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Aim: This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in‐hospital mortality and other clinical outcomes among patients with hyperglycemic crises. Method: This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In‐hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in‐hospital and other clinical outcomes. Outcome: One hundred twenty‐one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in‐hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06−1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56−12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26−116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41−79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37−458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37−13.82, p = 0.013) were independent risk factors of in‐hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31−15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01−4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19−2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33−3988.61, p = 0.031) of HC patients. Conclusion: CCI is associated with in‐hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients. [ABSTRACT FROM AUTHOR]

The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients. [ABSTRACT FROM AUTHOR]

Introduction: The usual methods of perfusion assessment in patients with shock, such as capillary refill time, skin mottling, and serial serum lactate measurements have many limitations. Veno-arterial difference in the partial pressure of carbon dioxide (PCO2 gap) is advocated being more reliable. We evaluated serial change in PCO2 gap during resuscitation in circulatory shock and its effect on ICU outcomes. Materials and methods: This prospective observational study included 110 adults with circulatory shock. Patients were resuscitated as per current standards of care. We recorded invasive arterial pressure, urine output, cardiac index (CI), PCO2 gap at ICU admission at 6, 12, and 24 hours, and various patient outcomes. Results: Significant decrease in PCO2 gap was observed at 6 h and was accompanied by improvement in serum lactate, mean arterial pressure, CI and urine output in (n = 61). We compared these patients with those in whom this decrease did not occur (n = 49). Mortality and ICU LOS was significantly lower in patients with low PCO2 gap, while more patients with high PCO2 gap required RRT. Conclusion: We found that a persistently high PCO2 gap at 6 and 12 h following resuscitation in patients with shock of various etiologies, was associated with increased mortality, need for RRT and increased ICU LOS. High PCO2 gap had a moderate discriminative ability to predict mortality. [ABSTRACT FROM AUTHOR]

Introduction: Children receiving extracorporeal membrane oxygenation are prone to delirium. This case report describes the nursing care of a child with delirium who received venoarterial extracorporeal membrane oxygenation. Relevant interventions and precautions are also discussed. Clinical Findings: A 6-year-old girl was admitted to the pediatric intensive care unit with a 2-day history of vomiting and fever. The child underwent cannulation for venoarterial extracorporeal membrane oxygenation. Diagnosis: The child was diagnosed with acute fulminant myocarditis, cardiac shock, and ventricular arrhythmia. Interventions: On the third day of extracorporeal membrane oxygenation, bedside nurses began using the Cornell Assessment of Pediatric Delirium to assess the child for delirium symptoms. The team of physicians and nurses incorporated a nonpharmacologic delirium management bundle into pediatric daily care. Delirium screening, analgesia and sedation management, sleep promotion, and family participation were implemented. Outcomes: During the 18 days of pediatric intensive care unit hospitalization, the child had 6 days of delirium: 1.5 days of hypoactive delirium, 1.5 days of hyperactive delirium, and 3 days of mixed delirium. The child was successfully discharged home on hospital day 22. Conclusion: Caring for a child with delirium receiving venoarterial extracorporeal membrane oxygenation required multidimensional nursing capabilities to prevent and reduce delirium while ensuring safe extracorporeal membrane oxygenation. This report may assist critical care nurses caring for children under similar circumstances. [ABSTRACT FROM AUTHOR]

Waveform capnography is a noninvasive measurement of ventilation and perfusion commonly employed in the prehospital setting. It is easy to apply, and modern cardiac monitors are equipped with the necessary ports and capability to display results. Despite its ease of use, end-tidal CO2 monitoring has not yet achieved widespread adoption within the hospital setting. It is routinely used in the emergency department and by anesthesiologists, but its application could support ICU management in critically ill patients. Its use is routinely supported by multiple professional societies, and it has been recommended as a requirement in all cardiac arrests. Careful analysis of the waveform and expired carbon dioxide can guide therapy for patients experiencing respiratory emergencies, hemodynamic compromise, metabolic acidosis, and shock due to trauma, hypovolemia, or sepsis. Use of capnography throughout the hospital could improve patient outcomes and prevent unidentified deterioration. [ABSTRACT FROM AUTHOR]

Background: Analyses of extensive, nationally representative databases indicate a rising prevalence of venous thromboembolism (VTE) among critically ill children. However, the majority of studies on childhood VTE have primarily concentrated on Caucasian populations in the United States and European countries. There is a lack of epidemiological studies on VTE in Chinese children. Methods: We conducted a retrospective cohort study of data from the Pediatric Intensive Care (PIC) database. Data were obtained and extracted by using Structured Query Language (SQL) and the administrative platform pgAdmin4 for PostgreSQL. Bivariate analyses were conducted in which categorical variables were analyzed by a chi-square test and continuous variables were analyzed by a Student's t-test. Separate multivariable logistic regressions were employed to investigate the associations between VTE and sociodemographic factors as well as clinical factors. Results: Our study included 12,881 pediatric patients from the PIC database, spanning the years 2010 to 2018. The incidence rate of pediatric VTE was 0.19% (24/12,881). The venous thrombotic locations were deep venous thrombosis extremities (n = 18), superior vena cava (n = 1), cerebral sinovenous (n = 1), and other deep venous thrombosis (n = 4). Univariate analysis showed that age, weight, shock, sepsis, cancer and vasopressor receipt were statistically significant risk factors for pediatric VTE (all p ≤ 0.05). After multivariable logistic regression analysis, only shock (aOR: 6.77, 95%CI: 1.33–34.73, p = 0.019) and admission for sepsis (aOR: 6.09, 95%CI: 1.76–21.09, p = 0.004) were statistically significant associated with pediatric VTE. Conclusions: In conclusion, data obtained from the Pediatric Intensive Care (PIC) database revealed a prevalence of VTE in pediatric patients of 0.19%. The most common location for venous thrombi was deep venous thrombosis (DVT) in the extremities. We identified that shock and sepsis were statistically significant factors associated with pediatric VTE. [ABSTRACT FROM AUTHOR]

Background: Suspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB. Methods: We conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort. Results: Two hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91–99) for hemostatic endotherapy [AUC of 0.81; 0.75–0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66–0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92–97). Conclusions: Our study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD. [ABSTRACT FROM AUTHOR]

