Acute and Critical Care

Original Articles

Pulmonary
Using machine learning techniques for early prediction of tracheal intubation in patients with septic shock: a multi-center study in Korea: Ji Han Heo, Taegyun Kim, Tae Gun Shin, Gil Joon Suh, Woon Yong Kwon, Hayoung Kim, Heesu Park, Heejun Kim, Sol Han; Received December 23, 2024 Accepted February 25, 2025 Published online April 30, 2025; DOI: https://doi.org/10.4266/acc.004776 [Epub ahead of print]

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Abstract PDF Supplementary Material: Background
Patients with septic shock frequently require tracheal intubation in the emergency department (ED). However, the criteria for tracheal intubation are subjective, based on physician experience, or require serial evaluations over relatively long intervals to make accurate predictions, which might not be feasible in the ED. We used supervised learning approaches and features routinely available during the initial stages of evaluation and resuscitation to stratify the risks of tracheal intubation within a 24-hour time window.
Methods
We retrospectively analyzed the data of patients diagnosed with septic shock based on the SEPSIS-3 criteria across 21 university hospital EDs in the Republic of Korea. A principal component analysis revealed a complex, non-linear decision boundary with respect to the application of tracheal intubation within a 24-hour time window. Stratified five-fold cross validation and a grid search were used with extreme gradient boost. Shapley values were calculated to explain feature importance and preferences.
Results
In total, data for 4,762 patients were analyzed; within that population, 1,486 (31%) were intubated within a 24-hour window, and 3,276 (69%) were not. The area under the receiver operating characteristic curve and F1 scores for intubation within a 24-hour window were 0.829 (95% CI, 0.801–0.878) and 0.654 (95% CI, 0.627–0.681), respectively. The Shapley values identified lactate level after initial fluids, suspected lung infection, initial pH, Sequential Organ Failure Assessment score at enrollment, and respiratory rate at enrollment as important features for prediction.
Conclusions
An extreme gradient boosting machine can moderately discriminate whether intubation is warranted within 24 hours of the recognition of septic shock in the ED.

Surgery
Classification of postoperative fever patients in the intensive care unit following intra-abdominal surgery: a machine learning-based cluster analysis using the Medical Information Mart for Intensive Care (MIMIC)-IV database, developed the United States: Sang Mok Lee, Hongjin Shim; Received November 29, 2024 Accepted February 6, 2025 Published online April 30, 2025; DOI: https://doi.org/10.4266/acc.004464 [Epub ahead of print]

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Abstract PDF: Background
Postoperative fever is common. However, it can sometimes indicate severe complications such as sepsis or pneumonia. Intensive care unit (ICU) patients who have undergone abdominal surgery have a higher risk of postoperative fever due the physical severity of this type of surgery. Nevertheless, determining when more aggressive or invasive management of fever is necessary remains a challenge.
Methods
We analyzed the Medical Information Mart for Intensive Care (MIMIC)-IV and MIMIC-IV-Note databases, which are open critical care big databases from a single institute in the United States. From this, we selected ICU patients who developed fever after intra-abdominal surgery and classified these patients into two groups using cluster analysis based on diverse variables from the MIMIC-IV databases. Following this cluster analysis, we assessed differences among the identified groups.
Results
Of 2,858 ICU stays after intra-abdominal surgery, 331 postoperative fever cases were identified. These patients were clustered into two groups. Group A included older patients with a higher mortality rate, while group B consisted of younger patients with a lower mortality rate.
Conclusions
Postoperative ICU patients with a fever could be classified into two distinct groups, a high-risk group and low-risk group. The high-risk patient group was characterized by older age, higher Sequential Organ Failure Assessment (SOFA) score, and more unstable hemodynamic status, indicating the need for aggressive management. Clustering postoperative fever patients by clinical variables can support medical decision-making and targeted treatment to improve patient outcomes.

