The latest medical research on Intensive Care Medicine

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Recent studies showed that biological subphenotypes in acute respiratory distress syndrome (ARDS) provide prognostic enrichment and show potential for predictive enrichment.

To determine whether these subphenotypes and their prognostic- and potential for predictive enrichment could be extended to other ICU patients, irrespective of fulfilling the definition of ARDS.

This is a secondary analysis of a prospective observational study of adult patients admitted to the ICU. We tested the prognostic enrichment of both cluster-derived and latent-class analysis (LCA)-derived biological ARDS subphenotypes by evaluating the association with clinical outcome (ICU-, 30-day mortality and ventilator-free days) using logistic regression and Cox regression analysis. We performed a principal component analysis to compare blood leukocyte gene expression profiles between subphenotypes and presence of ARDS.

We included 2499 mechanically ventilated patients (674 with and 1825 without ARDS). The cluster-derived "reactive" subphenotype was, independently of ARDS, significantly associated with a higher probability of ICU mortality, a higher 30-day mortality, and a lower probability of successful extubation while alive compared to the "uninflamed" subphenotype. The blood leukocyte gene expression profiles of individual subphenotypes were similar for patients with and without ARDS. LCA-derived subphenotypes also showed similar profiles.

The prognostic- and potential for predictive enrichment of biological ARDS subphenotypes may be extended to mechanically ventilated critically ill patients without ARDS. Using the concept of biological subphenotypes for splitting cohorts of critically ill patients could add to improving future precision-based trial strategies and lead to identifying treatable traits for all critically ill.

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Posttranscriptional modifications are implicated in vascular remodeling of pulmonary hypertension (PH). N6-methyladenosine (m6A) is an abundant RNA modification that is involved in various biological processes. Whether m6A RNA modification and m6A effector proteins play a role in pulmonary vascular remodeling and PH have not been demonstrated.

To determine whether m6A modification and m6A effectors contribute to the pathogenesis of PH.

m6A modification and YTHDF1 expression were measured in human and experimental PH samples. RIP analysis and m6A-sequencing were employed to screen m6A-marked transcripts. Genetic approaches were employed to assess the respective roles of YTHDF1 and MAGED1 in PH. Primary cells isolation and cultivation were utilized for function analysis of pulmonary artery smooth muscle cells (PASMCs).

Elevated m6A levels and increased YTHDF1 protein expression were found in human and rodent PH samples as well as in hypoxic PASMCs. Deletion of YTHDF1 ameliorated PASMCs proliferation, phenotype switch and PH development both in vivo and in vitro. m6A RIP analysis identified MAGED1 as an m6A-regulated gene in PH and genetic ablation of MAGED1 improved vascular remodeling and hemodynamic parameters in SU5416/Hypoxia mice. YTHDF1 recognized and promoted translation of MAGED1 in an m6A dependent manner which was absent in METTL3 deficient PASMCs. In addition, MAGED1 silencing inhibited hypoxia-induced proliferation of PASMCs through downregulating PCNA.

YTHDF1 promotes PASMCs proliferation and PH by enhancing MAGED1 translation. This study identifies the m6A RNA modification as a novel mediator of pathological changes in PASMCs and PH.

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Limited data are known about the prognostic value of right ventricle (RV) function in patients with first acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the prognostic value of RV dysfunction in predicting both in-hospital and long-term outcomes in these patients, irrespective of the site of necrosis.

We enrolled 502 consecutive patients with first acute STEMI treated with primary angioplasty and underwent echocardiography within 48 hours of admission. RV function was evaluated by RV myocardial performance index (RVMPI), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler S' wave velocity, and RV global longitudinal strain (RVGLS) of the free wall. The occurrence of in-hospital major adverse cardiac events (MACE) and 1-year survival rate were recorded.

In MACE group, RVFAC, TAPSE, and RV S' wave velocity were lower. However, RVMPI, RVGLS, and TR Vmax. were higher than MACE free group (P < .001). In multivariable analysis adjusted for other variables that predicted adverse outcomes, RVFAC < 35% (P < .001), TAPSE < 17 mm (P < .001), RVGLS > -17% (P < .001), RV S' wave velocity < 9.5 cm/s (P = .02), RVMPI > 0.43 (P < .001), and TR Vmax. > 2.8 m/s (P = .01) were strong independent predictors of in-hospital MACE. Lower 1-year survival was noted in patients with RV dysfunction, documented by these cutoffs values.

RV dysfunction, evidenced by multiparametric echocardiography, is predictive for adverse in-hospital outcomes, and lower 1-year survival rate in first acute STEMI regardless of the site of necrosis.

Pulmonary arteriovenous malformations are rare congenital vascular anomalies. They are usually associated with congenital hemorrhagic hemangioma. T...

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With a potentially life-threatening course, acute pancreatitis (AP) is one of the most common gastrointestinal diseases requiring hospitalization and often necessitating intensive care. Based on recent insights and recommendations, this review provides an overview on clinical management of AP patients with a focus on intensive care unit care.

Possible benefits of percutaneous paracentesis and/or drainage on outcome or inflammation have been further explored. Combined opioid and epidural analgesia for pain management might be a valuable alternative for pain management. Very recent international guidelines now agree on a step-up approach for the management of acute necrotizing pancreatitis favoring a minimally invasive approach with either endoscopic or percutaneous drainage first. Studies for the best timing of these interventions are ongoing. In spite of a better understanding of pathophysiological mechanisms mediating AP, specific treatments are still awaited.