Objective: Vasoplegic shock, sometimes referred to as distributive shock, is a life-threatening clinical syndrome involving systemic vasodilation and is associated with significant morbidity and mortality in intensive care unit (ICU) patients. The most common etiology is sepsis; others include post-cardiac bypass vasoplegia and various toxidromes. Key components of management include fluid resuscitation and vasopressors to restore vascular tone. Methylene blue selectively targets inducible nitric oxide synthase, a key component of early vasodilation in response to inflammation. We investigated whether the timing of administration of methylene blue influences clinical response, as measured by subsequent vasopressor requirements, fluid resuscitation, organ system function, and mortality. Design: This study was a retrospective case series including 33 cases. Data were collected for each case, including timing of administration, vasopressor and fluid requirements, Sequential Organ Failure Assessment (SOFA) scores, and inhospital mortality. A Spearman's rank correlation was performed to assess the correlation between the timing of administration of methylene blue and improvement in relevant clinical parameters. Setting: A large metropolitan Intensive Care Unit (47 beds). Patients and participants: Included in this study were adult patients who received methylene blue in the participating ICU between 2020 and 2022 for managing vasoplegic shock. Interventions: Administration of intravenous methylene blue. Measurements and results: No correlation between the timing of administration and reduction in vasopressor requirements was observed. Administration of methylene blue within 8 hours of the onset of shock refractory to 5 mcg/min of noradrenaline was found to weakly correlate with reduced total SOFA score on Day 1 (Rs=0.39, p=0.04), and patients who received methylene blue within eight hours had a lower mortality (60.0% vs 78.2%). Conclusions: These findings suggest that a prolonged period of vasoplegic shock before consideration of methylene blue should not discourage its use. A prospective randomized control study will be a valuable direction for future research. [ABSTRACT FROM AUTHOR]

Background: Patients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study. Methods: We prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1–4) by multivariable logistic regression. Results: A total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49–69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high. Conclusions: The majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome. [ABSTRACT FROM AUTHOR]

Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 outbreak presents challenges to the emergency care system. Advanced age is a risk factor formortality. This study aimed to investigate whether the shock index (SI) is an early pre- dictor of adverse outcomes in geriatric patients with COVID-19. Methods: Patients aged ≤ 60 yearswith COVID-19 betweenMay 1, 2021, and February 1, 2022,were in- cluded in a retrospective cohort study. These patients were divided into two groups based on ICU ad- mission. Variables were compared for the two groups. The receiver operating characteristic analysis of the SI and age--SI (ASI) was used to detect deteriorating outcomes early. Results: In total, 156 patients were included, and the mean age was 68.52 ± 7.25 years. ICU admission, intubation, andmortality were recorded in 46 (29.49%), 32 (20.51%), and 16 (10.26%) patients, respec- tively. Themean body weight, pulse rate, respiratory rate, pulse oximetry, SI, and ASI were significantly different between the two groups (p = 0.018, 0.032, 0.007, < 0.001, 0.004, and 0.007, respectively). CRP, LDH, ALT, ferritin, D-dimer, and sodiumlevels were significantly associated with ICU admission. Regard- ing ICU admission, intubation, and mortality, the areas under the curve (AUC) of the SI and ASI showed acceptable discrimination. The predictive power of the ASI was significantly higher than that of the SI for mortality (AUC difference, 0.088 ± 0.036 (95% CI 0.017--0.160); p = 0.016). Conclusion: The ASI is a useful triage tool for mortality prediction in geriatric patients with COVID-19. The SI and ASI can be used in conjunction with vital signs, oxygen saturation, and laboratory biomarkers for the early detection of ICU admission. [ABSTRACT FROM AUTHOR]

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Background: The aim of the study was to evaluate the utility of lactate, central venous oxygen saturation (ScvO2), and the difference in venous and arterial CO2 partial pressures (delta pCO2) levels and their relationship with the prognosis of critically ill children with circulatory failure in the pediatric intensive care unit (PICU). Subjects and Methods: Thirty children with circulatory failure who were admitted to the PICU of a tertiary university hospital between January 15 and November 1, 2020, were evaluated in this prospective observational study. Lactate levels, ScVO2, and delta pCO2 levels were evaluated on admission and at hours 4, 12, and 24 (T0, T4, T12, T24) in the PICU. Results: The mortality of the children with circulatory failure was 30% (n = 9). Arterial and venous lactate levels were highly correlated at T0, T4, T12, T24 (P < 0.001; P < 0.001; P < 0.001; P < 0.001, respectively). Nonsurvivors had always higher arterial lactate levels (T0, T4, T12, T24) (P = 0.019, P = 0.007, P = 0.002, P = 0.0003, respectively) and higher delta pCO2 at T0 (P = 0.039) when compared with survivors. Receiver operating characteristic analysis showed that T0 arterial lactate levels (area under the curve [AUC] 0.788, P = 0.019), T24 arterial lactate (AUC 0.918, P < 0,001), and T0 delta pCO2 levels (AUC 0,741, P = 0.039) and were predictive of mortality. Conclusions: Lactate remains the most important marker of microcirculatory dysfunction in critically ill children with circulatory failure. Delta pCO2 may be an additional marker of microcirculatory dysfunction in critically ill children. [ABSTRACT FROM AUTHOR]

Background: Despite significant loss of bicarbonate during acute diarrhea, pediatric data are scarce with acute diarrhea/severe dehydration (ADSD) and severe non-anion-gap metabolic acidemia (sNAGMA). We planned to study their clinical profile, critical care needs, and outcome. Patients: Children (1 month-12 years) with ADSD and sNAGMA (pH <7.2 and/or bicarbonate <15 mEq/L, and normal/mixed anion gap) admitted in Pediatric Emergency Department from January 2016 to December 2018 were enrolled. Children with pure high-anion-gap metabolic acidemia were excluded. Methods: Medical records were reviewed retrospectively. The primary outcome was time taken to resolve acidemia. Secondary outcomes were acute care area free days in 5 days (ACAFD5), and adverse outcome as composite of Pediatric Intensive Care Unit (PICU) admission and/or death. Results: Out of 929 diarrhea patients admitted for intravenous therapy, 121 (13%; median age, 4 months) had ADSD and sNAGMA. Median (IQR) pH was 7.11 (7.01-7.22); 21% patients had pH <7.00. Hyperchloremia (96%) and hypernatremia (45%) were common. About 12% patients each required inotropes and ventilation, while 58% had acute kidney injury (AKI). Median (IQR) time for resolution of acidemia among survivors was 24 (12, 24) hours. Thirty-two patients had adverse outcome. Higher grades of sNAGMA were associated with shock, AKI, coma, hypernatremia, hyperkalemia, adverse outcome, and lesser ACAFD5. Shock, ventilation, renal replacement therapy (RRT), and higher grades of sNAGMA were predictors of adverse outcome, with former two being independent predictors. Conclusions: Severe non-anion-gap metabolic acidemia in children with ADSD is associated with organ dysfunctions, dyselectrolytemias, and lesser ACAFDs. Resolution of acidemia took unacceptably longer time. Higher grades of sNAGMA were a predictor of adverse outcomes. Trials are suggested to assess the role of additional bicarbonate therapy. [ABSTRACT FROM AUTHOR]