Nutrition
Effect of nutrition support team on 28-day mortality in patients with acute respiratory failure: Inhan Lee, Junghyun Kim, Mihyun Ku, Yurim Choi, Sohyun Park, Ji Hyeon Bang, Joohae Kim; Received August 28, 2024 Accepted March 7, 2025 Published online April 28, 2025; DOI: https://doi.org/10.4266/acc.003312 [Epub ahead of print]

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Abstract PDF: Background
Providing optimal nutrition to patients with acute respiratory failure is difficult because nutritional requirements vary according to disease severity and comorbidities. In 2021, the National Medical Center initiated a protocol for screening upon admission and regular monitoring by a multidisciplinary nutritional support team (NST), for all patients in the medical intensive care unit (ICU). This study aimed to evaluate the effects of routine NST monitoring and active intervention on the clinical outcomes of patients with acute respiratory failure.
Methods
Patients with acute respiratory failure requiring high-flow nasal cannula, non-invasive ventilation, or mechanical ventilation were included. The primary outcome was 28-day mortality after ICU admission. Secondary outcomes included the supplied/target calorie ratio, supplied/target protein ratio on day 7, and complications.
Results
In total, 152 patients were included in the analysis. The patients were divided into a pre-monitoring (n=96) and post-monitoring groups (n=56). More patients in the post-monitoring group received NST intervention and had earlier initiation of enteral feeding. In survival analysis, 28-day mortality was significantly lower in post-monitoring group (adjusted hazard ratio, 0.42; 95% CI, 0.24–0.74). The ratio of achievement for required calories and protein on day 7 was higher, but not significantly, in the post-monitoring group. No significant differences were observed in the incidence of complications.
Conclusions
Regular NST monitoring in the ICU could have contributed to a reduced risk of 28-day mortality in critically ill patients with acute respiratory failure.

Letter to the Editor

Thoracic Surgery
Left ventricular unloading strategies in venoarterial extracorporeal membrane oxygenation patients: how much do we truly understand?: Jihyuk Chung, Su Yong Kim, Juhyun Lee, Yang Hyun Cho; Received December 31, 2024 Accepted March 12, 2025 Published online April 23, 2025; DOI: https://doi.org/10.4266/acc.005064 [Epub ahead of print]

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Original Articles

Neurology
Effectiveness of intravenous thrombolysis in patients with large-vessel occlusion receiving endovascular treatment in Korea: Min Kim, Ji Sung Lee, Seong-Joon Lee, So Young Park, Jungyun Seo, Ji Man Hong, Hee-Kwon Park, Jae-Kwan Cha, Jeffrey L. Saver, Jin Soo Lee; Received November 7, 2024 Accepted February 19, 2025 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.004248 [Epub ahead of print]

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Abstract PDF Supplementary Material: Background
The effectiveness of intravenous tissue plasminogen activator (IV tPA) in patients with large-vessel occlusion (LVO) receiving endovascular treatment (EVT) for acute ischemic stroke (AIS) has been questioned. We investigated IV tPA effectiveness in real-world AIS patients, including those with intracranial LVO receiving EVT.
Methods
We identified patients with AIS who presented to hospital with National Institutes of Health Stroke Scale ≥4 within 8 hours of symptom onset from the institutional stroke registry. The association of IV tPA use with effectiveness and safety outcomes was analyzed in overall enrolled AIS patients; LVO patients; and patients treated with EVT. The effect of IV tPA was assessed using multiple logistic regression.
Results
Among the 654 patients meeting study entry criteria, 238 (36.4%) received IV tPA and 416 (63.6%) did not. Multiple logistic regression analysis and shift analysis revealed IV tPA was associated with improved outcomes in overall enrolled AIS population, LVO, and EVT-treated subgroups. Among EVT-treated patients, IV tPA was associated with higher likelihood of ambulatory or better outcome (modified Rankin Scale 0–3) with odds ratio of 1.95 (P=0.03).
Conclusions
In this real-world study, IV tPA use was associated with improved outcomes for patients with AIS, including among LVO patients treated and not treated with EVT, in the contemporary mechanical thrombectomy era.

