Critical care medicine:

Abstract: Increased blood pressure variability (BPV) in the acute phases of cerebrovascular emergencies, such as acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH), has been shown to result in worsened outcomes. Although several studies have reported this association, no consensus exists for specific BPV targets or a consistent, unified definition of BPV in AIS or ICH. Therefore, we convened the Blood Pressure Variability in Cerebrovascular Emergencies Consortia, consisting of a multidisciplinary group of experts in stroke, neurocritical care, perioperative medicine, emergency medicine, and clinical pharmacy to assess the clinical impact of BPV and to develop a working consensus on defining BPV, identifying interventions to mitigate negative outcomes from increased BPV, and laying the groundwork for BPV research concepts in the future. First, the Consortia proposed bifurcating systolic BPV (SBPV) into two distinct periods-SBPV and SBPV. SBPV involves hyperacute management, when rapid and smooth blood pressure control is crucial. SBPV, the plateauing phase, consists of a more gradual, maintenance-therapy slope. For both periods, enabling a "smooth" (SBPV) and "sustained" (SBPV) trajectory is likely ideal, but more phase-specific research is required to validate this concept. Secondly, Consortia proposed to calculate BPV by subtracting maximum and minimum systolic blood pressure over subsequent measurements because it represents the most clinically feasible option among many proposed equations in the literature. Third, for ICH, the Consortia preferred intravenous antihypertensive medication to reach BPV goals as fast, safe, and efficiently as possible, consistent with American Heart Association/American Stroke Association guidelines recommending "treatment regimens that limit BPV and achieve smooth, sustained blood pressure control." For AIS, guidelines do not yet address BPV, but Consortia members proposed an algorithm with distinct SBPV goals based on time (as a function of stroke acuity), arterial subtype (large, medium, and small vessel), thrombolytic and/or thrombectomy status, and presenting SBP. As the understanding of BPV evolves, future research may build on and/or refine concepts proposed by this Consortia.

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Atrial fibrillation (AF) is the most common arrhythmia experienced by critically ill patients. It has been associated with adverse short-and long-term outcomes, including an increased risk of thromboembolic events, heart failure, and death. Due to complex and multifactorial pathophysiology, a heterogenous patient population, and a lack of clinical tools for risk stratification validated in this population, AF in critical illness is challenging to predict, prevent, and manage. Personalized management strategies that consider patient factors such as underlying cardiac structure and function, potentially reversible arrhythmogenic triggers, and risk for complications of AF are needed. Furthermore, evaluation of the effects of these interventions on long-term outcomes is warranted. Critical illness survivors who have had AF represent a unique population who require systematic follow-up after discharge. However, the frequency, type, and intensity of follow-up is unknown. This state-of-the-art review aims to summarize the evidence, contextualize the current guidelines within the setting of critical illness, and highlight gaps in knowledge and research opportunities to further our understanding of this arrhythmia and improve patient outcomes.

AIM: To examine global variation in the incidence and outcomes of Emergency Medical Services (EMS) attended and treated out-of-hospital cardiac arrest (OHCA) from initial asystole.

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CONCLUSIONS: Unfavorable SDoH disproportionately affected non-Hispanic Black, Mexican American, and Other Hispanic populations, and explained a higher proportion of racial disparities in lung function than previously reported.

Despite substantial advancements in the management of cardiogenic shock, mortality rates remain greater than 40%. Trials have shown that increasing survival rates in cardiogenic shock is challenging. Even the most successful trials show 5-15% reductions in mortality, and gains have been restricted to acute myocardial infarction cardiogenic shock, representing approximately 5% of the population with cardiogenic shock. Trials studying pharmacological strategies in all populations with cardiogenic shock have been consistently neutral or negative. The reasons are complex and include heterogeneity in cardiogenic shock phenotypes, timing of patient inclusion, high prevalence of multiorgan failure and cardiac arrest, and unrealistic estimated treatment effects that restrict sample size with sometimes inadequate funding leading to underpowered trials. In June, 2024, international experts from the fields of cardiology, anaesthesiology, critical care medicine, biostatistics, government regulation of trials, and patient advocacy convened at the sixth Critical Care Clinical Trialists Workshop to reflect on how to improve the design of future randomised clinical trials in cardiogenic shock. This Position Paper summarises the results of discussions regarding what an optimal randomised controlled trial on cardiogenic shock should entail in terms of population selection, primary objectives, statistical analysis, and incorporation of the patient's perspective.

BACKGROUND: Discharge from hospital against medical advice (AMA) carries a significant risk of readmission and has increased rates of morbidity and mortality. Little is known about the characteristics of pediatric trauma patients discharged AMA. We aimed to identify predictors for discharge AMA in pediatric trauma patients.