Background: Work of breathing (WOB) and non-comorbidities factors in the respiratory system are the two probable findings in pediatric COVID-19 patients. However, the association of those factors with level of care was not well reported. Purpose: This study aimed to identify the relation between potential predictors including comorbidity, low nutritional fulfillment, infectious disease, shock, cough, O2 saturation reduction, abnormal blood gas analysis and sore throat with the level of care among pediatric COVID-19 patients. We also analyzed the synergistic correlation of non-comorbidities factors in the respiratory system and work of breathing to predict level of care in pediatric COVID-19 patients. Methods: A cross-sectional study was conducted in the six referral hospitals from July to September 2020 in four provinces in Indonesia. An observation checklist was used to collect data from the medical records of pediatric patients with COVID-19, including medical diagnosis, demographic, and clinical manifestation. This study included 423 participants aged from 0 to 18. The multivariate logistic regression was performed to test the adjusted odds ratios (AORs) with the 95% confidence intervals (CIs) of the association between WOB, non-comorbid respiratory, and level of care. Moreover, dummy variables (2x2) were made to analyze synergistic correlation of non-comorbid respiratory disease and WOB. The AOR with the 95% CIs was applied in the association between the complication of non-comorbid respiratory diseases and high work of breathing with level of care among pediatric patients with COVID-19. Results: Results showed that age, presence of comorbidity, nutritional fulfillment, infectious disease, shock, work of breathing, O2 saturation reduction, abnormal blood gas analysis, sore throat, and convulsive meningeal consciousness were significantly associated with the level of care (p<0.05). Pediatric patients with non-comorbid respiratory and increased work of breathing had a 15.59 times higher risk of requiring PICU care level (p<0.01). Meanwhile, pediatric patients who experienced both non-comorbid respiratory and increased work of breathing had a 5.76 times risk of requiring an intermediate level of care (p<0.05), and 9.32 times higher risk of requiring a PICU level of care (p<.05). Conclusion: It was found that both non-comorbid respiratory and increased WOB had a significant relationship with the level of care for pediatric patients with COVID-19. Nurse should take into account those clinical findings to increase the awareness in monitoring clinical deterioration in pediatric COVID-19 patients. [ABSTRACT FROM AUTHOR]

Background: Children with multisystem inflammatory syndrome in children (MIS-C) often develop shock and require vasoactive agents. The vasoactive-inotropic score (VIS) is a potential scoring system to assess the amount of vasoactive agent support required. The study was conducted to correlate VIS at 6 and 12 h with the length of intensive care unit (ICU) stay and with COVID immunoglobulin G (IgG) antibody titers in cases of MIS-C with shock. Subjects and Methods: Demographic and clinical details were collected from patients with the diagnosis of MIS-C with shock requiring vasoactive agents. VIS was calculated at 6 and 12 h following initiation of the first inotropic/vasoactive agent. Results: Twenty-nine children admitted with the diagnosis of MIS-C who presented with shock or developed shock during hospital stay were the study population. On performing Spearman's correlation, a positive correlation was observed between COVID IgG titers and VIS at 6 h. There was no significant association between VIS and length of ICU stay. Conclusions: VIS had limited significance in predicting the length of ICU stay and the need for vasoactive agents required. [ABSTRACT FROM AUTHOR]

Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. [ABSTRACT FROM AUTHOR]

Acute circulatory collapse is one of the most familiar challenges in ICUs. It is considered that artefacts generated by lung ultrasound (LUS) can help in diagnosis and management. FALLS-protocol using LUS is a tool proposed for the management of unexplained shock. Objectives To investigate the role of LUS FALLS-protocol in differentiating types of shock in critically ill patients. Patients and methods A total of 50 patients presented with undiagnosed shock. Fast bedside echocardiography and LUS FALLS-protocol were applied along with inferior vena cava diameter and collapsibility measurement. Results A total of 19 patients with septic shock on presentation had A profile in all of themand AB profile in three of them, and after resuscitation, they were transformed to B profile with 100% sensitivity, 90.5% specificity, 90.5% positive predictive value (PPV), and 100% negative predictive value (NPV). Overall, 16 patients with hypovolemic shock had A profile in all of them on presentation and after resuscitation, with 100% sensitivity, 94.1% specificity, 88.9% PPV, and 100% NPV. Moreover, eight patients with cardiogenic shock had B profile in all of them on presentation with 100% sensitivity, 95.2% specificity, 80% PPV, and 100% NPV; three patients with obstructive shock had A profile in all of them on presentation, with 100% sensitivity, 25.5% specificity, 7.9% PPV, and 100% NPV; and two patients with anaphylactic shock had A profile in all of them on presentation and transformed to B profile after resuscitation with 100% sensitivity, 50% specificity, 9.5% PPV, and 100% NPV. Our findings showed preference of FALLS-protocol than inferior vena cava diameter and collapsibility in directing fluid therapy. Conclusion Bedside chest ultrasound FALLS-protocol should be considered in the resuscitation pathways with a possible significant effect on patient management. [ABSTRACT FROM AUTHOR]

Introduction: Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon's experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. Methods: Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention (≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. Results: Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25–38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. Conclusions: When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications. [ABSTRACT FROM AUTHOR]

Objective. This study aimed to investigate the clinical effect of ultrasound-guided transradial catheterization (TRC) for ICU patients with shock. Methods. 120 shock patients registered in the ICU of our hospital from January 2019 to June 2022 were selected for prospective study. The control group (60 patients) were treated with palpation-guided TRC. The observation group was treated with ultrasound-guided TRC and was divided into the internal puncture group (internal TRC) and external puncture group (external TRC), with 30 cases in each. The first attempt success rate, total success rate, operation duration, complication, measurement of radial artery, and VAS scores were compared in these groups. Results. The success rate was higher in the observation group than in the control group (P < 0.05), and higher in the internal puncture group than in the external puncture group (P < 0.05). The first attempt success rate was significantly higher in the observation group than in the control group (P < 0.05), with no significant difference in between (P > 0.05). The number of attempts and operation duration were lower in the observation group than in the control group (P < 0.05), with significantly more operation duration in the internal puncture group than in the external puncture group (P < 0.05) and no significant difference in the number of attempts (both P > 0.05). The complication rate was significantly lower in the observation group than in the control group (P < 0.05) and there was no significant difference in between (P > 0.05). The radial artery diameter, cross-sectional area, and depth from the skin in the observation group were larger than those in the control group (P < 0.05) and there was no significant difference in between (P > 0.05). At 1, 6, 24, and 48 h after the surgery, the observation group showed lower VAS scores than the control group (P < 0.05). Conclusion. The ultrasound-guided TRC reduced the number of attempts, the complication rates, and the operation duration. For patients with shock, if Doppler ultrasound cannot detect blood flow, the success rate in the observation group was higher than that in the control group, and its advantage is worthy of promotion in severe patients. [ABSTRACT FROM AUTHOR]