Nursing
Characteristics and associated risk factors of exposure keratopathy among ventilated patients in intensive care units in Jordan: Sajeda Al-Tamimi, Mohammad Y.N. Saleh, Al-Mutez Gharaibeh, Farah Al-A’mar, Rasmieh Al-Amer; Received September 19, 2024 Accepted January 27, 2025 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003648 [Epub ahead of print]

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Abstract PDF: Background
Exposure keratopathy is the most common ocular surface disorder in ventilated patients due to poor eyelid closure, decreased blink reflex, and the inability to produce tears. Healthcare providers in intensive care units (ICUs) play a significant role in preventing exposure keratopathy through appropriate eyelid taping and eye ointments.
Methods
This is a cross-sectional study to describe the characteristics and factors associated with exposure keratopathy in all mechanically ventilated patients admitted to an adult ICU between February and June 2023. Patients were examined for corneal changes using a corneal fluorescein staining test with a cobalt blue filter indirect ophthalmoscope.
Results
Of 156 ventilated patients included in this study, 42.3% had exposure keratopathy, 13.5% had lagophthalmos, and 26.9% of patients had chemosis. For patients with a Glasgow Coma Scale (GCS) score of 3, the odds ratio of exposure keratopathy was 21.47 (95% confidence interval [CI], 2.82–163.05). The use of inotropes increased the odds ratio to 35.55 (95% CI, 3.41–369.90), whereas a hospital stay >7.23 days increased the odds ratio to 43.59 (95% CI, 15.66–1,316.32).
Conclusions
The frequency of exposure keratopathy is high and is underestimated in ventilated patients, with lower GCS and increased hospital length of stay as the main risk factors. Prioritizing eye care in ventilated patients with low GCS scores or prolonged ICU stays is essential to reduce exposure keratopathy.

Basic science and research
Anesthesiological management in endovascular mechanical thrombectomy: a propensity score-matched retrospective analysis in Italy: Antonio Romanelli, Aniello Iovino, Daniele Giuseppe Romano, Antonella Langone, Rosa Napoletano, Giulia Frauenfelder, Flora Minichino, Liliana D’Ambrosio, Miriam Caterino, Raffaele Tortora, Renato Gammaldi, Paolo Barone, Renato Saponiero; Received July 23, 2024 Accepted November 19, 2024 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003000 [Epub ahead of print]

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Abstract PDF: Background
Endovascular mechanical thrombectomy (EMT) can be performed with general anesthesia (GA) or using non-GA techniques. Several meta-analyses on the topic have reported discordant main outcomes. The aim of this retrospective single-center study was to analyze the relationship between clinical outcomes and anesthesiological management (GA vs. non-GA) in patients who underwent EMT for acute anterior ischemic stroke (AIS).
Methods
We performed a propensity score-matched (PSM) analysis of patients who underwent EMT for acute AIS from January 2018 to December 2021. For PSM, we chose covariates influencing clinical decisions about anesthesiological management. Comparisons between groups were performed with the chi-square test for categorical variables and Student t-test or the Mann-Whitney U-test for continuous variables as appropriate. The relationships between anesthesiological management and clinical outcomes were analyzed using logistic regression, and results are reported as odds ratios with 95% confidence intervals. A two-sided P-value <0.05 was considered statistically significant.
Results
From 194 observations (78 in the GA group, 116 in the non-GA group), after PSM, we obtained 70 data pairs. Both anesthesiological approaches resulted in similar rates of in-hospital mortality, 90-day functional independence, full recanalization, procedural complications, and intracerebral hemorrhage (ICH). Performing EMT with GA was unrelated to the in-hospital and 90-day death rates, 90-day functional independence, full recanalization rate, procedural complications, and ICH (P>0.05).
Conclusions
Anesthesiological management did not influence clinical outcomes of EMT for acute AIS. Physiological stability during EMT may impact outcomes more significantly than anesthesiological management. Further studies on this topic are needed.

Letter to the Editor

Neurology
Neuroleptic malignant syndrome requiring intensive care unit admission in two patients with SARS-CoV-2 infection in Portugal: Marina Costa, Ana Raquel Covas, Fábio Neves Correia, Sara Bernardo, Pedro Silveira; Received December 4, 2024 Accepted January 28, 2025 Published online March 13, 2025; DOI: https://doi.org/10.4266/acc.004632 [Epub ahead of print]

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Review Article

Nephrology
Dialysis decision in critically ill patients in intensive care unit: Harin Rhee; Acute Crit Care. 2025;40(1):1-9. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.004896

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Abstract PDF: The 2012 Kidney Disease Improving Global Outcomes guidelines clearly define emergent indications for kidney replacement therapy; however, whether dialysis should be initiated in critically ill patients without these indications remains unclear. This review briefly summarizes the results of recent landmark trials and discusses their limitations originating from a criteria-based approach at a single time point. Moreover, a personalized approach based on each patient’s demand-capacity balance and its future benefits as a platform for kidney support therapy in critically ill patients are discussed.

