Beijing Association of Critical Care Physicians, Beijing Society of Critical Care Medicine, Beijing Center for Quality Control and Improvement of Critical Care Medicine
The condition of critically ill patients is inherently intricate and precarious, often compounded by the presence of complex ailments, organ dysfunction, or specialized invasive procedures. These factors significantly alter patients' pharmacokinetics, leading reduced drug efficacy and an escalated risk of adverse reactions. Currently, drug treatment protocols outlined in manuals and related documents is primarily derive from research conducted on typical patients, posing challenges in ensuring both efficacy and safety for critically ill individuals. Addressing the rational use of drugs and ensuring their safety has emerged as a pivotal concern for clinicians and clinical pharmacists in critical care. Based on the characteristics of drug metabolism in critically ill patients, we delved into the distinctive characteristics of drug metabolism in critically ill patients. It scrutinizes challenges pertaining to drug use amidst specific pathophysiological conditions, in vitro supportive treatment settings, and specialized drug delivery routes. By amalgamating the latest clinical evidence regarding severe drug treatments, this analysis proposes pragmatic strategies for rational drug administration.
To assess the efficacy and safety of Ceftazidime-Avibactam (CAZ-AVI) versus polymyxin B-based anti-infective therapy in patients with severe carbapenem-resistant Klebsiella pneumoniae (CRKP) pneumonia.
Methods
From June 2019 to September 2020, the data from patients in ICU of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. These patients were diagnosed with pneumonia caused by CRKP and were treated with either CAZ-AVI or polymyxin B-based anti-infective therapy. Clinical and microbiologic cure rates, 28-day survival, and safety evaluation were compared between patients in two groups.
Results
Among the 86 subjects, CRKP clearance was 71.7% (33/46) in the CAZ-AVI group and 45.0% (18/40) in the polymyxin B group, there was significant difference between two groups (χ2=6.338, P=0.012). The clinical cure rate was 52.2% (24/46), the 28-day survival rate was 69.6% (32/46) in the CAZ-AVI group while 32.5% (13/40) and 75.0% (30/40) in polymyxin B group, there were no significant difference between two groups (χ2=3.378, P=0.066; χ2=0.314, P=0.575). The multivariate logistic regression analysis and propensity score (PS) regression adjustment method were employed. The results indicated that the clinical cure rate was significantly higher in the CAZ-AVI group compared to the polymyxin B group (P values of 0.017 and 0.025, respectively). The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were 3.550 (1.250-10.078) and 3.062 (1.150-8.149), respectively. The microbial clearance in CAZ-AVI patients was significantly higher relative to the polymyxin B group (P values: 0.012, 0.015, respectively), adjusted ORs and 95% CIs were 3.320 (1.308-8.427), 3.297 (1.259-8.637). There was no significant difference in 28-day survival between the 2 groups (P values were 0.990 and 0.850, respectively). The CAZ-AVI group had a lower incidence of adverse reactions when compared with the polymyxin B group (8.7% vs 30.0%, χ2=6.413, P =0.011).
Conclusion
CAZ-AVI be a reasonable alternative to polymyxin B in the treatment of pneumonia caused by CRKP.
To identify different phenotypes and screen the prognostic phenotypes by cluster analysis of pulse-indicated continuous cardiac output monitoring technique (PiCCO) parameters in septic patients combined with low cardiac function.
Methods
Seventy-eight septic patients with low cardiac function index and PiCCO recordings were screened in the US Intensive Care Database (MIMIC Ⅳ 2.0) (2008-2019). Based on the PiCCO parameters (Cardiac Function Index CI, Whole Heart End-Diastolic Volume Index GEDI, Systemic Vascular Resistance Index SVRI, Extravascular Lung Water Index (ELWI) K-mean clustering characterized patients into different phenotypes. The inter-phenotypic parameters were compared in different phenotypes, such as CI, GEDI, SVRI, ELWI, heart rate (HR), mean arterial pressure (MAP), age, gender, body mass index (BMI), sequential organ failure score (SOFA), history of previous illness, in-hospital mortality for the primary clinical outcome, and incidence of acute kidney injury (AKI grade 3) for the secondary clinical outcome, difference in the length of hospital and ICU stay. Univariate and multivariate logistic regression models were established.
Results
Four different phenotypes were identified in this study. Phenotype 1: hypervolemic, high vascular resistance, very high extravascular lung water. Phenotype 2: normal blood volume, normal vascular resistance, normal extravascular lung water. Phenotype 3: normal blood volume, high vascular resistance, high extravascular lung water. Phenotype 4: high blood volume, normal vascular resistance, very high extravascular lung water. Phenotype 1 had the worst prognosis and the highest in-hospital mortality rate (66.7%). The difference of in-hospital mortality among the four phenotypes was statistically significant different (χ2=7.8, P=0.045). Multifactorial logistic regression showed, compared to phenotype 1, phenotype 2, phenotype 3, and phenotype 4 had an OR and 95%CI of 0.095 (0.017-0.540), 0.087 (0.013-0.580) and 0.067 (0.006-0.719), with significant differences (P<0.05).