Purpose Prolonged duration of intravenous (IV) vasopressor dependence in critically ill adult patients with vasodilatory shock results in increased length of stay in both the intensive care unit (ICU) and hospital, translating to higher risk of infection, delirium, immobility, and cost. Acceleration of vasopressor liberation can aid in reducing these risks. Midodrine is an oral α 1-adrenergic receptor agonist that offers a potential means of liberating patients from IV vasopressor therapy. This clinical review summarizes primary literature and proposes a clinical application for midodrine in the recovery phase of vasodilatory shock. Summary Five studies with a total of over 1,000 patients conducted between 2011 and 2021 were identified. In observational studies, midodrine administration was demonstrated to lead to faster time to liberation from IV vasopressor therapy and shorter ICU length of stay in patients recovering from vasodilatory shock. These findings were not replicated in a prospective, multicenter, randomized controlled trial. In this review, literature evaluating midodrine use for IV vasopressor liberation is summarized and study limitations are discussed. Conclusion On the basis of this review of current literature, recommendations are provided on selecting appropriate candidates for adjunctive midodrine in the recovery phase of vasodilatory shock and considerations are discussed for safely and effectively initiating, titrating, and discontinuing therapy. [ABSTRACT FROM AUTHOR]

Introduction: Although traumatic diaphragmatic ruptures are rare, intra-abdominal organ herniation occurs more commonly in the left diaphragm because the right diaphragm is held by the liver and ligaments underneath. Additionally, right diaphragmatic injuries are sometimes delayed or missed because other comorbidities cover them. This study examined a 10-year experience with traumatic diaphragmatic injuries to better understand the clinical characteristics according to diaphragmatic injury location and improve future treatments. Methods: This retrospective study enrolled 29 patients with traumatic diaphragmatic rupture admitted to the Chungbuk National University Hospital, South Korea, between January 2011 and December 2020. The patients' clinical characteristics and treatment outcomes were analyzed using the chi-square test and independent t-test. Results: The injury severity score showed that left diaphragmatic ruptures (31.36, standard deviation [SD] 10.89) were higher than right-sided ruptures (29.33, SD 10.21), but the difference was not statistically significant (p=0.61). Abdominal organ herniations were more common on the left side, and there were two cases of hollow viscus injuries as left-side ruptures and eight cases of abdominal solid organ injuries as rightside ruptures, but there was no statistical difference between the two groups. There was no significant difference between the two groups in the state of shock during the emergency room visits, intensive care unit, and ventilator care, and no difference was observed in survival. Conclusion: Depending on the location of the diaphragmatic rupture, there were differences in the number of abdominal organ herniation and surgical methods, but there was no difference in injury severity or outcome. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study is to investigate the instruction value of the serum cystatin C (Cys C) level monitoring for intervention opportunity of continuous blood purification technology (CBP) in children with severe sepsis. Methods. 67 children with severe sepsis in the pediatric intensive care unit (PICU) with CBP treatment were retrospectively selected from May 2016 to April 2020. According to the time intervals between the time point of serum Cys C level began to increase (>15 mg/L) and the time point of CBP began, all children were divided into group A (<24 h, 29 cases), group B (24–48 h, 22 cases), and group C (>48 h, 16 cases). The children's general characteristics, vital signs, biochemical parameters, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were evaluated. The influence factors of prognosis of children with severe sepsis were analyzed by multivariate regression analysis. Results. The intervals between the time point of PICU hospitalization and the time point of CBP began and the times of CBP in group A were significantly more than those in group B and C P < 0.05 . There was no statistically significant duration of CBP among three groups P > 0.05 . After follow-up of 28 d, there was no significant difference on the occurrence of coagulation disorders and hypovolemic shock induced by CBP among three groups P > 0.05 . However, the mortality of children in group A was lower than that in group C P < 0.05 . Children in group A had lower APACHE II scores, SOFA scores, serum K+, blood urea nitrogen (BUN), serum creatine (SCr), partial pressure of carbon dioxide (PCO2), and higher partial pressure of oxygen (PO2) than those of children in group C after CBP. P < 0.05 . SOFA scores ≥5 after CBP treatment and the time intervals between the time point of serum Cys C level began to increase (>15 mg/L) and the time point of CBP began ≥24 h were the independent influence factors on the prognosis by multivariate regression analysis. Conclusion. There are significant evidences that continuous blood purification technology within 24 h of serum Cys C level may better control the condition of children with severe sepsis. [ABSTRACT FROM AUTHOR]

Background: Refractory vasodilatory shock is a state of uncontrolled vasodilation associated with underlying inflammation and endothelial dysregulation. Rescue therapy for vasoplegia refractory to catecholamines includes methylene blue (MB) which restores vascular tone. We hypothesized that (1) at least 40% of critically ill patients would respond positively to MB administration and (2) that those who responded to MB would have a survival benefit. Methods: This study was a retrospective review that included all adult patients admitted to an intensive care unit treated with MB for the indication of refractory vasodilatory shock. Responders to MB were identified as those with a ≥ 10% increase in mean arterial pressure (MAP) within the first 1-2 hours after administration. We examined the association of mortality to the groups of responders versus non-responders to MB. A subgroup analysis in patients undergoing continuous renal replacement therapy (CRRT) was also performed. Statistical calculations were performed in Microsoft Excel® (Redmond, WA, USA). Where appropriate, the comparison of averages and standard deviations of demographics, dosing, MAP, and reductions in vasopressor dosing were performed via Chi squared, Fisher's exact test, or two-tailed t-test with a p-value < 0.05 being considered as statistically significant. After using the F-test to assess for differences in variance, the proper two tailed t-test was used to compare SOFA scores among responders versus non-responders. Results: A total of 223 patients were included in the responder analysis; 88 (39.5%) had a ≥ 10% increase in MAP post-MB administration that was not associated with a significant change in norepinephrine requirements between responders versus non-responders (p=0.41). There was a non-statistically significant trend (21.6% vs 14.8%, p=0.19) toward improved survival to hospital discharge in the MB responder group compared to the non-responder group. In 70 patients undergoing CRRT, there were 33 responders who were more likely to survive than those who were not (p = 0.0111). Conclusions: In patients with refractory shock receiving MB, there is a non-statistically significant trend toward improved outcomes in responders based on a MAP increase >10%. Patients supported with CRRT who were identified as responders had decreased ICU mortality compared to non-responders. [ABSTRACT FROM AUTHOR]

