The latest medical research on Intensive Care Medicine

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 intensive care medicine gathered by our medical AI research bot.

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A Randomized Double-Blinded Placebo Controlled Trial of Clazakizumab for the Treatment of COVID-19 Pneumonia With Hyperinflammation.

Critical Care Medicine

We designed this study to test whether clazakizumab, a direct interleukin-6 inhibitor, benefits patients hospitalized with severe or critical COVID-19 disease accompanied by hyperinflammation.

Eighty-one patients enrolled in phase II, randomized 1:1:1 to low-dose (12.5 mg) or high-dose (25 mg) clazakizumab or placebo. Ninety-seven patients enrolled in phase III, randomized 1:1 to high-dose clazakizumab or placebo.

The primary outcome was 28-day ventilator-free survival. Secondary outcomes included overall survival ,frequency and duration of intubation, and frequency and duration of ICU admission. Per Data Safety and Monitoring Board recommendations, additional secondary outcomes describing clinical status and status changes, as measured by an ordinal scale, were added. Bayesian cumulative proportional odds, logistic, and Poisson regression models were used. The low-dose arm was dropped when the phase II study suggested superiority of the high-dose arm. We report on 152 patients, 74 randomized to placebo and 78 to high-dose clazakizumab. Patients receiving clazakizumab had greater odds of 28-day ventilator-free survival (odds ratio [OR] = 3.84; p [OR > 1] 99.9%), as well as overall survival at 28 and 60 days (OR = 1.75; p [OR > 1] 86.5% and OR = 2.53; p [OR > 1] 97.7%). Clazakizumab was associated with lower odds of intubation (OR = 0.2; p [OR] < 1; 99.9%) and ICU admission (OR = 0.26; p [OR < 1] 99.6%); shorter durations of ventilation and ICU stay (risk ratio [RR] < 0.75; p [RR < 1] > 99% for both); and greater odds of improved clinical status at 14, 28, and 60 days (OR = 2.32, p [OR > 1] 98.1%; OR = 3.36, p [OR > 1] 99.6%; and OR = 3.52, p [OR > 1] 99.8%, respectively).

Clazakizumab significantly improved 28-day ventilator-free survival, 28- and 60-day overall survival, as well as clinical outcomes in hospitalized patients with COVID-19 and hyperinflammation.

Reduction of Lung Hyperinflation Improves Cardiac Preload, Contractility, and Output in Emphysema: A Prospective Cardiac Magnetic Resonance Study in Patients Who Received Endobronchial Valves.

Resp Crit Care Med

Pulmonary hyperinflation in patients with Chronic Obstructive Pulmonary Disease (COPD) has been related to smaller cardiac chamber sizes and impaired cardiac function. Nowadays, bronchoscopic lung volume reduction (BLVR) with endobronchial valves is a treatment option to reduce pulmonary hyperinflation in patients with severe emphysema.

We hypothesized that reduction of hyperinflation would improve cardiac preload in this patient group. In addition, we investigated whether the treatment would result in elevated pulmonary artery pressures due to pulmonary vascular bed reduction.

We included patients with emphysema and severe hyperinflation (defined by a baseline residual volume >175% of predicted) who were eligible for BLVR with endobronchial valves. Cardiac magnetic resonance imaging was obtained one day prior to treatment and at eight week follow-up. Primary endpoint was cardiac preload, as measured by the right ventricle end-diastolic volume index (RVEDVI). As secondary endpoints, we measured indexed end-diastolic and end-systolic volumes of the right ventricle, left atrium, and left ventricle, pulmonary artery pressures, cardiac output, ejection fraction, and strain.

Twenty-four patients were included. At eight week follow-up, RVEDVI was significantly improved (+7.9 ml/m2, SD 10.0, p=0.001). In addition to increased stroke volumes, we found significantly higher ejection fractions and strain measurements. Although cardiac output was significantly increased (+0.9L/min, SD 1.5, p=0.007), there were no changes in pulmonary artery pressures.

We found that reduction of hyperinflation using BLVR with endobronchial valves significantly improved cardiac preload, myocardial contractility, and cardiac output, without changes in pulmonary artery pressures. Clinical trial registered with ClinicalTrials.gov (NCT03474471).

