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Articles in E-pub version are posted online ahead of regular printed publication.

Original Articles
Trauma
Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit
Abdulrahman Özel, Esra Nur İlbeği, Servet Yüce
Received August 26, 2024  Accepted November 18, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.003528    [Epub ahead of print]
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AbstractAbstract PDF
Background
This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods
This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results
A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.75) for mortality. Pediatric Risk of Mortality-3 scores showed good predictive ability (AUC, 0.83), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.69). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusion
Initial lactate levels and Pediatric Risk of Mortality score 3 (PRISM-3)scores are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.
Infection
The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
Michael Roimi, Anat Shrot, Roy Ilan, Avraham Tenenbaum, Danny Epstein, Yaron Bar-Lavie
Received February 22, 2024  Accepted November 4, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.000696    [Epub ahead of print]
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AbstractAbstract PDF
Background
The pivotal role of the gastrointestinal (GI) tract in sepsis has long been recognized. This study aimed to evaluate the associations between defecation frequency as a basic assessment of GI function and the clinical outcomes of intensive care unit (ICU) patients with suspected sepsis.
Methods
This retrospective, single-center study included patients suspected of having sepsis >72 hours after ICU admission. The number of defecations and consecutive days without defecation during the 72 hours preceding the suspected infection were assessed as indicators of GI function. The primary outcome was 30-day all-cause mortality. Multivariate regression analysis adjusting for potential confounders was employed to establish the independent associations between GI function and clinical outcomes.
Results
The final analysis included 1,306 patients with a median age of 56.2 years (interquartile range [IQR], 39.6–69.1); 919 (70.4%) were male, and the median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 22.0 (IQR, 17.0–27.0). The median Sequential Organ Failure Assessment (SOFA) score at the time of suspected infection was 5.0 (IQR, 3.0–7.0). Mortality rates were 20.3%, 28.0%, and 34.3% for patients with 0–2, 3–5, and >5 defecations, respectively (P<0.001). There was a strong correlation between the number of defecations and mortality (r=0.7, P=0.01). In multivariate analyses, each defecation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.07; 95% CI, 1.01–1.12; P=0.01), while each consecutive day without a defecation was associated with reduced mortality (aOR, 0.84; 95% CI, 0.73–0.95; P=0.02).
Conclusions
A higher number of defecations in the 72 hours preceding suspected sepsis is associated with increased 30-day all-cause mortality, suggesting a potential association with GI tract dysfunction.
Trauma
Effect of atorvastatin as a renal protective agent in patients with systemic inflammatory response syndrome using the renal arterial resistive index
Mina Maher Raouf, Eslam Antar Shadad, Nagy Sayed Ali
Received October 14, 2024  Accepted October 30, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.003912    [Epub ahead of print]
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AbstractAbstract PDF
Background
Current meta-analyses have yielded inconclusive results regarding the effectiveness of statins in preventing early renal injury in the context of poly-trauma. Notably, renal artery Doppler-derived resistance indices have shown a strong correlation with early detection of renal impairment, underscoring their importance in clinical assessment.
Methods
The study involved 106 adults of both sexes aged 18 years and older who presented with poly-trauma with a two-point or greater increase in the sequential organ failure assessment score within the first 72 hours of hospital admission and who met two or more of the diagnostic criteria of systemic inflammatory response syndrome. Participants were randomly assigned to either the atorvastatin group, which received oral atorvastatin at a dosage of 20 mg every 12 hours for 1 week alongside conventional therapy (antimicrobial agents and balanced crystalloids), or the control group, which received conventional therapy along with a placebo tablet every 12 hours for 1 week.
Results
The atorvastatin group yielded a significantly lower incidence of acute kidney injury (AKI; P<0.001). Additionally, there was significant reduction in renal resistance and pulsatility indices in the atorvastatin group. Furthermore, the atorvastatin group exhibited a shorter intensive care unit (ICU) stay (P=0.004). The renal index had a sensitivity of 90% and specificity of 68% for AKI prediction when the cutoff value was 0.61. Pulsatility index had a sensitivity of 90% and a specificity of 53% when the cutoff value was 1.28.
