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Letter to the Editor
Thoracic Surgery
Comment on “Risk factors for intensive care unit readmission after lung transplantation: a retrospective cohort study”
Maida Qazi, Mahnoor Amin
Received September 28, 2022  Accepted November 25, 2022  Published online January 26, 2023  
DOI: https://doi.org/10.4266/acc.2022.01214    [Epub ahead of print]
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Original Article
Liver
Alcohol use disorder in the intensive care unit; a highly morbid condition; chemical dependency discussions during admission improves outcomes
Kristin Colling, Alexandra K. Kraft, Melissa L. Harry
Received April 26, 2022  Accepted September 23, 2022  Published online January 10, 2023  
DOI: https://doi.org/10.4266/acc.2022.00584    [Epub ahead of print]
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AbstractAbstract PDF
Background
Alcohol use disorders (AUD) are common in patients admitted to intensive care units (ICU) and increase the risk for worse outcomes. In this study, we describe factors associated with patient mortality after ICU admission and the effect of chemical dependency (CD) counseling on outcomes in the year following ICU admission.
Methods
We retrospectively reviewed patient demographics, hospital data, and documentation of CD counseling by medical providers for all ICU patients with AUD admitted to our institution between January 2017 and March 2019. Primary outcomes were in-hospital and 1-year mortality.
Results
Of the 527 patients with AUD requiring ICU care, median age was 56 years (range, 18–86 years). Both in-hospital mortality (12%) and 1-year mortality rates (27%) were high. . Rural patients, comorbidities, older age, need for mechanical ventilation, and complications were associated with increased risk of in-hospital and 1-year mortality. CD counseling was documented for 73% of patients, and 50% of these patients accepted alcohol treatment or resources prior to discharge. CD evaluation and acceptance was associated with a significantly decreased rate of readmission for liver or alcohol-related issues (36% vs. 58%; odds ratio [OR], 0.41; 95% confidence intervals [CI], 0.27–0.61) and 1-year mortality (7% vs. 19.5%; OR, 0.32; 95% CI, 0.16–0.64). CD evaluation alone, regardless of patient acceptance, was associated with a significantly decreased 1-year post-discharge mortality rate (12% vs. 23%; OR, 0.44; 95% CI, 0.25–0.77.)
Conclusions
ICU patients with AUD had high in-hospital and 1-year mortality. CD evaluation, regardless of patient acceptance, was associated with a significant decrease in 1-year mortality.
Case Report
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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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.
Review Article
Pulmonary
Asynchronies during invasive mechanical ventilation: narrative review and update
Santiago Nicolás Saavedra, Patrick Valentino Sepúlveda Barisich, José Benito Parra Maldonado, Romina Belén Lumini, Alberto Gómez-González, Adrián Gallardo
Acute Crit Care. 2022;37(4):491-501.   Published online November 30, 2022
DOI: https://doi.org/10.4266/acc.2022.01158
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AbstractAbstract PDFSupplementary Material
Invasive mechanical ventilation is a frequent therapy in critically ill patients in critical care units. To achieve favorable outcomes, patient and ventilator interaction must be adequate. However, many clinical situations could attempt against this principle and generate a mismatch between these two actors. These asynchronies can lead the patient to worst outcomes; that is why it is vital to recognize and treat these entities as soon as possible. Early detection and recognition of the different asynchronies could favor the reduction of the days of mechanical ventilation, the days of hospital stay, and intensive care and improve clinical results.
Corrigendum
Neurology
Contrast media mimicking subarachnoid hemorrhage after intrathecal injection in a patient with Creutzfeldt-Jakob disease
Taegyun Kim
Acute Crit Care. 2022;37(4):693-693.   Published online November 30, 2022
DOI: https://doi.org/10.4266/acc.2022.00339.e1
Corrects: Acute Crit Care 2022;37(3):474
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Editorial
Pediatrics
An advanced pediatric early warning system: a reliable sentinel, not annoying extra work
Young Joo Han
Acute Crit Care. 2022;37(4):667-668.   Published online November 29, 2022
DOI: https://doi.org/10.4266/acc.2022.01445
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Letter to the Editor
Rapid response system
Current status of the rapid response system and early warning score: a survey-based analysis
Sang-Hyeon Park, Jeehoon Kang, Tae Jung Kim, Hong Yeul Lee, Hyun-Jai Cho, Sang-Min Lee
Acute Crit Care. 2022;37(4):687-689.   Published online November 21, 2022
DOI: https://doi.org/10.4266/acc.2022.01144
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PDFSupplementary Material
Review Article
Pulmonary
Lung ultrasound for evaluation of dyspnea: a pictorial review
Aparna Murali, Anjali Prakash, Rashmi Dixit, Monica Juneja, Naresh Kumar
Acute Crit Care. 2022;37(4):502-515.   Published online November 21, 2022
DOI: https://doi.org/10.4266/acc.2022.00780
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AbstractAbstract PDFSupplementary Material
Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. In recent years, lung ultrasound has emerged as an important alternative for quick evaluation of the patient at the bedside. Several techniques and protocols for performing lung ultrasound have been described in the literature, with the most popular one being the Bedside Lung Ultrasound in Emergency (BLUE) protocol which can be utilized to diagnose the cause of acute dyspnea at the bedside. We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea.
