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Review Articles
Basic science and research
Sex or gender differences in treatment outcomes of sepsis and septic shock
Seung Yeon Min, Ho Jin Yong, Dohhyung Kim
Received April 3, 2024  Accepted April 12, 2024  Published online May 24, 2024  
DOI: https://doi.org/10.4266/acc.2024.00591    [Epub ahead of print]
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AbstractAbstract PDF
Gender disparities in intensive care unit (ICU) treatment approaches and outcomes are evident. However, clinicians often pay little attention to the importance of biological sex and sociocultural gender in their treatment courses. Previous studies have reported that differences between sexes or genders can significantly affect the manifestation of diseases, diagnosis, clinicians' treatment decisions, scope of treatment, and treatment outcomes in the intensive care field. In addition, numerous reports have suggested that immunomodulatory effects of sex hormones and differences in gene expression from X chromosomes between genders might play a significant role in treatment outcomes of various diseases. However, results from clinical studies are conflicting. Recently, the need for customized treatment based on physical, physiological, and genetic differences between females and males and sociocultural characteristics of society have been increasingly emphasized. However, interest in and research into this field are remarkably lacking in Asian countries, including South Korea. Through this review, we hope to enhance our awareness of the importance of sex and gender in intensive care treatment and research by briefly summarizing several principal issues, mainly focusing on sex and sex hormone-based outcomes in patients admitted to the ICU with sepsis and septic shock.
Infection
Microbial infections in burn patients
Souvik Roy, Preeti Mukherjee, Sutrisha Kundu, Debashrita Majumder, Vivek Raychaudhuri, Lopamudra Choudhury
Received December 8, 2023  Accepted March 27, 2024  Published online May 24, 2024  
DOI: https://doi.org/10.4266/acc.2023.01571    [Epub ahead of print]
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AbstractAbstract PDF
Polymicrobial infections are the leading causes of complications incurred from injuries that burn patients develop. Such patients admitted to the hospital have a high risk of developing hospital-acquired infections, with longer patient stays leading to increased chances of acquiring such drug-resistant infections. Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis are the most common multidrug-resistant (MDR) Gram-negative bacteria identified in burn wound infections (BWIs). BWIs caused by viruses, like Herpes Simplex and Varicella Zoster, and fungi-like Candida spp. appear to occur occasionally. However, the preponderance of infection by opportunistic pathogens is very high in burn patients. Variations in the causative agents of BWIs are due to differences in geographic location and infection control measures. Overall, burn injuries are characterized by elevated serum cytokine levels, systemic immune response, and immunosuppression. Hence, early detection and treatment can accelerate the wound-healing process and reduce the risk of further infections at the site of injury. A multidisciplinary collaboration between burn surgeons and infectious disease specialists is also needed to properly monitor antibiotic resistance in BWI pathogens, help check the super-spread of MDR pathogens, and improve treatment outcomes as a result.
Original Article
CPR/Resuscitation
Effects of ketamine on the severity of depression and anxiety following postoperative mechanical ventilation: a single-blind randomized clinical trial in Iran
Seyedbabak Mojaveraghili, Fatemeh Talebi, Sima Ghorbanoghli, Shahram Moghaddam, Hamidreza Shakouri, Ruzbeh Shamsamiri, Fatemeh Mehravar
Received September 21, 2023  Accepted April 9, 2024  Published online May 24, 2024  
DOI: https://doi.org/10.4266/acc.2023.01186    [Epub ahead of print]
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AbstractAbstract PDF
Background
In this study, we compare the effects of ketamine and the combination of midazolam and morphine on the severity of depression and anxiety in mechanically ventilated patients after discharge from the intensive care unit (ICU).
