled by either averaging or omitting all BP values within each prespecified time bin to compare the different sampling rates.

Out of 34 patients (age 72 ± 12.7 years, 67.6% men), 10 (29.4%) achieved a favorable functional outcome and 24 (70.6%) had an unfavorable functional outcome at 3 months. No group differences were found in mean absolute systolic BP (SBP) (130 ± 18 mm Hg, p = 0.82) and diastolic BP (DBP) (59 ± 10 mm Hg, p = 1.00) during the monitoring time. BPV only reached predictive significance when using successive variation extracted from downsampled (averaged over 5 min) SBP data (median 4.8 mm Hg [range 3.8-7.1]) in patients with favorable versus 7.1 mmHg [range 5.5-9.7] in those with unfavorable outcome, area under the curve = 0.74 [confidence interval (CI) 0.57-0.85; p = 0.031], or the power of midrange frequencies between 1/20 and 1/5 min [area under the curve = 0.75 (CI 0.59-0.86), p = 0.020].

Using high-resolution BP data of 1 Hz, downsampling by averaging all BP values within 5-min intervals is essential to find relevant differences in systolic BPV, as noise can be avoided (confirmed by the significance of the power of midrange frequencies). These results demonstrate how high-resolution BP data can be processed for effective outcome prediction.