Aerosolization of Mycobacterium tuberculosis by Tidal Breathing.

Resp Crit Care Med

Interrupting tuberculosis (TB) transmission requires an improved understanding of how - and when - the causative organism, Mycobacterium tuberculosis (Mtb), is aerosolized. Although cough is commonly assumed to be the dominant source of Mtb aerosols, recent evidence of cough-independent Mtb release implies the contribution of alternative mechanisms.

To compare the aerosolization of Mtb bacilli and total particulate matter from TB patients during three separate respiratory manoeuvres: Tidal Breathing (TiBr), Forced Vital Capacity (FVC), and cough.

Bioaerosol sampling and Mtb enumeration by live-cell, fluorescence microscopy were combined with real-time measurement of CO2 concentration and total particle counts from 38 GeneXpert-positive TB patients prior to treatment initiation.

For all manoeuvres, the proportions of particles detected across five size categories were similar with most particles falling between 0.5-5 μm. Although total particle counts were 4.8-fold greater in cough samples than either TiBr or FVC, all three manoeuvres returned similar rates of positivity for Mtb. No correlation was observed between total particle production and Mtb count. Instead, for total Mtb counts, the variability between individuals was greater than the variability between sampling manoeuvres. Finally, when modelled utilizing 24-hour breath and cough frequencies, our data indicate that TiBr might contribute >90% of the daily aerosolised Mtb among symptomatic TB patients.

Assuming the number of viable Mtb organisms released offers a reliable proxy of patient infectiousness, our observations imply that TiBr and inter-individual variability in Mtb release might be significant contributors to TB transmission among active cases. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Muscle Protein Synthesis Following Protein Administration in Critical Illness.

Resp Crit Care Med

Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly...

Cytomegalovirus blood reactivation in COVID-19 critically ill patients: risk factors and impact on mortality.

Intensive Care Medicine

Cytomegalovirus (CMV) reactivation in immunocompetent critically ill patients is common and relates to a worsening outcome. In this large observational study, we evaluated the incidence and the risk factors associated with CMV reactivation and its effects on mortality in a large cohort of patients affected by coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU).

Consecutive patients with confirmed SARS-CoV-2 infection and acute respiratory distress syndrome admitted to three ICUs from February 2020 to July 2021 were included. The patients were screened at ICU admission and once or twice per week for quantitative CMV-DNAemia in the blood. The risk factors associated with CMV blood reactivation and its association with mortality were estimated by adjusted Cox proportional hazards regression models.

CMV blood reactivation was observed in 88 patients (20.4%) of the 431 patients studied. Simplified Acute Physiology Score (SAPS) II score (HR 1031, 95% CI 1010-1053, p = 0.006), platelet count (HR 0.0996, 95% CI 0.993-0.999, p = 0.004), invasive mechanical ventilation (HR 2611, 95% CI 1223-5571, p = 0.013) and secondary bacterial infection (HR 5041; 95% CI 2852-8911, p < 0.0001) during ICU stay were related to CMV reactivation. Hospital mortality was higher in patients with (67.0%) than in patients without (24.5%) CMV reactivation but the adjusted analysis did not confirm this association (HR 1141, 95% CI 0.757-1721, p = 0.528).

The severity of illness and the occurrence of secondary bacterial infections were associated with an increased risk of CMV blood reactivation, which, however, does not seem to influence the outcome of COVID-19 ICU patients independently.

Hemodialysis vascular access in elderly patients: A comprehensive review.

J Vasc Access

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the pref...

A novel extra-catheter guide wire technique for in situ exchange of dysfunctional tunnelled central venous hemodialysis catheter.

J Vasc Access

Tunneled central venous catheters (tCVC) exchange may be difficult in some situations. We retrospectively report our preliminary experience of a novel extra-catheter guide wire technique for exchange of dysfunctional tCVC.

Retrospectively analyze the demographics, treatment details and outcomes data of 39 patients received tCVC exchange from January 2018 to January 2019. According to whether guide wire could pass through the catheter lumen, patients were divided into in-catheter group and extra-catheter group. The technical successful rate, peri-operative complications, 1-month and 6-month catheter flow rate was recorded and compared between the 2 groups.