Letter to the Editor

Anesthesiology
Concentration of local anesthetics is important in nerve blocks: Raghuraman M. Sethuraman; Acute Crit Care. 2025;40(1):150-151. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.002544

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Original Articles

Pediatrics
Effects of rescue airway pressure release ventilation on mortality in severe pediatric acute respiratory distress syndrome: a retrospective comparative analysis from India: Sudha Chandelia, Sunil Kishore, Maansi Gangwal, Devika Shanmugasundaram; Acute Crit Care. 2025;40(1):113-121. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.002520

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Abstract PDF: Background
Pediatric acute respiratory distress syndrome (PARDS) has a mortality rate of up to 75%, which can be up to 90% in high-risk patients. Even with the use of advanced ventilation strategies, mortality remains unacceptably high at 40%. Airway pressure release ventilation (APRV) mode is a new strategy in PARDS. Our aim was to evaluate whether use of APRV mode in severe PARDS was associated with reduced hospital mortality compared to other modes of ventilation.
Methods
This was a retrospective comparative study using data from case files in a pediatric intensive care unit of a university-affiliated tertiary-care hospital. The study period (January 2014 to December 2019) covered three years before routine use of APRV mode to three years after its implementation. We compared severe PARDS patients in two groups: The APRV group (who received APRV as rescue therapy after failing protective ventilation); and The Non-APRV group, who received other modes of ventilation.
Results
A total of 24 patients in each group were analyzed. Overall in-hospital mortality in the APRV group was 79% versus 91% in the Non-APRV group. In-hospital mortality was significantly lower in the APRV group (univariate analysis: hazard ratio [HR], 0.27; 95% CI, 0.14–0.52; P=0.001 and multivariate analysis: HR, 0.03; 95% CI, 0.005–0.17; P=0.001). Survival times were significantly longer in the APRV group (median time to death: 7.5 days in APRV vs. 4.3 days in non-APRV; P=0.001).
Conclusions
Use of rescue APRV mode in severe PARDS may yield lower mortality rates and longer survival times.

Pediatrics
Acute severe hepatitis in children following extrahepatic infection in South Korea: etiology, clinical course, and outcomes: Sanghoon Lee, Young Ok Kim, Seo-Hee Kim; Acute Crit Care. 2025;40(1):122-127. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.000600

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Abstract PDF: Background
Acute hepatitis can occur in association with systemic diseases outside the liver. Acute severe hepatitis with markedly elevated transaminase levels following extrahepatic infection has been reported in children. However, research on this condition remains limited. This study aimed to investigate its etiology, clinical course, and outcomes.
Methods
We retrospectively reviewed data from 2013 to 2020 for children under 12 years old with elevated liver enzymes following systemic infection. Acute severe hepatitis was defined as serum transaminase levels exceeding 1,000 IU/L in the absence of underlying liver disease. We analyzed hepatitis-associated pathogens, liver enzyme trends, and factors influencing recovery.
Results
A total of 39 patients were included in this study. The most common age group was 7–12 months (54.8%), and 53.8% were male. Respiratory infections were the most common (61.5%), followed by gastrointestinal infections (23.1%), meningitis (10.3%), and urinary tract infections (5.1%). The median peak alanine transaminase (ALT) level was 1,515.8±424.2 IU/L, with a median time to peak ALT of 4.2±2.3 days from symptom onset. ALT levels normalized within 21 days in 71.8% of patients and within 28 days in 94.9%. Younger age was associated with delayed ALT normalization, whereas hepatoprotective agent use was associated with faster normalization.
Conclusions
Acute severe hepatitis can develop following respiratory and other systemic infections. Younger children were more susceptible and had a more prolonged disease course.