Conclusions
Atorvastatin was impactful in mitigating the incidence of AKI, improving renal resistive vascular indices, and abbreviating ICU stays in the poly-traumatized population.
Review Article
Nursing
Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries
Anabela Carvalho Raposo, Maria Candida Durao, Maria do Rosário Pinto, Helga Rafael Henriques, Joana Ferreira Teixeira
Received November 19, 2023  Accepted November 16, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.005014    [Epub ahead of print]
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AbstractAbstract PDF
Corneal surface injuries occur frequently (59.4%) in critically ill patients, and the average time for their appearance is eight days. Such injuries are primarily related to dry eye, which increases the risk of exposure injury in patients admitted to intensive care units. This can result in a severe ulcer or perforation that results in partial to total loss of vision, decreasing the quality of the patient's life. This is a sensitive nursing care area requiring further investigation. Thus, this review aims to analyse nursing interventions that aim to prevent ocular surface injuries. An integrative literature review was carried out from May to August 2023 in the Medline, CINAHL, Scopus, Web of Science, and PubMed databases using the Whittemore and Knafl methodology. Inclusion and exclusion criteria were subsequently applied to assess the results. After verifying result eligibility, seven documents were identified for data extraction and analysis. The results suggest the importance of recognizing risk factors for ocular injuries in critically ill patients, surveillance as a nursing competency, adequate ocular hygiene and effective lubrication, and managing environmental conditions to prevent corneal injuries. Implementing surveillance and intervention protocols for critically ill patients at risk of corneal injuries requires specialised training for critical care nurses. Specifically, environmental management, including temperature and humidity control, is highlighted as an area that merits further research.
Original Articles
Rapid response system
Resident and nurse attitudes toward a rapid response team in a tertiary hospital in South Korea
Sung Yoon Lim, Ho Geol Woo, Jong Sun Park, Young-Jae Cho, Jae Ho Lee, Yeon Joo Lee
Received November 7, 2024  Accepted December 4, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.004272    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
Residents and nurses who activate rapid response teams (RRTs) are well positioned to offer insights on its effectiveness. Here, we assess such evaluation of RRTs and identify barriers to activation in a 1,400-bed teaching hospital.
Methods
We conducted a 24-item Likert-scale survey from January to May 2017 among residents and ward nurses with RRT experience. Factor analysis was used to identify the barriers.
Results
This study comprised 305 nurses and 53 residents, most of whom were satisfied with their RRT experiences. Factor analysis showed that lack of awareness of activation criteria was a major barrier, with only 21.4% and 22.2% participants, respectively, confident about their knowledge of activation protocols. Of the survey respondents, 85.7% reported first contacting the doctor before activating the RRT. Despite the protocol, 66.7% first discussed the decision with other staff, and 71.5% called the RRT when the patient’s condition worsened despite management.
Conclusions
Nurses and residents value RRTs but face barriers in initiation, primarily due to a lack of confidence in applying the activation criteria. Many prefer to consult a doctor or manage the patient before calling the RRT.
Basic science and research
Impact of tadalafil on cardiovascular and organ dysfunction induced by experimental sepsis
Marcelo Almeida Nakashima, Gabrielle Delfrate, Lucas Braga Albino, Gustavo Ferreira Alves, Junior Garcia Oliveira, Daniel Fernandes
Received June 18, 2024  Accepted November 2, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.002904    [Epub ahead of print]
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AbstractAbstract PDF
Background
Sepsis is a life-threatening condition that affects the cardiovascular and renal systems. Severe hypotension during sepsis compromises tissue perfusion, which can lead to multiple organ dysfunction and death. Phosphodiesterase 5 (PDE5) degrades intracellular cyclic guanosine monophosphate (cGMP) levels which promotes vasodilatation in specific sites. Our previous studies show that inhibiting cGMP production in early sepsis increases mortality, implying a protective role for cGMP production. Then, we hypothesized that cGMP increased by tadalafil (PDE5 inhibitor) could improve microcirculation and prevent sepsis-induced organ dysfunction.