Methods
This randomized single-blind clinical trial included 50 patients who were candidates for craniotomy and postoperative mechanical ventilation in the ICU of 5 Azar Teaching Hospital in Gorgan City, North Iran, from 2021 to 2022. Patients were allocated to two groups by quadruple block randomization. In group A, 0.5 mg/kg of ketamine was infused over 15 minutes after craniotomy, and then continued at a dose of 5 µ/kg/min during mechanical ventilation. In group B, midazolam was infused at a dose of 2–3 mg/hr and morphine at a dose of 3–5 mg/hr. After patients were discharged from the ICU, if their Glasgow Coma Scale scores were ≥14, Beck’s anxiety and depression inventories were completed by a psychologist within 2 weeks, 2 months, and 6 months after discharge.
Results
The mean scores of depression at 2 months (P=0.01) and 6 months (P=0.03) after discharge were significantly lower in the ketamine group than in the midazolam and morphine group. The mean anxiety scores were significantly lower in the ketamine group 2 weeks (P=0.006) and 6 months (P=0.002) after discharge.
Conclusions
Ketamine is an effective drug for preventing and treating anxiety and depression over the long term in patients discharged from the ICU. However, further larger volume studies are required to validate these results.
Review Article
Pulmonary
Beyond survival: understanding post-intensive care syndrome
Lovish Gupta, Maazen Naduthra Subair, Jaskaran Munjal, Bhupinder Singh, Vasu Bansal, Vasu Gupta, Rohit Jain
Received September 11, 2023  Accepted November 8, 2023  Published online May 24, 2024  
DOI: https://doi.org/10.4266/acc.2023.01158    [Epub ahead of print]
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AbstractAbstract PDF
Post-intensive care syndrome (PICS) refers to persistent or new onset physical, mental, and neurocognitive complications that can occur following a stay in the intensive care unit. PICS encompasses muscle weakness; neuropathy; cognitive deficits including memory, executive, and attention impairments; post-traumatic stress disorder; and other mood disorders. PICS can last long after hospital admission and can cause significant physical, emotional, and financial stress for patients and their families. Several modifiable risk factors, such as duration of sepsis, delirium, and mechanical ventilation, are associated with PICS. However, due to limited awareness about PICS, these factors are often overlooked. The objective of this paper is to highlight the pathophysiology, clinical features, diagnostic methods, and available preventive and treatment options for PICS.
Original Articles
Ethics
Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea
Claire Junga Kim, Kyung Sook Hong, Sooyoung Cho, Jin Park
Received August 29, 2023  Accepted April 5, 2024  Published online May 24, 2024  
DOI: https://doi.org/10.4266/acc.2023.01130    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
The decision to discontinue intensive care unit (ICU) treatment during the end-of-life stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization.
Methods
In this retrospective study, we examined medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not.
Results
Among 54,699 hospital admissions, LST was withdrawn from 550 patients (1%). Cancer was the most common disease, followed by pneumonia, and cerebral infarction. Among patients admitted to the ICU, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.05) and had longer total hospital stays (16 vs. 11 days, P<0.001) and higher ICU readmission rates than control patients (ICU patients for whom LST was not withdrawn). When healthcare costs were compared, there was no significant difference in the cost of ICU stay between the two groups. The family played a crucial role in the LST decision (86% of LST decisions).
Conclusions
The decision to withdraw LST of ICU patients was influenced by age, readmission, and disease category. ICU costs were similar for patients who withdrew from LST treatment and those who did not. Further research is need to help patients and families tailor LST decisions in the ICU.
Pulmonary
Are sodium-glucose co-transporter-2 inhibitors associated with improved outcomes in diabetic patients admitted to intensive care units with septic shock?
Nikita Ashcherkin, Abdelmohaymin A. Abdalla, Simran Gupta, Shubhang Bhatt, Claire I. Yee, Rodrigo Cartin-Ceba
Received August 19, 2023  Accepted March 16, 2024  Published online May 14, 2024  
DOI: https://doi.org/10.4266/acc.2023.01046    [Epub ahead of print]
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AbstractAbstract PDF
Background
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce organ dysfunction in renal and cardiovascular disease. There are limited data on the role of SGLT2i in acute organ dysfunction. We conducted a study to assess the effect of SGLT2i taken prior to intensive care unit (ICU) admission in diabetic patients admitted with septic shock.