Editorial

Rapid response system
Transforming rapid response team through artificial intelligence: Kwangha Lee; Acute Crit Care. 2025;40(1):136-137. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.000425

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Original Articles

Neurosurgery
Cost-effectiveness of intracranial pressure monitoring in severe traumatic brain injury in Southern Thailand: Jidapa Jitchanvichai, Thara Tunthanathip; Acute Crit Care. 2025;40(1):69-78. Published online February 21, 2025; DOI: https://doi.org/10.4266/acc.004080

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Abstract PDF Supplementary Material: Background
Traumatic brain injury (TBI) is a leading cause of fatalities and disabilities in the public health domain, particularly in Thailand. Guidelines for TBI patients advise intracranial pressure monitoring (ICPm) for intensive care. However, information about the cost-effectiveness (CE) of ICPm in cases of severe TBI is lacking. This study assessed the CE of ICPm in severe TBI.
Methods
This was a retrospective cohort economic evaluation study from the perspective of the healthcare system. Direct costs were sourced from electronic medical records, and quality-adjusted life years (QALY) for each individual were computed using multiple linear regression with standardization. Incremental costs, incremental QALY, and the incremental CE ratio (ICER) were estimated, and the bootstrap method with 1,000 iterations was used in uncertainty analysis.
Results
The analysis included 821 individuals, with 4.1% undergoing intraparenchymal ICPm. The average cost of hospitalization was United States dollar ($)8,697.13 (±6,271.26) in both groups. The incremental cost and incremental QALY of the ICPm group compared with the non-ICPm group were $3,322.88 and –0.070, with the base-case ICER of $–47,504.08 per additional QALY. Results demonstrated that 0.007% of bootstrapped ICERs were below the willingness-to-pay (WTP) threshold of Thailand.
Conclusions
ICPm for severe TBI was not cost-effective compared with the WTP threshold of Thailand. Resource allocation for TBI prognosis requires further development of cost-effective treatment guidelines.

Neurosurgery
A low preoperative platelet-to-white blood cell ratio is associated with acute kidney injury following cerebral aneurysm treatment in South Korea: Seung-Woon Lim, Woo-Young Jo, Hee-Pyoung Park; Acute Crit Care. 2025;40(1):59-68. Published online February 21, 2025; DOI: https://doi.org/10.4266/acc.003120

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Abstract PDF Supplementary Material: Background
Inflammation is involved in the pathophysiology of postoperative acute kidney injury (AKI). We investigated whether preoperative platelet-to-white blood cell ratio (PWR), a novel serum biomarker of systemic inflammation, was associated with postoperative AKI following cerebral aneurysm treatment. We also compared the discrimination power of preoperative PWR with those of other preoperative systemic inflammatory indices in predicting postoperative AKI.
Methods
Perioperative data including preoperative systemic inflammatory indices and cerebral aneurysm-related variables were retrospectively analyzed in 4,429 cerebral aneurysm patients undergoing surgical clipping or endovascular coiling. Based on the cutoff value of preoperative PWR, patients were divided into the high PWR (≥39.04, n=1,924) and low PWR (<39.04, n=2,505) groups. After propensity score matching (PSM), 1,168 patients in each group were included in the data analysis. AKI was defined according to the Kidney Disease Improving Global Outcomes guidelines.
Results
Postoperative AKI occurred more frequently in the low PWR group than in the high PWR group before PSM (45 [1.8%] vs. 7 [0.4%], P<0.001) and after (17 [1.5%] vs. 5 [0.4%], P=0.016). A low preoperative PWR was predictive of postoperative AKI before PSM (odds ratio [95% CI], 3.93 [1.74–8.87]; P<0.001) and after (3.44 [1.26–9.34], P=0.016). Preoperative PWR showed the highest area under the curve for postoperative AKI (0.713 [0.644–0.782], P<0.001), followed by preoperative platelet-to-neutrophil ratio (0.694 [0.619–0.769], P<0.001), neutrophil percentage-to-albumin ratio (0.671 [0.592–0.750], P<0.001), white blood cell-to-hemoglobin ratio (0.665 [0.579–0.750], P<0.001), neutrophil-to-lymphocyte ratio (0.648 [0.569–0.728], P<0.001), and systemic inflammatory index (0.615 [0.532–0.698], P=0.004).
Conclusions
A low preoperative PWR was associated with postoperative AKI following cerebral aneurysm treatment.

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