Methods
Rats were submitted to cecal ligation and puncture (CLP) sepsis model and treated with tadalafil (2 mg/kg, s.c.) 8 hours after the procedure. Hemodynamic, inflammatory and biochemical assessments were performed 24 hours after sepsis induction. Moreover, the effect of tadalafil on the survival of septic rats was evaluated for 5 days.
Results
Tadalafil treatment improves basal renal blood flow during sepsis and preserves it during noradrenaline infusion. Sepsis induces hypotension, impaired response to noradrenaline, and increased cardiac and renal neutrophil infiltration, in addition to increased levels of plasma nitric oxide and lactate. None of these dysfunctions were changed by tadalafil. Additionally, tadalafil treatment did not increase the survival rate of septic rats.
Conclusion
Tadalafil improved microcirculation of septic animals; however, no beneficial effects were observed on microcirculation and inflammation parameters. Then, the potential benefit of tadalafil in the prognosis of sepsis should be evaluated within a therapeutic strategy covering all sepsis injury mechanisms.
Pediatrics
Hyper- and hypomagnesemia as an initial predictor of outcomes in septic pediatric patients in Egypt
Aya Osama Mohamed
Received February 6, 2024  Accepted October 31, 2024  Published online February 4, 2025  
DOI: https://doi.org/10.4266/acc.000480    [Epub ahead of print]
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AbstractAbstract PDF
Background
Critically ill septic children are susceptible to electrolyte abnormalities, including magnesium disturbance, that can easily be neglected. This study examined the potential correlation between serum magnesium levels upon admission to the pediatric intensive care unit (PICU) and the outcomes of critically ill septic patients.
Methods
This prospective study, conducted from May 2023 to November 2023, included 76 children with sepsis who underwent clinical and lab assessments that included initial magnesium levels. The outcome of sepsis was documented. Predictors of mortality were identified through multivariate logistic regression models, with discrimination and calibration assessed using the area under the curve (AUC).
Results
The median magnesium level upon PICU admission was 2.0 mg/dl (range 1.1–4.9), and it was slightly higher in non-survivors than survivors (2.1 mg/dl; interquartile range [IQR], 1.9–2.5 vs. 2.0; IQR, 1.8–2.6, respectively), Hypermagnesemia was observed to have a negative effect on critically ill septic patients. It was also found that hypermagnesemia was associated with low C-reactive protein levels (P=0.043). With a cut-off of 5.5, the pediatric Sequential Organ Failure Assessment score strongly predicted mortality (AUC=0.717, P<0.001), with a sensitivity of 64.3% and specificity of 68.8%.
Conclusion
As an initial predictor of mortality, the serum magnesium level cannot be used alone; however, hypermagnesemia has a negative impact on critically ill septic patients. Thus, healthcare professionals should be cautious with magnesium administration.
Thoracic Surgery
Connective tissue disease is associated with the risk of posterior reversible encephalopathy syndrome following lung transplantation in Korea
Tae Jung Kim, Hyun Joo Lee, Samina Park, Sang-Bae Ko, Soo-Hyun Park, Seung Hwan Yoon, Kwon Joong Na, In Kyu Park, Chang Hyun Kang, Young Tae Kim, Sun Mi Choi, Jimyung Park, Joong-Yub Kim, Hong Yeul Lee
Received September 5, 2024  Accepted November 14, 2024  Published online January 7, 2025  
DOI: https://doi.org/10.4266/acc.003384    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
Posterior reversible encephalopathy syndrome (PRES) is a rare complication of lung transplantation with poorly understood risk factors and clinical characteristics. This study aimed to examine the occurrence, risk factors, and clinical data of patients who developed PRES following lung transplantation.
Methods
A retrospective analysis was conducted on 147 patients who underwent lung transplantation between February 2013 and December 2023. The patients were diagnosed with PRES based on the clinical symptoms and radiological findings. We compared the baseline characteristics and clinical information, including primary lung diseases and immunosuppressive therapy related to lung transplantation operations, between the PRES and non-PRES groups.