Methods
This retrospective cohort study used electronic medical records and included diabetic patients admitted to the ICU with septic shock. We compared diabetic patients on SGLT2i to those who were not on SGLT2i prior to admission. The primary outcome was in-hospital mortality, and secondary outcomes included hospital and ICU length of stay, use of renal replacement therapy, and 28- and 90-day mortality.
Results
A total of 98 diabetic patients was included in the study, 36 in the SGLT2i group and 62 in the non-SGLT2i group. The Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation III scores were similar in the groups. Inpatient mortality was significantly lower in the SGLT2i group (5.6% vs. 27.4%, P=0.008). There was no significant difference in secondary outcomes.
Conclusion
Our study found that diabetic patients on SGLT2i prior to hospitalization who were admitted to the ICU with septic shock had lower inpatient mortality compared to patients not on SGLT2i.
Cardiology
Implementation of Society for Cardiovascular Angiography and Interventions classification in patients with cardiogenic shock secondary to acute myocardial infarction in a spanish university hospital
Javier Pérez Cervera, Carlos Antonio Aranda López, Rosa Navarro Romero, Javier Corral Macías, Juan Manuel Nogales Asensio, José Ramón López Mínguez
Received December 19, 2023  Accepted March 6, 2024  Published online May 13, 2024  
DOI: https://doi.org/10.4266/acc.2023.01620    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
The Killip-Kimball classification has been used for estimating death risk in patients suffering acute myocardial infarction. Stage IV of this classification corresponds to cardiogenic shock. However, the ______ (SCAI) classification provides a more precise tool to classify patients according to shock severity. The aim of this study was to apply this classification to a cohort of Killip IV patients and to analyze the differences in death risk estimation between the two classifications.
Methods
A single-center retrospective cohort study of 100 consecutive patients hospitalized for “Killip IV Acute Myocardial Infarction” between 2016 and 2023 was performed to reclassify patients according to SCAI stage.
Results
Distribution of patients according to SCAI stages was: B=4%; C=53%; D=27%, E=16%. Thirty-day mortality increased progressively according to these stages (B=0%; C=11.88%; D=55.56%; E=87.50%; P<0.001). The exclusive use of Killip IV stage overestimated death risk compared to SCAI C (35% vs. 11.88%; P=0.002) and underestimated it compared to SCAI D and E stages (35% vs. 55.56% and 87.50%, respectively; P<0.05 for both). Multivariable Cox regression analysis provided 30-day mortality predictors for _____ (AMICS): age >69 years (hazard ratio [HR], 2.34; 95% CI, 1.15–4.86), creatinine >1.15 mg/dl (HR, 11.52; 95% CI, 1.43–92.77) and advanced SCAI stages (SCAI D: HR, 3.29; 95% CI, 1.20–9.01 and SCAI E: HR, 6.21; 95% CI, 2.28–16.88; all P<0.05). Mechanical circulatory support (MCS) use showed an almost significant benefit in advanced SCAI stages (D and E: HR, 0.45; 95% CI, 0.19–1.06; P=0.058).
Conclusions
SCAI classification showed superior death risk estimation compared to Killip IV. Age, creatinine levels and advanced SCAI stages were independent predictors of 30-day mortality. MCS could play a beneficial role in advanced SCAI stages.
Pediatrics
Mortality rates among adult critical care patients with unusual or extreme values of vital signs and other physiological parameters: a retrospective study
Charles Harding, Marybeth Pompei, Dmitriy Burmistrov, Francesco Pompei
Received October 26, 2023  Accepted March 6, 2024  Published online May 13, 2024  
DOI: https://doi.org/10.4266/acc.2023.01361    [Epub ahead of print]
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AbstractAbstract PDF
Background
We evaluated relationships of vital signs and laboratory-tested physiological parameters with in-hospital mortality, focusing on values that are unusual or extreme even in critical care settings.