A 35-year-old man who was admitted to the intensive care unit for dengue fever developed hypotension on Day 2 of hospitalisation. He had no significant past medical history. His height was 1.7 m and weight was 70 kg. In the past 24 hours, he had received 3 L of intravenous normal saline but had passed urine only twice. He was alert and there was no obvious blood loss. His vital signs were as follows: temperature 37°C, pulse rate 120/min, respiratory rate 20/min, blood pressure (by oscillometry in both arms) 80/60 mmHg. Capillary refill time was six seconds, and venous lactate was 5 mmol/L. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. Methods: Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI‐associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. Results: A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7–108] months) than that for ICU TIs (15 [3–91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = –1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = –0.3%, 95% CI = –2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = –3.4%, 95% CI = –5.9 to –0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. Conclusions: While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED. [ABSTRACT FROM AUTHOR]

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A retrospective study that compared children younger than 6 months versus older children of a Spanish cohort of patients diagnosed with Kawasaki disease between 2011 and 2016 (Kawa-Race study). From the 598 patients recruited, 42 patients were younger than 6 months (7%) and presented more frequently with an incomplete diagnosis of Kawasaki disease (52.4 vs 27.9%, p = 0.001). Cardiac abnormalities detected by echocardiography were more common in younger patients (52.4 vs 30%, p = 0.002). These younger patients presented with a higher proportion of coronary aneurysms as well (19 vs 8.6%, p < 0.001). Shock at diagnosis (9.5 vs 1.9%, p = 0.016) and admission to intensive care units (17.7 vs 4.1%, p = 0.003) were more frequent in patients younger than 6 months. There were no statistically significant differences in relation to infections, non-response to IVIG, or mid- or long-term outcomes. Conclusion: Data of the Spanish cohort are consistent with other American and Asian studies, although Spanish children younger than 6 months had a lower rate of non-response to IVIG and better clinical outcomes. A high index of suspicion should be considered for this population due to a higher risk of coronary abnormalities, presentation of shock, and admission to the intensive care unit. What is Known: •Children below 6 months of age with Kawasaki disease (KD) have different features compared to older. •Younger patients usually have an incomplete form of KD and coronary artery abnormalities. What is New: •Younger than 6 months with KD presented with shock and required admission to PICU more frequently compared to older. •Infections play a similar role in KD despite the age of the patients. [ABSTRACT FROM AUTHOR]

Objective: (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children.Design/setting: Observational study in 11 European EDs (2017-2018).Patients: Febrile children with measured blood pressure.Main Outcome Measures: Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs).Results: Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8.Conclusions: High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to retrospectively analyze clinical characteristics and prognostic risk factors of urosepsis patients admitted to two intensive care units in Shanghai, China. Methods: Clinical data from patients diagnosed with urosepsis were retrospectively retrieved and analyzed from ICU in two regional medical centers from January 2015 to December 2019. Results: Two hundred two patients were included in the subsequent analysis eventually, with an average age of 72.02 ± 9.66 years, 79.21% of the patients were female and the mortality rate of 15.84%.The proportion of patients with chronic underlying diseases such as diabetes and hypertension was relatively high (56.44, 49.50%, respectively), and the incidence of shock was also high (41.58%) correspondingly. The most common pathogen isolated was Escherichia coli (79.20%), of which the extended-spectrumβ-lactamases (ESBLs)(+) accounted for 42.57%. In multivariate analysis, the strongest predictors for death were mechanical ventilation (OR 7.260, 95% CI 2.200–23.963; P = 0.001),chronic kidney disease (CKD) (OR 5.140, 95% CI 1.596–16.550; P = 0.006), APACHE II score (OR 1.321, 95% CI 1.184–1.473; P < 0.001) and lactate (OR 1.258, 95% CI 1.037–1.527; P = 0.020). Both APACHE II score and lactate had the ideal predictive value, with the area under the ROC curve (AUC) of 0.858 and 0.805 respectively. Conclusion: The patients with urosepsis were characterized by a higher proportion of female, older age, more percentage of comorbidities in this region, and patients with ESBLs (+) Escherichia coli infection were more prone to shock. Mechanical ventilation, comorbidity with CKD, APACHE II score and lactate were independent risk factors for death in urosepsis patient, but lactate level and APACHE II score had better predictive value for prognosis. [ABSTRACT FROM AUTHOR]

Background: Circulatory failure frequently occurs after out-of-hospital cardiac arrest (OHCA) and is part of post-cardiac arrest syndrome (PCAS). The aim of this study was to investigate circulatory disturbances in PCAS by assessing the circulatory trajectory during treatment in the intensive care unit (ICU). Methods: This was a prospective single-center observational cohort study of patients after OHCA. Circulation was continuously and invasively monitored from the time of admission through the following five days. Every hour, patients were classified into one of three predefined circulatory states, yielding a longitudinal sequence of states for each patient. We used sequence analysis to describe the overall circulatory development and to identify clusters of patients with similar circulatory trajectories. We used ordered logistic regression to identify predictors for cluster membership. Results: Among 71 patients admitted to the ICU after OHCA during the study period, 50 were included in the study. The overall circulatory development after OHCA was two-phased. Low cardiac output (CO) and high systemic vascular resistance (SVR) characterized the initial phase, whereas high CO and low SVR characterized the later phase. Most patients were stabilized with respect to circulatory state within 72 h after cardiac arrest. We identified four clusters of circulatory trajectories. Initial shockable cardiac rhythm was associated with a favorable circulatory trajectory, whereas low base excess at admission was associated with an unfavorable circulatory trajectory. Conclusion: Circulatory failure after OHCA exhibits time-dependent characteristics. We identified four distinct circulatory trajectories and their characteristics. These findings may guide clinical support for circulatory failure after OHCA. Trial registration : ClinicalTrials.gov: NCT02648061 [ABSTRACT FROM AUTHOR]