New evidence and recent international consensus direct the current management of AP toward a tailored, multidisciplinary and less invasive therapy with complementary roles for hepatologists, intensivists, radiologists, and surgeons.

Cytochrome C oxidase (CCO) acts as final electron acceptor in the respiratory chain, possibly providing information concerning cellular oxygenation...

Although respiratory sounds are useful indicators for evaluating abnormalities of the upper airway and lungs, the accuracy of their evaluation may ...

Because the use of conventional digital palpation technique for the identification of cricothyroid membrane (CTM) has been widely believed to be un...

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study design
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inclusion/exclusion criteria
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To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury.

A single center observational cohort study.

Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre).

During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV.

Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation.

Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated.

AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.

objective
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measurements and main results
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Weaning parameters are well studied in patients undergoing first time extubation. Fewer data exists to guide re-extubation of patients who failed their first extubation attempt. It is reasonable to postulate that improved weaning parameters between the first and second extubation attempt would lead to improved rates of re-extubation success. To investigate, we studied a cohort of patients who failed their first extubation attempt and underwent a second attempt at extubation. We hypothesized that improvement in weaning parameters between the first and the second extubation attempt is associated with successful reextubation.

Rapid shallow breathing index (RSBI), maximum inspiratory pressure (MIP), vital capacity (VC), and the blood partial pressure of CO2 (PaCO2) were measured and recorded in the medical record prior to extubation along with demographic information. We examined the relationship between the change in extubation and re-extubation weaning parameters and re-extubation success.

A total of 1283 adult patients were included. All weaning parameters obtained prior to re-extubation differed between those who were successful and those who required a second reintubation. Those with reextubation success had slightly lower PaCO2 values (39.5 ± 7.4 mmHg vs. 41.6 ± 9.1 mmHg, p = 0.0045) and about 13% higher vital capacity volumes (1021 ± 410 mL vs. 907 ± 396 mL, p = 0.0093). Lower values for RSBI (53 ± 32 breaths/min/L vs. 69 ± 42 breaths/min/L, p < 0.001) and MIP (-41 ± 12 cmH2O vs. -38 ± 13 cm H2O), p = 0.0225) were seen in those with re-extubation success. Multivariable logistical regression demonstrates lack of independent associated between the change in parameters between the 2 attempts and re-extubation success.

The relationship between the changes in extubation parameters through successive attempts is driven primarily by the value obtained immediately prior to re-extubation. These findings do not support waiting for an improvement in extubation parameters to extubate patients who failed a first attempt at extubation if extubation parameters are compatible with success.

background
methods
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The role of artificial and bioartificial liver support systems in acute-on-chronic liver failure (ACLF) is still controversial. We aimed to perform the first network meta-analysis comparing and ranking different liver support systems and standard medical therapy (SMT) in patients with ACLF.

The study protocol was registered with PROSPERO (CRD42020155850). A systematic search was conducted in five databases. We conducted a Bayesian network meta-analysis of randomized controlled trials assessing the effect of artificial or bioartificial liver support systems on survival in patients with ACLF. Ranking was performed by calculating the surface under cumulative ranking (SUCRA) curve values. The RoB2 tool and a modified GRADE approach were used for the assessment of the risk of bias and quality of evidence (QE).

In the quantitative synthesis 16 trials were included, using MARS®, Prometheus®, ELAD®, plasma exchange (PE) and BioLogic-DT®. Overall (OS) and transplant-free (TFS) survival were assessed at 1 and 3 months. PE significantly improved 3-month OS compared to SMT (RR 0.74, CrI: 0.6-0.94) and ranked first on the cumulative ranking curves for both OS outcomes (SUCRA: 86% at 3 months; 77% at 1 month) and 3-month TFS (SUCRA: 87%) and second after ELAD for 1-month TFS (SUCRA: 76%). Other comparisons did not reach statistical significance. QE was moderate for PE concerning 1-month OS and both TFS outcomes. Other results were of very low certainty.

PE seems to be the best currently available liver support therapy in ACLF regarding 3-month OS. Based on the low QE, randomized trials are needed to confirm our findings for already existing options and to introduce new devices.

Hypothermia is common occurrence in patients undergoing colonic surgeries. We hypothesized that the underbody forced air warming blankets will be b...

The latest medical research on Intensive Care Medicine

Biological Subphenotypes of ARDS Show Prognostic Enrichment in Mechanically Ventilated Patients Without ARDS.

YTHDF1 Regulates Pulmonary Hypertension Through Translational Control of MAGED1.

Short- and long-term prognostic value of right ventricular function in patients with first acute ST elevation myocardial infarction treated by primary angioplasty.

A rare cause of newborn central cyanosis.

Advances in acute pancreatitis.

Quantitative assessment of cytochrome C oxidase patterns in muscle tissue by the use of near-infrared spectroscopy (NIRS) in healthy volunteers.

A novel system that continuously visualizes and analyzes respiratory sounds to promptly evaluate upper airway abnormalities: a pilot study.

Comparison between laryngeal handshake and palpation techniques in the identification of cricothyroid membrane: a meta-analysis.

Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study.

Use of the Change in Weaning Parameters as a Predictor of Successful Re-Extubation.

Uncertainty in the impact of liver support systems in acute-on-chronic liver failure: a systematic review and network meta-analysis.

Comparison of two forced air warming systems for prevention of intraoperative hypothermia in carcinoma colon patients: a prospective randomized study.

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