Methods
We retrospectively studied Philips Healthcare–MIT eICU data (207 U.S. hospitals, 2014–2015), including 166,959 adult-patient critical care admissions. Analyzing most-deranged (worst) value measured in the first admission day, we investigated vital signs (body temperature, heart rate, mean arterial pressure, and respiratory rate) as well as albumin, bilirubin, blood pH via arterial blood gas (ABG), blood urea nitrogen, creatinine, FiO2 ABG, glucose, hematocrit, PaO2 ABG, PaCO2 ABG, sodium, 24-hour urine output, and white blood cell count (WBC).
Results
In-hospital mortality was ≥50% at extremes of low blood pH, low and high body temperature, low albumin, low glucose, and low heart rate. Near extremes of blood pH, temperature, glucose, heart rate, PaO2, and WBC, relatively small changes in measured values correlated with several-fold mortality rate increases. However, high mortality rates and abrupt mortality increases were often hidden by the common practice of thresholding or binning physiological parameters. The best predictors of in-hospital mortality were blood pH, temperature, and FiO2 (scaled Brier scores: 0.084, 0.063, and 0.049, respectively).
Conclusions
In-hospital mortality is high and sharply increasing at extremes of blood pH, body temperature, and other parameters. Common-practice thresholding obscures these associations. In practice, vital signs are sometimes treated more casually than laboratory-tested parameters. Yet, vitals are easier to obtain and we found they are often the best mortality predictors, supporting perspectives that vitals are undervalued.
Letter to the Editor
Neurology
Could fever dreams influence sleep in intensive care units?
Jeng Swen Ng, Sheryn Tan, Sanjana Santhosh, Brandon Stretton, Joshua Kovoor, Aashray Gupta, Stephen Bacchi
Received August 20, 2023  Accepted March 21, 2024  Published online May 7, 2024  
DOI: https://doi.org/10.4266/acc.2023.01074    [Epub ahead of print]
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PDFSupplementary Material
Corrigendum
Pediatrics
Corrigendum to: Development of a deep learning model for predicting critical events in a pediatric intensive care unit
In Kyung Lee, Bongjin Lee, June Dong Park
Received March 15, 2024  Accepted March 15, 2024  Published online April 1, 2024  
DOI: https://doi.org/10.4266/acc.2023.01424.e1    [Epub ahead of print]
Corrects: Acute Crit Care 2024;39(1):186
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PDF
Original Article
Infection
Comparative evaluation of tocilizumab and itolizumab for treatment of severe COVID-19 in India: a retrospective cohort study
Abhyuday Kumar, Neeraj Kumar, Arunima Pattanayak, Ajeet Kumar, Saravanan Palavesam, Pradhan Manigowdanahundi Nagaraju, Rekha Das
Received August 1, 2023  Accepted February 4, 2024  Published online April 1, 2024  
DOI: https://doi.org/10.4266/acc.2023.00983    [Epub ahead of print]
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AbstractAbstract PDF
Background
Itolizumab downregulates the synthesis of proinflammatory cytokines and adhesion molecules by inhibiting CD6 leading to lower levels of interferon-γ, interleukin-6, and tumor necrotic factor-α and reduced T-cell infiltration at inflammatory sites. This study aims to compare the effects of tocilizumab and itolizumab in the management of severe coronavirus disease 2019 (COVID-19).
Methods
The study population was adults (>18 years) with severe COVID-19 pneumonia admitted to the intensive care unit receiving either tocilizumab or itolizumab during their stay. The primary outcome was clinical improvement (CI), defined as a two-point reduction on a seven-point ordinal scale in the status of the patient from initiating the drug or live discharge. The secondary outcomes were time until CI, improvement in PO2/FiO2 ratio, best PO2/FiO2 ratio, need for mechanical ventilation after administration of study drugs, time to discharge, and survival days.