Results
PRES manifested in 7.5% (n=11) of the patients who underwent lung transplantation, with a median onset of 15 days after operation. Seizures were identified as the predominant clinical manifestation (81.8%, n=9) in the group diagnosed with PRES. All patients diagnosed with PRES recovered fully. Patients with PRES were significantly associated with connective tissue disease-associated interstitial lung disease (45.5% vs. 18.4%, P=0.019, odds ratio=9.808; 95% CI, 1.064–90.386, P=0.044). Nonetheless, no significant variance was observed in the type of immunotherapy, such as the use of calcineurin inhibitors, blood pressure, or acute renal failure subsequent to lung transplantation.
Conclusions
PRES typically manifests shortly after lung transplantation, with seizures being the predominant initial symptom. The presence of preexisting connective tissue disease as the primary lung disease represents a significant risk factor for PRES following lung transplantation.
Case Reports
Neurosurgery
Use of droxidopa for blood pressure augmentation after acute spinal cord injury: case reports
Christopher S. Hong, Muhammad K. Effendi, Abdalla A. Ammar, Kent A. Owusu, Mahmoud A. Ammar, Andrew B. Koo, Layton A. Lamsam, Aladine A. Elsamadicy, Gregory A. Kuzmik, Maxwell Laurans, Michael L. DiLuna, Mark L. Landreneau
Received December 3, 2021  Accepted September 14, 2022  Published online December 7, 2022  
DOI: https://doi.org/10.4266/acc.2021.01662    [Epub ahead of print]
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  • 2 Crossref
AbstractAbstract PDF
Hypotension secondary to autonomic dysfunction is a common complication of acute spinal cord injury (SCI) that may worsen neurologic outcomes. Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of droxidopa, an enteral precursor of norepinephrine that is approved to treat neurogenic orthostatic hypotension, in the acute post-SCI setting. Droxidopa may be an alternative enteral therapy for those intolerant of midodrine due to reflex bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with droxidopa after failing with midodrine. The first patient was a 64-year-old male who underwent C3–6 laminectomies and fusion after a ten-foot fall resulting in quadriparesis. Post-operatively, the addition of midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive bradycardia. Treatment with droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3–5 laminectomies and fusion for a traumatic hyperflexion injury causing paraplegia. The addition of midodrine resulted in severe bradycardia, prompting consideration of pacemaker placement. However, with the addition of droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral therapy with midodrine and droxidopa. Droxidopa may be a viable enteral therapy to treat hypotension in patients after acute SCI who are otherwise not tolerating midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.

Citations

Citations to this article as recorded by  
  • A Guide to the Use of Vasopressors and Inotropes for Patients in Shock
    Anaas Moncef Mergoum, Abigail Rebecca Rhone, Nicholas James Larson, David J Dries, Benoit Blondeau, Frederick Bolles Rogers
    Journal of Intensive Care Medicine.2024;[Epub]     CrossRef
  • Oral blood pressure augmenting agents for intravenous vasopressor weaning
    John C Robinson, Mariam ElSaban, Nathan J Smischney, Patrick M Wieruszewski
    World Journal of Clinical Cases.2024; 12(36): 6892.     CrossRef
Neurosurgery
A point-of-care evaluation after visual loss following paraclinoid aneurysm repair: the role of sonographic and pupillometer assessment
Giacomo Bertolini, Ernesto Migliorino, Diego Mazzatenta, Carlo Bortolotti, Raffaele Aspide
Received January 9, 2022  Accepted March 17, 2022  Published online July 5, 2022  
DOI: https://doi.org/10.4266/acc.2022.00045    [Epub ahead of print]
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AbstractAbstract PDF
Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of a paraclinoid aneurysms. A 20-year-old male were admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission the patient reported a left amaurosis. To exclude secondary etiologies an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) were performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserve a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.

ACC : Acute and Critical Care
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