Conclusion
Cluster analysis based on PiCCO parameters confirmed different phenotypes of haemodynamic status in patients with sepsis combined with low cardiac function index and identified critically ill patients based on the phenotypes, thus predicting the prognosis of patients.
To assess the impact of prone positioning (PP) on lung ventilation and perfusion in COVID-9 patients with moderate to severe acute respiratory distress syndrome (ARDS) using electrical impedance tomography (EIT), to investigate the effects of PP on the distribution of ventilation and oxygenation in non-intubated patients.
Methods
This prospective study comprised 15 patients with COVID-19 ARDS who received treatment in the prone position and were admitted to the Critical Care Medicine Department of Shanghai General Hospital, affiliated with Shanghai Jiaotong University, between December 2022 and February 2023. Arterial blood gas (ABG) analysis, ventilator parameters, and hemodynamic parameters of all patients at three-time points before the start of the prone position (T0), 2 hours after the start of the prone position (T1), 2 hours after the end of the prone position (T2) were collected. Measurements of heart rate (HR), mean arterial pressure (MAP), and EIT recordings were conducted simultaneously at T0, T1, and T2.
Results
After prone positioning, PaO2/FiO2 increased significantly [T0 vs T1 vs T2: (173.17±17.73) mmHg vs (257.05±57.39) mmHg vs (299.03±71.18) mmHg, F=15.270, P<0.001]. Additionally, there was an increase in the proportion of dorsal ventilation after PPV [T0 vs T1 vs T2: (39.87±18.74) % vs (62.20±18.70)% vs (51.40±18.43)%, F=9.340, P=0.001]. The minute ventilation (MV) was significantly increased [T0 vs T1 vs T2: (8.14±2.38) L/min vs (8.89±1.29) L/min vs (11.40±1.91) L/min, F=22.917, P<0.001, respectively]. Similarly, respiratory compliance (Crs) showed a substantial improvement at different time points [T0 vs T1 vs T2: (27.63±7.50) ml/cmH2O vs (30.60±7.40) ml/cmH2O vs (31.53±8.29)ml/cmH2O, F=3.582, P=0.041, respectively]. The ventilation-perfusion matching showed a substantial improvement after PP compared to before PP [T0 vs T1: (66.67±12.81)% vs (78.24±10.60)%, P=0.03].
Conclusion
PP improves the uniformity of ventilation distribution and ventilation-perfusion matching in patients with COVID-19 ARDS.
To understand the best evidence application of enteral nutrition (EN) combined with diarrhea in ICU patients, analyze obstacles and promoting factors, and provide reference for clinical conversion of evidence.
Methods
Based on the clinical evidence model of Joanna Briggs Institute (JBI), the best evidence of EN complicated with diarrhea in ICU patients was obtained. Review indicators and methods were developed for clinical review. Obstacle and promoting factors were analyzed based on the review results, and action strategies were developed.
Results
A total of 5 guidelines were included, 12 best evidence of EN complicated with diarrhea in ICU patients were summarized, and 11 review indicators of the best evidence of EN complicated with diarrhea in ICU patients were the best evidence of EN complicated with diarrhea in ICU patients constructed. The implementation rate of one review indicator was 100.0%, while the other 10 implementation rates were 0-85.7%. The main obstacle factors were the lack of a comprehensive and unified evaluation of EN complicated with diarrhea in the department, the lack of diarrhea evaluation tools, insufficient understanding of the best evidence for diarrhea management by nurses, lack of emphasis on the implementation of EN by nurses, and inconvenient access to bedside hand disinfectant. The main promoting factors were strong organizational leadership, strong learning ability of nurses, and a good atmosphere of medical and nursing cooperation, and based on this, action strategies were formulated.
Conclusion
There is a gap between the best evidence and clinical application of EN combined with diarrhea in ICU patients, and improvement should be made based on obstacle factors to promote the clinical application of the evidence.
Cold-inducible RNA-binding protein (CIRP) is an RNA chaperone protein localized in nucleus and widely expressed in most tissue and organs. In recent years, numerous studies have confirmed that CIRP could be released from injured tissue and cells, interacting with immune cells and being involved in triggering inflammatory response as a damage-associated molecular patterns (DAMPs). In addition, elevation of extracellular CIRP have been found in peripheral blood in septic patients, severe acute pancreatitis patients and post-cardiopulmonary resuscitation patients, associated with poor prognosis. The purpose of this review is to provide a theoretical basis for conducting CIRP relevant research through summarize current knowledge on routes of extracellular CIRP being released, its effects on target cell, and underlying mechanisms.