Original Article
Pediatrics
Characteristics and timing of mortality in children dying in pediatric intensive care: a 5-year experience
Edin Botan, Emrah Gün, Emine Kübra Şden, Cansu Yöndem, Anar Gurbanov, Burak Balaban, Fevzi Kahveci, Hasan Özen, Hacer Uçmak, Ali Genco Gençay, Tanil Kendirli
Acute Crit Care. 2022;37(4):644-653.   Published online November 11, 2022
DOI: https://doi.org/10.4266/acc.2022.00395
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AbstractAbstract PDF
Background
Pediatric intensive care units (PICUs), where children with critical illnesses are treated, require considerable manpower and technological infrastructure in order to keep children alive and free from sequelae. Methods: In this retrospective comparative cohort study, hospital records of patients aged 1 month to 18 years who died in the study PICU between January 2015 and December 2019 were reviewed. Results: A total of 2,781 critically ill children were admitted to the PICU. The mean±standard deviation age of 254 nonsurvivors was 64.34±69.48 months. The mean PICU length of stay was 17 days (range, 1–205 days), with 40 children dying early (<1 day of PICU admission). The majority of nonsurvivors (83.9%) had comorbid illnesses. Children with early mortality were more likely to have neurological findings (62.5%), hypotension (82.5%), oliguria (47.5%), acidosis (92.5%), coagulopathy (30.0%), and cardiac arrest (45.0%) and less likely to have terminal illnesses (52.5%) and chronic illnesses (75.6%). Children who died early had a higher mean age (81.8 months) and Pediatric Risk of Mortality (PRISM) III score (37). In children who died early, the first three signs during ICU admission were hypoglycemia in 68.5%, neurological symptoms in 43.5%, and acidosis in 78.3%. Sixty-seven patients needed continuous renal replacement therapy, 51 required extracorporeal membrane oxygenation support, and 10 underwent extracorporeal cardiopulmonary resuscitation. Conclusions: We found that rates of neurological findings, hypotension, oliguria, acidosis, coagulation disorder, and cardiac arrest and PRISM III scores were higher in children who died early compared to those who died later.
Review Article
Neurosurgery
Target temperature management in traumatic brain injury with a focus on adverse events, recognition, and prevention
Kwang Wook Jo
Acute Crit Care. 2022;37(4):483-490.   Published online November 10, 2022
DOI: https://doi.org/10.4266/acc.2022.01291
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AbstractAbstract PDF
Traumatic brain injury (TBI) is a critical cause of disability and death worldwide. Many studies have been conducted aimed at achieving favorable neurologic outcomes by reducing secondary brain injury in TBI patients. However, ground-breaking outcomes are still insufficient so far. Because mild-to-moderate hypothermia (32°C–35°C) has been confirmed to help neurological recovery for recovered patients after circulatory arrest, it has been recognized as a major neuroprotective treatment plan for TBI patients. Thereafter, many clinical studies about the effect of therapeutic hypothermia (TH) on severe TBI have been conducted. However, efficacy and safety have not been demonstrated in many large-scale randomized controlled studies. Rather, some studies have demonstrated an increase in mortality rate due to complications such as pneumonia, so it is not highly recommended for severe TBI patients. Recently, some studies have shown results suggesting TH may help reperfusion/ischemic injury prevention after surgery in the case of mass lesions, such as acute subdural hematoma, and it has also been shown to be effective in intracranial pressure control. In conclusion, TH is still at the center of neuroprotective therapeutic studies regarding TBI. If proper measures can be taken to mitigate the many adverse events that may occur during the course of treatment, more positive efficacy can be confirmed. In this review, we look into adverse events that may occur during the process of the induction, maintenance, and rewarming of targeted temperature management and consider ways to prevent and address them.