The final study population consists of 39 patients, including 16 in-catheter group and 23 extra-catheter group. The technical successful rate was 100% in both groups. All patients achieved restoration of line patency and completed at least 1 hemodialysis section. The 1-month (267.69 ± 20.12 vs. 274.13 ± 17.69, p = 0.604) and 6-month (255.81 ± 12.93 vs. 256.97 ± 11.20, p = 0.403) catheter flow rate was comparable between the 2 groups.

The novel extra-catheter guide wire technique was helpful for in situ exchange of dysfunctional tunneled central venous hemodialysis catheters, especially when the guide wire could not pass through the catheter lumen.

Comparative intervention assessing a catheter stabilization device on peripheral intravenous line loss.

J Vasc Access

Short peripheral intravenous catheters are the most common invasive procedure used to deliver medications, blood products, and fluids to patients, and failure has the potential to impact the quality of care.

This study compared IVs stabilized with current transparent film dressing to those using an engineered stabilization device. The first phase of the study evaluated documentation; data from patient records were found less than optimal but most complete for securement and removal, the two fields most critical to the study. The second phase measured IV dwell time, restart rates, and time between IV loss and restarts.

Although there were no statistically significant differences in restarts, the IV dwell time was longer when the engineered device was in place, helping to extend the life of the IV and prevent interruption of care. In the absence of data on the cost of infections and other complications, the use of an engineered device increased the cost of IV starts.

Adding an engineered stabilization device increases the cost of peripheral IV starts, but contributes to reducing IV restarts and preventing IV complications due to destabilized IVs. Although there were no statistically significant differences in restarts, the IV dwell time was longer when the device was in place, helping to extend the life of the IV and prevent interruption of care. Complete and accurate documentation and improved quality depended upon the ability to abstract unit-level data, which is vital for capturing the appropriate healthcare indicators. Clinical nurses must be involved in the decision-making regarding health records and operability at the unit level.

Reliability and compliance of peripheral intravenous catheter documentation: A prospective observational study.

J Vasc Access

Proper documentation of the functionality and complications of peripheral intravenous catheters (PIVC) is the standard of care. This data can improve communication among team members about access concerns and highlight opportunities to improve PIVC care. Our objective is to determine if nursing personnel are compliant with institutional standards for documentation and documentation is reliable.

This prospective observational analysis was conducted at a tertiary care academic center with 120,000 ED visits and 1100 hospital beds. Adults over 18 with a PIVC placed in the ED via palpation technique who were being admitted to regular medical/surgical wards were eligible. The primary outcome was compliance with PIVC documentation per institutional standards. Secondary outcomes included compliance subcategorized as insertion, daily assessment, and removal and reliability of assessments.

During July and August 2020, 77 patients were enrolled with a total of 1201 observations of PIVC compliance. PIVC documentation compliance was 86.0% (1033/1201). Compliance on insertion and removal was 93.3% (431/462) and 80.5% (186/231), respectively, with removal assessment being the least compliant at 49.4%. Daily catheter assessments were compliant 81.9% (416/508) of the time. PIVC documentation reliability was based on 693 total observations with 87.9% (609/693) reliability overall, and a reliability of 91.6% (423/462) and 74.9% (173/231) for insertion and removal, respectively. PIVC orientation had the highest reliability (98.7%) while post-removal assessment had the lowest reliability (45.5%).

We observed moderate documentation compliance and reliability for PIVC assessments for catheters placed in the ED. Documentation of removal-related variables was the most deficient aspect of the assessments. Given the high rate of PIVC failure and its vast array of consequences, improvement of PIVC documentation of removal reasons is essential to better identify type and incidence of complications and help develop targeted solutions. Further larger studies are needed to survey PIVC documentation practices.

General versus regional anaesthesia for hip fracture surgery - impact on mortality and length of stay.

Anaesthesiology Intensive Therapy

Hip fractures are extremely common and are considered a public health problem. The best anaesthetic technique for this surgery remains controversial. The aim of this study is to determine the impact of anaesthesia on perioperative and 30-day mortality and length of stay, in patients undergoing hip fracture surgery.

Adults undergoing hip fracture surgery, between January 1st, 2017 and December 31st, 2018, were retrospectively identified and categorized according to the anaesthetic technique. Perioperative and 30-day mortality rates and the length of stay were analysed.