CONCLUSIONS: Failed opioid weaning was common, and high percentage reductions in continuous opioid infusion were linked to weaning failure. Findings suggest the need for structured, gradual opioid tapering strategies and standardised weaning protocols in adult ICUs.

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CONCLUSIONS: We successfully established a mouse intensive care unit that integrated all critical aspects of a human intensive care unit simultaneously. By highlighting sex- and age-related differences following lipopolysaccharide stimulation and mechanical ventilation, our study underscored the need for diversity in preclinical models to improve translation of findings on critical illnesses like acute lung injury into clinical settings.

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BackgroundIn recent years, although there have been many domestic and international reports on risk factors for pulmonary embolism (PE), there has not yet been a comprehensive and systematic analysis of risk factors for death from PE In this study, we conducted a meta-analysis of the research literature on PE published from June 2012 to January 2024.AimThe aim of this study was to systematically and comprehensively assess the risk factors, association strength, and quality of evidence for death in patients with pulmonary embolism.MethodsThe search strategy was developed in accordance with the PICOS principles (P: Participant, ie, study subject; I: Intervention, ie, intervention; C: Comparison, ie, control group; O: ie, Outcome study endpoints; S: Study design, ie, study design), and the search strategy was developed through computerized searches of English databases (including PubMed, Web of Science, Cochrane Library,EMbase) and Chinese databases, including China Biomedical Literature Database (CBM), Wanfang Data Medical Journals Repository, Wipo Database and China Knowledge Network. The search period was from the construction of the database to January 2024.ResultsTwenty-four papers met the nadir criteria, and the total number of cases and controls were 8769 and 8,830, respectively. Meta-analysis showed that the Odds ratio (OR) for the risk of death from PE were: age >70 years (1.65, 95% confidence interval 1.62 to 1.68), hyponatremia (2.68, 2.25 to 3.19), D-dimer(1.51, 1.38 to 1.67), Troponin I (3.56, 1.83 to 6.90), Malignancy (3.67, 3.01 to 4.48), Diabetes mellitus (1.58, 1.33 to 1.88), and S protein factor activity (0.72, 0.65 to 0.81). (See Table 3).ConclusionThe results of this study showed that age over 70, hyponatremia, D-dimer, troponin I, malignancy, diabetes, and decreased protein S activity are independent risk factors for acute death in patients with pulmonary embolism. However, controlling certain risk factors alone may not reduce the mortality of PE. First, many of the risk factors for PE death are not modifiable (age, diabetes, malignancy). Secondly, the association between a risk factor and mortality is not always causal. Efforts to address a risk factor may not result in improved outcomes if there is no causal link. Therefore, these risk factors can be tracked in future randomized controlled trial studies.

Abstract: Tracheal intubation (TI) of an obstetrical patient around the time of delivery can be an upsetting event for involved providers. It can also cause an unpredictable use of intensive care resources. Its incidence is currently poorly characterized in the literature. We analyzed the 2019 National Inpatient Sample (NIS) to assess the incidence rate and associated risk factors. Patients were identified by International Classification of Diseases, 10th edition codes for delivery of a child. Measured endpoints were the incidence of TI and factors associated. Categorical variables were compared using Chi squared or Fisher's Exact. Continuous variables were compared using the Student T-test or the Mann Whitney rank sum U-test. A logistic regression model was created to determine the odds for each variable contributing to TI. A P value of 0.05 was considered the minimum standard for significance. There was a low rate of TI (0.03%). Mortality was rare (0.004%) and there was a higher rate of mortality among patients who underwent tracheal intubation (5.5% vs 0.003% among patients not intubated,  < .001). The majority of intubations occurred among patients who delivered via CD. Pneumonia, cardiomyopathy, eclampsia, and postpartum hemorrhage were all independently associated with increased odds for TI. There are risk factors which may increase the likelihood for tracheal intubation. The diagnosis of a cardiomyopathy was strongly associated with an increased odds for TI and may result from acute respiratory failure. PPH and eclampsia were also associated with a greater odds for intubation.

Traumatic Brain Injury (TBI) is a major cause of mortality and disability worldwide. Clinical research is a cornerstone to improve patients' outcomes. The empowerment of patients and relatives in research initiatives is now recommended to improve the relevance of trials. We performed an online survey in collaboration with the French National Association of Patients with Brain Injury (France Cérébrolésion) from November to December 2024, to understand their point of view regarding potential outcomes that could qualify hypertonic saline perfusion as relevant in the coming multicentric randomized-controlled COSMOS trial involving 760 moderate-to-severe TBI. 32 persons responded (19 (59.4%) relatives and 13 (40.6%) former patients). Using a 5-grade Likert scale, 23 (71.9%) responders rather agreed or entirely agreed that mortality was a relevant outcome; 26 (81.3%) rated activities of daily living as relevant; 27 (84.4%) rated cognitive function as relevant; 30 (93.7%) rated memory function as relevant; 17 (53.2%) rated functional outcome as relevant; 26 (81.3%) rated anxiety and depression symptoms as relevant; 27 (84.4%) rated quality of life as relevant. Ten (31.3%) responders could not understand the concept of functional outcome. The highest-ranked outcomes were mortality (16 responders gave the highest mark of 7), activities in daily living (14 responders), and memory (11 responders). Although this survey does not have the value of a consensus and further studies are needed to encompass other stakeholders' opinions, we have modified the primary outcomes in COSMOS: functional outcome has been replaced by a hierarchy with 1/ survival and 2/activities in daily living.