Results
Of the 126 patients included in the study, 92 received tocilizumab and 34 received itolizumab. CI was seen in 46.7% and 61.7% of the patients in the tocilizumab and itolizumab groups, respectively and was not statistically significant (P=0.134). The PO2/FiO2 ratio was significantly better with itolizumab compared to tocilizumab (median [interquartile range]: 315 [200–380] vs. 250 [150–350], P=0.043). The incidence of serious adverse events due to the study drugs was significantly higher with itolizumab compared to tocilizumab (14.7% vs. 3.3%, P=0.032).
Conclusions
The CI with itolizumab is similar to tocilizumab. Better oxygenation can be achieved with itolizumab and it can be a substitute for tocilizumab in managing severe COVID-19.
Guideline
Pulmonary
Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines
Tae Sun Ha, Dong Kyu Oh, Hak-Jae Lee, Youjin Chang, In Seok Jeong, Yun Su Sim, Suk-Kyung Hong, Sunghoon Park, Gee Young Suh, So Young Park
Acute Crit Care. 2024;39(1):1-23.   Published online February 28, 2024
DOI: https://doi.org/10.4266/acc.2024.00052
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AbstractAbstract PDFSupplementary Material
Background
Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator. Methods: Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations. Results: Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation. Conclusions: We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.
Review Article
Meta-analysis
The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials
Yerkin Abdildin, Karina Tapinova, Assel Nemerenova, Dmitriy Viderman
Acute Crit Care. 2024;39(1):34-46.   Published online February 28, 2024
DOI: https://doi.org/10.4266/acc.2023.00829
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AbstractAbstract PDF
Background
This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients.
Methods
We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay.
Results
Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome.
Conclusions
Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.
Editorial
Cardiology
Nuances of pleural effusion after left ventricular assist devices implantation: insights from therapeutic drainage and preoperative predictors
Huijin Lee, Jeehoon Kang
Acute Crit Care. 2024;39(1):192-193.   Published online February 23, 2024
DOI: https://doi.org/10.4266/acc.2024.00157
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PDF
Original Article
Trauma
Bedside ultrasonographic evaluation of optic nerve sheath diameter for monitoring of intracranial pressure in traumatic brain injury patients: a cross sectional study in level II trauma care center in India
Sujit J. Kshirsagar, Anandkumar H. Pande, Sanyogita V. Naik, Alok Yadav, Ruchira M. Sakhala, Sangharsh M. Salve, Aysath Nuhaimah, Priyanka Desai
Acute Crit Care. 2024;39(1):155-161.   Published online February 23, 2024
DOI: https://doi.org/10.4266/acc.2023.01172
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AbstractAbstract PDF
Background
Optic nerve sheath diameter (ONSD) is an emerging non-invasive, easily accessible, and possibly useful measurement for evaluating changes in intracranial pressure (ICP). The utilization of bedside ultrasonography (USG) to measure ONSD has garnered increased attention due to its portability, real-time capability, and lack of ionizing radiation. The primary aim of the study was to assess whether bedside USG-guided ONSD measurement can reliably predict increased ICP in traumatic brain injury (TBI) patients. Methods: A total of 95 patients admitted to the trauma intensive care unit was included in this cross sectional study. Patient brain computed tomography (CT) scans and Glasgow Coma Scale (GCS) scores were assessed at the time of admission. Bedside USG-guided binocular ONSD was measured and the mean ONSD was noted. Microsoft Excel was used for statistical analysis. Results: Patients with low GCS had higher mean ONSD values (6.4±1.0 mm). A highly significant association was found among the GCS, CT results, and ONSD measurements (P<0.001). Compared to CT scans, the bedside USG ONSD had 86.42% sensitivity and 64.29% specificity for detecting elevated ICP. The positive predictive value of ONSD to identify elevated ICP was 93.33%, and its negative predictive value was 45.00%. ONSD measurement accuracy was 83.16%. Conclusions: Increased ICP can be accurately predicted by bedside USG measurement of ONSD and can be a valuable adjunctive tool in the management of TBI patients.

ACC : Acute and Critical Care