Background Evidence on risk for adverse outcomes from coronavirus disease 2019 (COVID-19) among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, and whether these associations differ by race/ethnicity, and describe discharge status by COVID-19 diagnosis and maternal complications. Methods Data from 703 hospitals in the Premier Healthcare Database during March–September 2020 were included. Adjusted risk ratios (aRRs) overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. Results Among 489 471 delivery hospitalizations, 6550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for acute respiratory distress syndrome (aRR, 34.4), death (aRR, 17.0), sepsis (aRR, 13.6), mechanical ventilation (aRR, 12.7), shock (aRR, 5.1), intensive care unit admission (aRR, 3.6), acute renal failure (aRR, 3.5), thromboembolic disease (aRR, 2.7), adverse cardiac event/outcome (aRR, 2.2), and preterm labor with preterm delivery (aRR, 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (vs without) COVID-19 were not discharged home. Conclusions These findings emphasize the importance of implementing recommended prevention strategies to reduce risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Patients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP).Research Question: Is obesity associated with an increased incidence of VAP?Study Design and Methods: This study was a post hoc analysis of the Impact of Early Enteral vs Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA2) open-label, randomized controlled trial performed in 44 French ICUs. Adults receiving invasive mechanical ventilation and vasopressor support for shock and parenteral nutrition or enteral nutrition were included. Obesity was defined as BMI ≥ 30 kg/m2 at ICU admission. VAP diagnosis was adjudicated by an independent blinded committee, based on all available clinical, radiologic, and microbiologic data. Only first VAP episodes were taken into account. Incidence of VAP was analyzed by using the Fine and Gray model, with extubation and death as competing risks.Results: A total of 699 (30%) of the 2,325 included patients had obesity; 224 first VAP episodes were diagnosed (60 and 164 in obese and nonobese groups, respectively). The incidence of VAP at day 28 was 8.6% vs 10.1% in the two groups (hazard ratio, 0.85; 95% CI 0.63-1.14; P = .26). After adjustment on sex, McCabe score, age, antiulcer treatment, and Sequential Organ Failure Assessment at randomization, the incidence of VAP remained nonsignificant between obese and nonobese patients (hazard ratio, 0.893; 95% CI, 0.66-1.2; P = .46). Although no significant difference was found in duration of mechanical ventilation and ICU length of stay, 90-day mortality was significantly lower in obese than in nonobese patients (272 of 692 [39.3%] patients vs 718 of 1,605 [44.7%]; P = .02). In a subgroup of patients (n = 123) with available pepsin and alpha-amylase measurements, no significant difference was found in rate of abundant microaspiration of gastric contents, or oropharyngeal secretions between obese and nonobese patients.Interpretation: Our results suggest that obesity has no significant impact on the incidence of VAP. [ABSTRACT FROM AUTHOR]

Objectives: To compare the incidence of healthcare-associated infections (HAI) and their outcomes between patients admitted to the ICU with sepsis and those admitted with non-sepsis diagnoses. Materials and methods: We performed a single-center, prospective, observational study of ICU patients at a tertiary level medical-surgical unit from April 2018 to October 2018. All patients admitted to the ICU with a length of stay (LOS) > 48 hours were included. Baseline data including demographics, co-morbidities, and severity of illness scores were collected. Index occurrence of HAI in all these patients was noted and data regarding organ support and patient outcomes were recorded. The incidence, complications, ICU LOS, and 30-day mortality of HAI were compared between the patients admitted to ICU originally with sepsis and non-sepsis diagnoses. Results: A total of 271 patients were evaluated in our study (N = 106 for the sepsis group and N = 165 for the non-sepsis group). No significant difference between the groups was found in the incidence of HAI (29.2% in sepsis group vs 24.4% in non-sepsis group; p = 0.07). Complications (acute kidney injury (AKI): 71 vs 45%; p = 0.01, shock: 81 vs 55%; p = 0.05, need for mechanical ventilation (MV): 30 vs 15%; p = 0.04) were more common in sepsis group compared to the non-sepsis group. The ICU LOS (12.2 ± 5.2 days vs 8.8 ± 2.05 days; p = 0.01) was significantly longer in the sepsis group. There was no significant difference in 30-day mortality between the groups (45 vs 25%; p = 0.07). Conclusions: The incidence of HAI seems to be similar between patients admitted with sepsis and non-sepsis diagnoses. However, patients admitted with sepsis develop higher rates of organ failure secondary to HAI and have a longer ICU LOS compared to patients admitted with non-sepsis diagnoses. The mortality rate of HAI did not differ between these two groups. [ABSTRACT FROM AUTHOR]

After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects. [ABSTRACT FROM AUTHOR]

Background: Multisystem inflammatory syndrome (MIS) associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) (MIS-C) in children is being increasingly reported across the world. Materials and methods: Children fulfilling the World Health Organization criteria of MIS-C needing pediatric intensive care unit between April 15 and July 26, 2020 were studied. Results: There were 21 patients with median age of 7 years [interquartile range (IQR) 1.9-12.1], of which 11 were females. SARS-CoV-2 real-time polymerase chain reaction positive in 8/21 and/or antibody positive 16/21. Fever was present in all patients, and gastrointestinal symptoms being second most frequent (16/21). One child had aplastic anemia, while the rest had no comorbidities. Nearly all presented with shock (n = 20/21) and 90% needed vasoactive drugs with a median Vasoactive Inotropic Score of 40 (IQR 20--95). Thirteen children needed ventilatory support and one needed peritoneal dialysis. Nine children had left ventricular dysfunction and five had dilatation of coronaries on echocardiography. Inflammatory markers C-reactive protein [98 mg/dL (IQR 89-119)], serum ferritin [710 mg/dL (IQR 422-1,609)], and serum interleukin-6 levels [215 ng/L (IQR 43-527)] were uniformly elevated. Eighteen children received pulse methyl-prednisolone, eleven intravenous immunoglobulins, and four tocilizumab. Eighteen children (86%) were discharged home while three died. Conclusion: In our cohort, MIS-C was seen in previously healthy children with fever, gastrointestinal symptoms, and shock. Early and aggressive management of shock and immune modulation with methyl-prednisolone and intravenous immunoglobulin were used. [ABSTRACT FROM AUTHOR]