In recent years, a variety of critical care clinical studies were developed in China, which arose in different systems or study areas. Chief among these endeavors, the investigation into corona virus disease 2019 (COVID-19) has garnered paramount attention. Some studies demonstrate that RNA capacity of COVID-19 was associated with the severity in clinical status, while others have suggested that immune system dysregulation contributes to the etiology of COVID-19, potentially leading to myocardial damage. Encouragingly, the positive therapeutic outcomes have been reported concerning respiratory strategies. Moreover, sepsis remains a societal burden, and recent research highlighting immunosuppressed neutrophils poses a promising avenue for novel therapeutic interventions. The implementation of hierarchical patient management has facilitated nuanced adjustments in fluid resuscitation strategies. Apart from the conventional research strategies, the contemporary integration of machine learning into phenotypic analysis, particularly in acute respiratory distress syndrome, exhibits promising adaptability. In the future, the individualized diagnosis and treatment principle of precision therapy will become an important guide for the daily work of critical care medicine. This paper offers a comprehensive review of clinical research conducted in China over the past three years, aiming to provide a robust theoretical foundation for future study.
Central nervous system infection (CNSI) is a general term for a group of diseases in which central nervous system is invaded by different pathogens, resulting in damage to the corresponding nerve tissue and clinical symptoms. Early diagnosis and timely and thorough treatment are key steps to reduce mortality and complications. However, the sensitivity and specificity of current diagnostic methods do not fully meet clinical needs. The chemokine CXC ligand 13 (CXCL13) is an important pillar of host immune response, which can maintain and promote inflammation, and is closely related to inflammatory diseases in central nervous system. Therefore, CXCL13 is considered a potential biomarker for diagnosis and treatment of CNSI. This article aims to explore the role of CXCL13 in CNSI and analyze its significance in diagnosing CNSI, assessing disease progression and efficacy.
Connexin 43 (Cx43), as the first discovered connexin, plays a vital role in intercellular junction and communication, and its expression in the lung has a great influence on the regulation of the air-blood barrier and permeability. Cx43 was proven to promote or inhibit various lung diseases, including acute lung injury/acute respiratory distress syndrome, asthma, pulmonary hypertension, lung cancer, COVID-19, and others. It depends on the mediating signal pathway and the interaction of different signal molecules. We aim to investigate the function of Cx43 in lung growth and development, as well as its involvement in injury repair and various lung disorders. Through an comprehensive understanding of the regulatory mechanism of Cx43 in these diseases, it is expected that new insights will be provided for the prevention, diagnosis, and treatment of lung diseases, and guide future research and clinical practice.
In recent years, artificial intelligence was increasingly applied in clinical medicine research. The integration of artificial intelligence with clinical medicine brings more recognition to clinicians, and being an important tool to promote rapid development in various medical fields. Huge amount of data and information in intensive care unit makes it ideal to apply artificial intelligence in ICU. AI aided diagnosis and interventions still need to be investigated and confirmed. The application of artificial intelligence in acute respiratory distress syndrome patients will be a way to go. This review explores the progress of artificial intelligence application in acute respiratory distress syndrome in 7 aspects: artificial intelligence application in intensive care, ARDS clinical phenotype identification, ARDS severity evaluation, quantitative imaging, quantitative bedside lung ultrasound evaluation, respiratory mechanics monitoring, mechanical ventilation strategy, candidate medication screening and so on.
Cardiac efficiency is a hemodynamic variable derived from thermodynamics. It refers to the percentage of energy consumed to complete cardiac external work to total energy consumed by cardiac activity. It can be obtained from P-V loop curve. In recent years, cardiac efficiency can also be derived directly from minimally invasive devices. Studies have shown that it can change dynamically during hemodynamic management, and it is a good predictor for prognosis, which requires clinical attention. This article reviews the research progress of cardiac efficiency in hemodynamic management.
The fundamental pathogenesis of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) lies in the imbalance between proinflammatory and anti-inflammatory responses caused by various etiology, which leads to uncontrolled inflammatory response and a series of pathophysiological changes. Macrophages play an important role in the progression of lung inflammation through different mechanism, including apoptosis, autophagy, pyroptosis, necrosis and so on. It is of great significance to explore specific mechanism of macrophages in ALI/ARDS and find potential targets for drug therapy. This article reviews such mechanisms in ALI/ARDS, in order to provide thoughts for development of new treatment for ALI/ARDS.
One patient with extremely severe burn, with an area of about 85% (deep second to third degree), received continuous renal replacement therapy (CRRT) for 19 days. This was prompted by a sudden and significant release of fluid from the burn wound, followed by an infection caused by pan-drug resistant Acinetobacter baumannii. The infection affected various parts of the body, including the wound, lungs, bloodstream, and digestive tract, leading to multiple organ failure. Despite active treatment of the wound, the patient experienced recurring infections and required multiple rounds of combined treatment involving polymyxin B. Through therapeutic drug monitoring (TDM), the drug concentration of polymyxin B was monitored many times throughout treatment, allowing for appropriate dosage adjustment. After the amputation of the left leg, there was a change in body mass and an increase in drug concentration. Finally, through the adjustment of the dosage, the patient's infection was well controled.
To summarize the nursing critical points in a case of acute infectious purpura fulminans caused by Streptococcuspyogenes, which include a comprehensive hemodynamic assessment to effectively guide fluid resuscitation, the nursing of blood purification, wound treatment, fine medication management, prevention and care of thromboembolism, posture management and catheter care. After effective treatment and careful nursing, the patient's condition improved and was discharged from hospital after 28 days.