Letter to the Editor
Ethics
A comprehensive intensive care for senior citizens: the need for public health policy
Dalmacito A. Cordero Jr
Acute Crit Care. 2022;37(4):690-692.   Published online November 10, 2022
DOI: https://doi.org/10.4266/acc.2022.01151
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Original Articles
Pulmonary
Extravascular lung water index, pulmonary vascular permeability index, and global end-diastolic volume index in mechanically ventilated COVID-19 patients requiring prone position ventilation: a preliminary retrospective study
Rosanna Carmela De Rosa, Antonio Romanelli, Michele Gallifuoco, Giovanni Messina, Marianne Di Costanzo, Antonio Corcione
Acute Crit Care. 2022;37(4):571-579.   Published online November 10, 2022
DOI: https://doi.org/10.4266/acc.2022.00423
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AbstractAbstract PDF
Background
There is a lack of data on extravascular lung water index (EVLWi), pulmonary vascular permeability index (PVPi), and global end-diastolic volume index (GEDVi) during prone position ventilation (PPV) in coronavirus disease 2019 (COVID-19) patients. The objectives of this study were to analyze trends in EVLWi, PVPi, and GEDVi during PPV and the relationships between these parameters and PaO2/FiO2. Methods: In this preliminary retrospective observational study, we performed transpulmonary thermodilution (TPTD) in seven mechanically ventilated COVID-19 patients without cardiac and pulmonary comorbidities requiring PPV for 18 hours, at specific times (30 minutes pre-PPV, 18 hours after PPV, and 3 hours after supination). EVLWi, PVPi and GEDVi were measured. The relationships between PaO2/FiO2 and EVLWi, and PVPi and GEDVi values, in the supine position were analyzed by linear regression. Correlation and determination coefficients were calculated. Results: EVLWi was significantly different between three time points (analysis of variance, P=0.004). After 18 hours in PPV, EVLWi was lower compared with values before PPV (12.7±0.9 ml/kg vs. 15.3±1.5 ml/kg, P=0.002). Linear regression showed that only EVLWi was correlated with PaO2/FiO2 (β =–5.757; 95% confidence interval, –10.835 to –0.679; r=–0.58; R2 =0.34; F-test P=0.029). Conclusions: EVLWi was significantly reduced after 18 hours in PPV and values measured in supine positions were correlated with PaO2/FiO2. This relationship can help clinicians discriminate whether deterioration in gas exchange is related to fluid overload or disease progression. Further clinical research should evaluate the role of TPTD parameters as markers to stratify disease severity and guide clinical management.
Pulmonary
Association between timing of intubation and mortality in patients with idiopathic pulmonary fibrosis
Eunhye Bae, Jimyung Park, Sun Mi Choi, Jinwoo Lee, Sang-Min Lee, Hong Yeul Lee
Acute Crit Care. 2022;37(4):561-570.   Published online October 28, 2022
DOI: https://doi.org/10.4266/acc.2022.00444
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AbstractAbstract PDFSupplementary Material
Background
Delayed intubation is associated with poor prognosis in patients with respiratory failure. However, the effect of delayed intubation in patients with idiopathic pulmonary fibrosis (IPF) remains unknown. This study aimed to analyze whether timing of intubation after high-concentration oxygen therapy was associated with worse clinical outcomes in IPF patients. Methods: This retrospective propensity score-matched study enrolled adult patients with IPF who underwent mechanical ventilation between January 2011 and July 2021. Patients were divided into early and delayed intubation groups. Delayed intubation was defined as use of high-concentration oxygen therapy for at least 48 hours before tracheal intubation. The primary outcome was intensive care unit (ICU) mortality, and a conditional logistic regression model was used to evaluate the association between timing of intubation and clinical outcomes. Results: The median duration of high-concentration oxygen therapy before intubation was 0.5 days in the early intubation group (n=60) and 5.1 days in the delayed intubation group (n=36). The ICU mortality rate was 56.7% and 75% in the early and delayed intubation groups, respectively, before propensity matching (P=0.075). After matching for demographic and clinical covariates, 33 matched pairs were selected. In the propensity-matched cohort, delayed intubation significantly increased the risk of ICU mortality (adjusted odds ratio, 3.99; 95% confidence interval, 1.02–15.63; P=0.046). However, in-hospital mortality did not differ significantly between the groups. Conclusions: In patients with IPF, delayed intubation after initiation of high-concentration oxygen therapy was significantly associated with increased risk of ICU mortality compared to early intubation.