Objectives: Capillary refill time is a noninvasive method to assess tissue perfusion to determine shock status. Capillary refill time is defined as the time required to regain skin color after blanching pressure is applied. Although common methods to measure capillary refill time depend on clinicians' visual assessment, a new approach using a pulse oximeter waveform analysis exists, referred to as full finger reperfusion time. We aim to evaluate reproducibility and validity of the novel full finger reperfusion time measurement using clinicians' visual capillary refill time assessment as a reference standard.Design: Prospective observational study.Setting: PICUs and operating suites at a large academic children's hospital.Patients: Ninety-nine children 1-12 years old with various skin color tones.Interventions: Each child had 10 measurements, including five full finger reperfusion time and five clinician capillary refill time, alternating second and third digits.Measurements and Main Results: Eighteen children had prolonged capillary refill time (> 2 s) and four children with capillary refill time greater than 3 seconds. Four-hundred eighty-five data pairs were analyzed. Intraclass correlation coefficient of full finger reperfusion time within each patient was 0.76 (95% CI, 0.68-0.83), demonstrating good reproducibility. Correlation coefficient between full finger reperfusion time and clinician capillary refill time was moderate: r = 0.37 (p < 0.0001; 95% CI, 0.29-0.44) for the pairs and r = 0.52 (p < 0.0001; 95% CI, 0.36-0.65) for patient average. Bland-Altman plot showed a consistent difference between full finger reperfusion time and clinician capillary refill time (full finger reperfusion time 1.14 s longer). Weak association was found between force and full finger reperfusion time (β = -0.033 ± 0.016; 95% CI, -0.065 to -0.0016; p = 0.04), finger thickness (β = -0.20 ± 0.089; 95% CI, -0.37 to -0.19; p = 0.03), except for color tone (p = 0.31). Finger temperature was associated with full finger reperfusion time (β = -0.18 ± 0.041; 95% CI, -0.26 to -0.0999; p < 0.0001).Conclusions: Full finger reperfusion time demonstrated good reproducibility. Full finger reperfusion time showed moderate correlation with clinician capillary refill time. Full finger reperfusion time was 1.14 seconds longer than capillary refill time. Future studies should focus on the clinical value of full finger reperfusion time as a monitoring device for hemodynamics in critically ill children. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality.Design: Multicenter prospective cohort study between September 2017 and February 2018.Settings: Thirty-four hospitals in the United States and Jordan.Patients: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor.Interventions: None.Measurement and Main Results: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18).Conclusions: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about frailty that develops following critical illness. We sought to describe the prevalence of newly acquired frailty, its clinical course, and the co-occurrence of frailty with disability and cognitive impairment in survivors of critical illness.Design: Longitudinal prospective cohort study.Setting: Medical and surgical ICUs at five U.S. centers.Patients: Adult patients treated for respiratory failure and/or shock.Measurements and Main Results: We measured frailty with the Clinical Frailty Scale at baseline (i.e., study enrollment) and at 3 and 12 months postdischarge. We constructed alluvial diagrams to describe the course of frailty and Venn diagrams to describe the overlap of frailty with disability in activities of daily living and cognitive impairment. We included 567 participants a median (interquartile range) of 61 years old (51-70 yr old) with a high severity of illness (Acute Physiology and Chronic Health Evaluation II of 23). Frailty (Clinical Frailty Scale scores ≥ 5) was present in 135 of 567 (24%) at baseline, 239 of 530 (45%) at 3 months, and 163 of 445 (37%) at 12 months. Of those with frailty at 3- or 12-month follow-up, 61% were not frail at baseline. Transition to a worse frailty state occurred in 242 of 530 of patients (46%) between baseline and 3 months and in 179 of 445 of patients (40%) between baseline and 12 months. There were 376 patients with frailty, disability, or cognitive impairment at 3-month follow-up. Of these, 53 (14%) had frailty alone. At 12 months, 276 patients had frailty, disability, or cognitive impairment, 37 (13%) of whom had frailty alone.Conclusions: Frailty is common among survivors of critical illness. In the majority, frailty is newly acquired. Roughly one in seven had frailty without co-occurring disability or cognitive impairment. Studies to understand outcomes of frailty that develops as the result of a critical illness and to identify modifiable risk factors for this potentially reversible syndrome are needed. [ABSTRACT FROM AUTHOR]

Road traffic injuries in Thailand are the major cause of death and disabilities in young adults. The presence of shock plays an important role in clinical outcomes. This cross-sectional study aimed to determine the incidence of shock and to identify factors predicting the presence of shock on discharge from the emergency department in patients sustaining moderate to serious road traffic injuries in Thailand. Five hundred and three patients (N=503), who scored at least 16 on the Injury Severity Score on admission to an emergency department were recruited. Population and contextual variables were collected from patients' medical records and patients and triage nurses' interviews. Two standardized tools were used to measure the severity of injury and the presence of shock. Data analyses included descriptive statistics, univariate analysis and multivariate logistical regression. Results indicated that the majority of patients were males, wearing no safety devices and had consumed alcohol prior to driving their motorcycle. The incidence of shock on discharge from the emergency department to the operating room, intensive care unit or general ward was 35%. Transport time, injury severity, shock on arrival and time spent in the emergency department all made significant contributions to whether patients were in shock on discharge from the emergency department. Our findings suggest that emergency nurses should perform routine ongoing calculation of Modified Shock Index scores for monitoring the moderately to severely injured. Further studies examining the superiority of the Modified Shock Index over cardiorespiratory parameters alone could provide evidence to consider the inclusion of this Index into best practice guidelines. [ABSTRACT FROM AUTHOR]

Background. Shock is one of the causes of mortality in the intensive care unit (ICU). Traditionally, hemodynamics related to shock have been monitored by broad-spectrum devices with treatment guided by many inaccurate variables to describe the pathophysiological changes. Critical care ultrasound (CCUS) has been widely advocated as a preferred tool to monitor shock patients. The purpose of this study was to analyze and broaden current knowledge of the characteristics of ultrasonic hemodynamic pattern and investigate their relationship to outcome. Methods. This prospective study of shock patients in CCUS was conducted in 181 adult patients between April 2016 and June 2017 in the Department of Intensive Care Unit of West China Hospital. CCUS was performed within the initial 6 hours after shock patients were enrolled. The demographic and clinical characteristics, ultrasonic pattern of hemodynamics, and outcome were recorded. A stepwise bivariate logistic regression model was established to identify the correlation between ultrasonic variables and the 28-day mortality. Results. A total of 181 patients with shock were included in our study (male/female: 113/68). The mean age was 58.2 ± 18.0 years ; the mean Acute Physiology and Chronic Health Evaluation II (APACHE II score) was 23.7 ± 8.7 , and the 28-day mortality was 44.8% (81/181). The details of ultrasonic pattern were well represented, and the multivariate analysis revealed that mitral annular plane systolic excursion (MAPSE), mitral annular peak systolic velocity (S ′ -MV), tricuspid annular plane systolic excursion (TAPSE), and lung ultrasound score (LUSS) were the independent risk factors for 28-day mortality in our study, as well as APACHE II score, PaO2/FiO2, and lactate (p = 0.047 , 0.041, 0.022, 0.002, 0.027, 0.028, and 0.01, respectively). Conclusions. CCUS exam on admission provided valuable information to describe the pathophysiological changes of shock patients and the mechanism of shock. Several critical variables obtained by CCUS were related to outcome, hence deserving more attention in clinical decision-making. Trial Registration. The study was approved by the Ethics Committee of West China Hospital Review Board for human research with the following reference number 201736 and was registered on ClinicalTrials. This trial is registered with NCT03082326 on 3 March 2017 (retrospectively registered). [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is common in hospitalized and critically ill children. Apart from primary kidney disease, etiologies of AKI are usually related to systemic disease and nephrotoxic insult. This study examines the incidence, characteristics, and mortality risks of AKI in critically ill children without primary renal disease or previously known chronic kidney disease. Methods: A retrospective cohort study was conducted of patients aged 1–18 years, diagnosed with AKI (excluding severe glomerulonephritis and previously known chronic kidney disease) in pediatric intensive care units between 2013 and 2016. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes classifications. Cox proportional hazards regression analysis was employed to assess the relationship between the risk factors and mortality. Results: Of 1,377 pediatric intensive care unit patients, 253 (18.4%) developed AKI and only 169 (12.3%) who did not have previously known renal disease were included. Of these 169 AKI patients, the mean age was 8.1 ± 4.7 years; 88 (52.1%) patients were male; and 60 (35.5%) patients had AKI stage 3. The most common etiologies of AKI were sepsis (76.9%) and shock (64.5%). Fifty‐three (31.4%) of those patients died during admission. The risk factors for death were the need for mechanical ventilation (adjusted hazard ratio, 17.82; 95% CI, 2.41–132.06) and AKI stage 3 (adjusted hazard ratio, 2.32; 95% CI, 1.07–5.00). Conclusions: Acute kidney injury in critically ill children without previously known renal disease was approximately two‐thirds of the overall incidence. The risk factors of in‐hospital death were the use of mechanical ventilation, and AKI stage 3. [ABSTRACT FROM AUTHOR]