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INTRODUCTION: The impact of motorcycle trauma on military readiness is unknown. We sought to describe morbidity from major motorcycle trauma in active duty patients and to characterize its impact on active duty readiness.

Traumatic complete spinal cord injury (CSCI) leads to severe impairment of sensory-motor function, and patients often suffer from neuropsychological deficits such as anxiety, depression, and cognitive deficits, which involve different brain functional modules. However, the alterations in modular organization and the interactions between these modules in pediatric patients with CSCI remain unclear. In this study, a total of 70 participants, including 34 pediatric CSCI patients and 36 healthy controls (HCs) aged 6 to 12 years, underwent whole-brain resting-state functional MRI. The functional networks were analyzed via a graph theory approach based on the 90-region Automated Anatomical Labeling (AAL 90) atlas, generating a 90 × 90 correlation matrix. Metrics for nodal, global, and modular scales were calculated to evaluate alterations in the network's topology. Between-group comparisons and partial correlation analysis were performed. Compared to HCs, pediatric CSCI patients exhibited significant decreases in nodal metrics, particularly in subcortical networks (SN) like the bilateral thalamus. Besides, the distribution of core nodes changed, with five newly added core nodes primarily located in the regions of the default mode network (DMN). For modular interactions, patients group presented increased connectivity within the DMN and between the DMN and the attention network (AN) but reduced connectivity between DMN and SN, DMN and vision network (VN), and AN and SN. Notably, the participation coefficient (Pc) of the TPOmid.L (left temporal pole: middle temporal gyrus) was positively correlated with motor scores, suggesting its potential as an indicator for evaluating the motor function in pediatric CSCI patients. Additionally, the patients demonstrated a different modular structure with significantly lower modularity. These findings suggest that functional network and modular alterations chiefly occur in emotional cognition and vision-associated regions, emphasizing the importance to focus on their psychocognitive well-being and providing evidence for visual-feedback related rehabilitation strategies.

This study investigated the association between repetitive head impacts (RHIs) and multimodal neuroimaging, biomechanical, and neuropsychological data in 72 youth football players and 17 controls, aged 8-12 years. Helmet sensors measured RHI exposure while imaging and psychological data were collected before and after the season. Risk-weighted exposure metrics were calculated to quantify cumulative RHI exposure. Changes in magnetoencephalography (MEG) and diffusion kurtosis imaging were analyzed by calculating voxel-wise difference, and z-score maps were thresholded with respect to controls. Using linear regression, statistically significant positive associations were observed between abnormally increased MEG-measured theta (5-7 Hz) power and RHI measures. No associations were found between RHI and other neuroimaging metrics. Football players and controls exhibited significant yet divergent associations between alpha (8-12 Hz) power as well as mean kurtosis and neuropsychological changes. These findings indicate a potential association between youth football players' exposure to RHI and neurophysiological alterations.

Enhanced recovery after surgery (ERAS) is an interdisciplinary and multimodal approach to surgical patient management. Two primary objectives of the ERAS philosophy have been the standardization of practices and the reduction of variations in treatment. A notable achievement of ERAS has been its ability to enhance and combine into bundles elements that were already well-known but disconnected in clinical practice, such as preadmission, prehabilitation, and multimodal analgesia. Key concepts of ERAS pathways include multimodal, optimization, early and minimal; while the essential principles for success are research, education, and audit. Current literature suggests that a compliance rate of over 70% is associated with better clinical outcomes and improved survival rates. However, it is not yet possible to determine which specific elements are the most critical for ERAS outcomes, nor it is easy to demonstrate which combinations of items are best suited to individual patients. Three types of barriers (cultural, organizational, and structural) can be highlighted as opponents to ERAS implementation. The concept of partial ERAS is gaining increased interest. Adhering to ERAS protocols was not easy, as it required anesthetists to step outside the confines of the operating room, both physically and culturally, and to consciously assume the role of clinical support to surgeons and their patients. Through innovation, collaboration, and advocacy for their indispensable role, anesthetists can lead the evolution of perioperative medicine, ensuring that both patients and the profession thrive in the era of precision care and rapidly changing healthcare environments.