We identified 562 patients who underwent hip fracture surgery, 361 of whom were submitted to general anaesthesia and 201 to regional anaesthesia. The adjusted analysis showed no statistically significant difference in the risk of perioperative and 30-day mortality (odds ratio 1.12, 95% CI: 0.62-2.03; odds ratio 1.17, 95% CI: 0.72-1.92) or length of stay (0, 9 days [-1.6 to 3.4], P = 0.301).

Our results were similar to those of studies already published in other countries. Within the limitations of our study, we concluded that there is no impact of the anaesthetic technique on perioperative and 30-day mortality rates and on the length of stay, for hip fracture surgery. In future studies, it will be opportune to investigate factors that influence the safety of anaesthetic techniques and that are subject to intervention by the anaesthesiologist.

Malignant hyperthermia in Mazovia Province - are we adequately prepared?

Anaesthesiology Intensive Therapy

Malignant hyperthermia (MH) is a life-threatening syndrome caused by sudden skeletal muscle hypermetabolism in response to inhalation anaesthetics and depolarising relaxants. The estimated incidence of MH is between 1 : 10,000 and 1 : 250,000 anaesthetic procedures. In Poland the incidence of MH is unknown. Dantrolene is imported as a life-saving drug and temporally authorised for sale. The aim of the study is to assess the incidence of MH and access to dantrolene in the Mazovia Province.

Anonymous questionnaires were sent to anaesthesia departments in the Mazovia Province after prior contact by phone and e-mail. The survey was approved by the local ethical review board.

Completed surveys were received from 60 respondents which represents 72% of anaesthesiology departments in Mazovia. In the last 5 years there have been 4 episodes of MH in the Mazovia Province. Three patients survived the MH crisis. In a centre that did not have access to dantrolene, the patient died. Dantrolene is found only in 11 (18.3%) anaesthesiology departments in Mazovia. Only 6 (10%) hospitals are able to administer dantrolene within 5 minutes of suspecting MH crisis, while 5 centres may receive it after a few days. Only 38% of units have an algorithm for dealing with MH crisis in the operating theatres.

MH is rare, but if untreated, it can be fatal. Therefore prompt diagnosis and treatment are crucial to avoid fatal outcome. Every centre using inhalational anaesthetics and/or succinylcholine should have dantrolene. To ensure the safety of our patients, we must be better prepared.

Cardiovascular Benefit of CPAP in Adults with Coronary Artery Disease and OSA without Excessive Sleepiness.

Resp Crit Care Med

Randomized controlled trials of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) have not demonstrated protection against adverse cardiovascular outcomes. Recently, observational studies revealed that OSA-related cardiovascular risk is concentrated in patients with an elevated pulse rate response to respiratory events (ΔHR). Here, in this post-hoc analysis of a prospective clinical trial, we test the hypothesis that a greater pre-treatment ΔHR is associated with greater CPAP-related protection against adverse cardiovascular outcomes.

∆HR was measured from baseline polysomnography of RICCADSA randomized controlled trial (patients with coronary artery disease [CAD] and OSA [apnea-hypopnea-index ≥15 events/h] with Epworth Sleepiness Scale score <10]; (NCPAP:Ncontrol=113:113; male=85%; age=66±8 [mean±SD] yr). The primary outcome was a composite of repeat revascularization, myocardial infarction, stroke, and cardiovascular mortality. Multivariable Cox regression assessed whether the effect of CPAP was moderated by ∆HR (treatment-by-∆HR interaction).

The CPAP-related reduction in risk rose progressively with increasing pre-treatment ΔHR (interaction hazard ratio [95%CI]: 0.49 [0.27, 0.90] per SD increase in ∆HR, p<0.05). This means that in patients with a ∆HR of1SD above the mean (i.e. 10 beats/minute), CPAP was estimated to reduce cardiovascular risk by 59 [6, 82] % (p<0.05), but no significant risk reduction was estimated in patients with a mean ∆HR ( 6 beats/minute; CPAP risk reduction = 16 [-53, 54] %, p=0.6).

The protective effect of CPAP in patients with CAD and OSA without excessive sleepiness was modified by the ∆HR. Specifically, patients with higher ∆HR exhibit greater cardiovascular benefit from CPAP therapy.