CPR/Resuscitation
Diet-related complications according to the timing of enteral nutrition support in patients who recovered from out-of-hospital cardiac arrest: a propensity score matched analysis
Gun Woo Kim, Young-Il Roh, Kyoung-Chul Cha, Sung Oh Hwang, Jae Hun Han, Woo Jin Jung
Acute Crit Care. 2022;37(4):610-617.   Published online October 27, 2022
DOI: https://doi.org/10.4266/acc.2022.00696
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AbstractAbstract PDFSupplementary Material
Background
A proper nutritional plan for resuscitated patients is important in intensive care; however, specific nutritional guidelines have not yet been established. This study aimed to determine the incidence of diet-related complications that were affected by the timing of enteral nutrition in resuscitated patients after cardiac arrest. Methods: This retrospective and 1:1 propensity score matching study involved patients who recovered after nontraumatic, out-of-hospital cardiac arrest at a tertiary hospital. Patients were divided into an early nutrition support (ENS) group and a delayed nutrition support (DNS) group according to the nutritional support time within 48 hours after admission. The incidence of major clinical complications was compared between the groups. Results: A total of 46 patients (ENS: 23, DNS: 23) were enrolled in the study. There were no differences in body mass index, comorbidity, and time of cardiopulmonary resuscitation between the two groups. There were 9 patients (ENS: 4, DNS: 5) with aspiration pneumonia; 4 patients (ENS: 2, DNS: 2) with regurgitation; 1 patient (ENS: 0, DNS: 1) with ileus; 21 patients (ENS: 10, DNS: 11) with fever; 13 patients (ENS: 8, DNS: 5) with hypoglycemia; and 20 patients (ENS: 11, DNS: 9) with hyperglycemia. The relative risk of each complication during post-resuscitation care was no different between groups. Conclusions: There was a similar incidence of diet-related complications during post cardiac arrest care according to the timing of enteral nutrition.
Pulmonary
Agreement between two methods for assessment of maximal inspiratory pressure in patients weaning from mechanical ventilation
Emanuelle Olympia Silva Ribeiro, Rik Gosselink, Lizandra Eveline da Silva Moura, Raissa Farias Correia, Wagner Souza Leite, Maria das Graças Rodrigues de Araújo, Armele Dornelas de Andrade, Daniella Cunha Brandão, Shirley Lima Campos
Acute Crit Care. 2022;37(4):592-600.   Published online October 27, 2022
DOI: https://doi.org/10.4266/acc.2022.00325
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AbstractAbstract PDF
Background
Respiratory muscle strength in patients with an artificial airway is commonly assessed as the maximal inspiratory pressure (MIP) and is measured using analogue or digital manometers. Recently, new electronic loading devices have been proposed to measure respiratory muscle strength. This study evaluates the agreement between the MIPs measured by a digital manometer and those according to an electronic loading device in patients being weaned from mechanical ventilation. Methods: In this prospective study, the standard MIP was obtained using a protocol adapted from Marini, in which repetitive inspiratory efforts were performed against an occluded airway with a one-way valve and were recorded with a digital manometer for 40 seconds (MIPDM). The MIP measured using the electronic loading device (MIPELD) was obtained from repetitively tapered flow resistive inspirations sustained for at least 2 seconds during a 40-second test. The agreement between the results was verified by a Bland-Altman analysis. Results: A total of 39 subjects (17 men, 55.4±17.7 years) was enrolled. Although a strong correlation between MIPDM and MIPELD (R=0.73, P<0.001) was observed, the Bland-Altman analysis showed a high bias of –47.4 (standard deviation, 22.3 cm H2O; 95% confidence interval, –54.7 to –40.2 cm H2O). Conclusions: The protocol of repetitively tapering flow resistive inspirations to measure the MIP with the electronic loading device is not in agreement with the standard protocol using one-way valve inspiratory occlusion when applied in poorly cooperative patients being weaned from mechanical ventilation.

ACC : Acute and Critical Care