Objectives: Delirium, a heterogenous syndrome, is associated with worse long-term cognition after critical illness. We sought to determine if duration of motoric subtypes of delirium are associated with worse cognition.Design: Secondary analysis of prospective multicenter cohort study.Setting: Academic, community, and Veteran Affairs hospitals.Patients: Five-hundred eighty-two survivors of respiratory failure or shock.Interventions: We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale daily during hospitalization. We defined a day with hypoactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score less than or equal to 0 and a day with hyperactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score greater than 0. At 3 and 12 months, we assessed global cognition with the Repeatable Battery for the Assessment of Neurologic Status and executive function with the Trail Making Test Part B. We used multivariable regression to examine the associations between days of hypoactive and hyperactive delirium with cognition outcomes. We allowed for interaction between days of hypoactive and hyperactive delirium and adjusted for baseline and in-hospital covariates.Measurements and Results: Hypoactive delirium was more common and persistent than hyperactive delirium (71% vs 17%; median 3 vs 1 d). Longer duration of hypoactive delirium was associated with worse global cognition at 3 (-5.13 [-8.75 to -1.51]; p = 0.03) but not 12 (-5.76 [-9.99 to -1.53]; p = 0.08) months and with worse executive functioning at 3 (-3.61 [-7.48 to 0.26]; p = 0.03) and 12 (-6.22 [-10.12 to -2.33]; p = 0.004) months; these associations were not modified by hyperactive delirium. Hyperactive delirium was not associated with global cognition or executive function in this cohort.Conclusions: Longer duration of hypoactive delirium was independently associated with worse long-term cognition. Assessing motoric subtypes of delirium in the ICU might aid in prognosis and intervention allocation. Future studies should consider delineating motoric subtypes of delirium. [ABSTRACT FROM AUTHOR]

Background: The value of routine blood pressure measurement in the emergency department (ED) is unclear.Objective: To determine the association between hypotension in addition to tachycardia and the Shock Index for serious illness.Design: Observational study.Setting: University ED (2009-2016).Participants, Methods and Main Outcomes: Routine data collected from consecutive children <16 years. Using logistic regression, we assessed the association between hypotension (adjusted for tachycardia) and Shock Index (ratio heart rate/blood pressure [BP]) for serious illness. The predictive accuracy (sensitivity, specificity) for hypotension and Shock Index was determined for serious illness, defined as intensive care unit (ICU) and hospital admissions.Results: We included 10 698 children with measured BP. According to three age-adjusted clinical cut-offs (Advanced Paediatric Life Support, Paediatric Advanced Life Support and Paediatric Early Warning Score), hypotension was significantly associated with ICU admission when adjusted for tachycardia (range OR 2.6-5.3). Hypotension showed low sensitivity (range 0.05-0.12) and high specificity (range 0.95-0.99) for ICU admission. Combining hypotension and tachycardia did not change the predictive value for ICU admission. Similar results were found for hospitalisation. Shock index was associated with serious illness. However, no specific cut-off value was identified in different age groups.Conclusions: Hypotension, adjusted for tachycardia, is associated with serious illness, although its sensitivity is limited. Shock index showed an association with serious illness, but no acceptable cut-off value could be identified. Routine BP measurement in all children to detect hypotension has limited value in the ED. Future studies need to confirm which patients could benefit from BP measurement. [ABSTRACT FROM AUTHOR]

Objective: To identify the role of left ventricular end-diastolic volume index as a predictor of fluid responsiveness in children. Design: This was a diagnostic study in children with shock in the Emergency Room and Pediatric Intensive Care Unit of Cipto Mangunkusumo Hospital from June to November 2018. The left ventricular end-diastolic volume index measurements were performed using ultrasonic cardiac output monitor and compared to the increase in stroke volume of ≥15% after fluid challenge as fluid responsiveness criteria. Samples were categorized into fluid responsive and non-responsive. Results: Out of 40 subjects, 60 fluid challenge samples were obtained. There were 31 and 29 . samples in the fluid responsive and non-responsive group, respectively. There was no significant difference in mean left ventricular end-diastolic volume index between the two groups (p=0.161). The area under the receiver operating characteristic (AUROC) of the left ventricular end-diastolic volume index was 40.9% with a cutoff value of 68.95 ml/m². The sensitivity and specificity were 45.16% and 44.83%, respectively. At the left ventricular end-diastolic volume index value of 81.10 ml/m2, the specificity was 72.41% with 22.6% sensitivity. Conclusion: This study cannot justify the use of left ventricular end-diastolic volume index can act as a predictor of fluid responsiveness in children. [ABSTRACT FROM AUTHOR]

The objective of the present study was to identify risk factors for mortality at admission in children admitted to the Pediatric Intensive Care Unit (PICU) with acute gastroenteritis (AGE) with severe dehydration and shock. This was a retrospective chart review of all cases of AGE with severe dehydration and shock admitted to the PICU from 2012 to 2017. Children who died during hospital stay were compared with those who survived. A total of 62 children were admitted with AGE to the PICU during this period. Twenty-four children (39%) died. The following variables were found to be significantly associated with death on univariate analysis: clinical pallor (p = 0.01), thrombocytopenia (p = 0.018), elevated leucocyte count (p = 0.02), hypoalbuminemia (p = 0.02) and severe acute malnutrition (SAM) (p = 0.04). On multivariate analysis, only hypoalbuminemia {RR [95% CI: 2.6 (1.27 to 9.21)]; 0.039} and SAM {RR [95% CI: 4.9 (1.12 to 10)]; 0.045} remained statistically significant. Children admitted with severe dehydration and shock had high mortality rates. These children were a sicker subset with probable sepsis. Severe acute malnutrition and hypoalbuminemia were associated with increased risk of death in these patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 2-year-old male presented with a chief complaint of fever, difficulty breathing, and diffuse erythematous rash. It mentions his medical examination revealed tenderness, swelling, and erythroderma over his anterior chest wall and also the chest computed tomography revealed sternal osteomyelitis with scattered sternal fragments layered within a surrounding abscess.