Critical Care Medicine最新文献

Objective: The Pa o2 /F io2 (PF) ratio is widely used as an assessment of respiratory failure in guiding ventilation strategies and prognostication in critically ill patients. However, given that it mandates invasive arterial access, the Sp o2 /F io2 (SF) ratio has been suggested as a noninvasive and readily accessible alternative. What are the best ways to convert SF and PF ratios in critically ill patients, in terms of their diagnostic/prognostic accuracy and clinical utility?

Data sources: We comprehensively searched databases (MEDLINE, Embase, Web of Science, Cochrane library) to identify relevant studies.

Study selection: Any observational studies that compared the SF to PF ratio in critically ill patients. We assessed individual study risk of bias (ROB) using the revised QUADAS II tool.

Data extraction: We included 45 observational studies, ranging from 61 to 141,000 measurements.

Data synthesis: SF to PF imputation was less accurate when the Sp o2 was equal to or greater than 97%. Otherwise, all studies were able to establish strong correlational relationships between SF and PF ratios, but there was no clear best equation. Based on ease of use, size, generalizability and methodology, we were able to prioritize four equations (one linear, one logarithmic linear, and two nonlinear). All four equations showed strong correlation between SF and PF ratios, with the linear equation being easiest to apply. The SF ratio also correlated well with clinical outcomes when compared with the PF ratio, both as an individual value and as part of a comprehensive score, with more discriminating performance in some cases.

Conclusions: SF and PF ratios demonstrate good correlation, and may have similar prognostic value. Although there is no clear optimal method to convert SF to PF ratios, linear equations show acceptable correlation and are most easily applied at the bedside.

Objectives: Despite advances in critical care medicine, many questions remain unanswered, and existing guidelines are often based on low-quality evidence. This priority setting partnership (PSP), following the James Lind Alliance (JLA) methodology, aimed to identify the top ten research priorities for critical care medicine in Canada based on input from patients, families, and healthcare providers.

Design: Three-phase, national, JLA PSP.

Setting: Canada-wide, involving adult and PICUs.

Subjects: Patients with lived experience of critical illness, family members of ICU patients, and healthcare providers (physicians, nurses, and allied health professionals).

Interventions: None.

Measurements and main results: Participants contributed uncertainties through open surveys (phase 1), ranked questions through a national survey (phase 2), and achieved consensus on the final priorities during a virtual workshop (phase 3). Phase 1 included 154 respondents (44 patients/family members, 110 healthcare providers) submitting 509 in scope questions, resulting in 64 unique indicative questions. Phase 2 included 244 participants (63 patients/families, 191 healthcare providers), prioritizing 20 questions to advance to the final workshop. Phase 3 involved 24 individuals (12 with lived experience, 12 healthcare providers) from six provinces, who reached consensus on the top ten research priorities. Briefly, the top three priorities were: 1) improving physical, cognitive, and mental health outcomes post-ICU/PICU; 2) supporting goals-of-care conversations with families; and 3) characterizing short- and long-term post-ICU outcomes and predictors. The full top ten priorities are presented in the article.

Conclusions: This national JLA PSP identified the top ten patient, family, and healthcare provider-driven research priorities for critical care medicine in Canada. These priorities aim to guide future research that is meaningful, inclusive, and evidence-informed.

Objective: The cholinergic anti-inflammatory pathway (ChAP) is the key regulator of the dysregulated cytokine storm in sepsis, with acetylcholine acting on alpha-7 nicotinic acetylcholine receptors (α7nAChRs) to suppress excessive inflammation. The objective of this study was to evaluate whether neostigmine administration modulates the inflammatory response in sepsis by enhancing cholinergic anti-inflammatory activity.

Design: A single-center, prospective, randomized, double-blinded, placebo-controlled study.

Setting: One adult ICU at a tertiary academic medical institution.

Intervention: Patients were randomized to receive neostigmine at a fixed rate of 0.2 mg/hr (2 mL/hr) or placebo. Study drug was administered for 5 days.

Measurements and results: The primary outcome measure was decrease in tumor necrosis factor-alpha levels, in patients treated with neostigmine adjuvant therapy vs. the standard therapy. The secondary outcomes were hemodynamic parameters, septic shock reversal, changes in procalcitonin levels, and organ failure scores. The mean tumor necrosis factor-alpha levels were significantly lower in the neostigmine group (40 ± 36 pg/mL, mean ± sd ) on day 5 as compared with the control group (67 ± 43 pg/mL; p = 0.002). There was a significant reduction in Sequential Organ Failure Assessment scores from day 1 to day 5 ( p < 0.001) and 28-day mortality was also lower in the neostigmine group (26%) as compared with control group (54%, p = 0.02).

Conclusions: The neostigmine infusion modulates the ChAP by potentiating the acetylcholine release leading to reduced systemic inflammation and decreased cytokine levels in septic shock patients. (Clinical Trial Registry of India number: CTRI/2023/07/ 055054).

Due to its nonspecific clinical criteria, sepsis is clinically, microbiologically, pathophysiologically and immunologically highly heterogeneous. Consequently, despite hundreds of clinical trials, no host-targeted therapy has been shown to be ubiquitously efficacious, leading investigators to pursue more precision-based approaches for enriching sepsis populations through the identification of subgroups or phenotypes. Here, we review the myriad domains in which heterogeneity is observed in sepsis and the challenges and opportunities they offer to improve outcomes. We review current strategies used by investigators leveraging novel biological measurements and/or computational algorithms to identify more homogeneous subgroups either based on pathogen or host characteristics or both. Finally, we review some of the most promising recent advances that seek to bring these complex and innovative discoveries to the bedside to facilitate precision medicine in sepsis.