Acute and Critical Care

Volume 39 (2); May 2024

Review Articles

Basic science and research
Sex or gender differences in treatment outcomes of sepsis and septic shock: Seung Yeon Min, Ho Jin Yong, Dohhyung Kim; Acute Crit Care. 2024;39(2):207-213. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2024.00591

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Abstract PDF: Gender disparities in intensive care unit (ICU) treatment approaches and outcomes are evident. However, clinicians often pay little attention to the importance of biological sex and sociocultural gender in their treatment courses. Previous studies have reported that differences between sexes or genders can significantly affect the manifestation of diseases, diagnosis, clinicians' treatment decisions, scope of treatment, and treatment outcomes in the intensive care field. In addition, numerous reports have suggested that immunomodulatory effects of sex hormones and differences in gene expression from X chromosomes between genders might play a significant role in treatment outcomes of various diseases. However, results from clinical studies are conflicting. Recently, the need for customized treatment based on physical, physiological, and genetic differences between females and males and sociocultural characteristics of society have been increasingly emphasized. However, interest in and research into this field are remarkably lacking in Asian countries, including South Korea. Through this review, we hope to enhance our awareness of the importance of sex and gender in intensive care treatment and research by briefly summarizing several principal issues, mainly focusing on sex and sex hormone-based outcomes in patients admitted to the ICU with sepsis and septic shock.

Infection
Microbial infections in burn patients: Souvik Roy, Preeti Mukherjee, Sutrisha Kundu, Debashrita Majumder, Vivek Raychaudhuri, Lopamudra Choudhury; Acute Crit Care. 2024;39(2):214-225. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01571

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Abstract PDF: Polymicrobial infections are the leading causes of complications incurred from injuries that burn patients develop. Such patients admitted to the hospital have a high risk of developing hospital-acquired infections, with longer patient stays leading to increased chances of acquiring such drug-resistant infections. Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis are the most common multidrug-resistant (MDR) Gram-negative bacteria identified in burn wound infections (BWIs). BWIs caused by viruses, like Herpes Simplex and Varicella Zoster, and fungi-like Candida spp. appear to occur occasionally. However, the preponderance of infection by opportunistic pathogens is very high in burn patients. Variations in the causative agents of BWIs are due to differences in geographic location and infection control measures. Overall, burn injuries are characterized by elevated serum cytokine levels, systemic immune response, and immunosuppression. Hence, early detection and treatment can accelerate the wound-healing process and reduce the risk of further infections at the site of injury. A multidisciplinary collaboration between burn surgeons and infectious disease specialists is also needed to properly monitor antibiotic resistance in BWI pathogens, help check the super-spread of MDR pathogens, and improve treatment outcomes as a result.

Pulmonary
Beyond survival: understanding post-intensive care syndrome: Lovish Gupta, Maazen Naduthra Subair, Jaskaran Munjal, Bhupinder Singh, Vasu Bansal, Vasu Gupta, Rohit Jain; Acute Crit Care. 2024;39(2):226-233. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01158

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Abstract PDF: Post-intensive care syndrome (PICS) refers to persistent or new onset physical, mental, and neurocognitive complications that can occur following a stay in the intensive care unit. PICS encompasses muscle weakness; neuropathy; cognitive deficits including memory, executive, and attention impairments; post-traumatic stress disorder; and other mood disorders. PICS can last long after hospital admission and can cause significant physical, emotional, and financial stress for patients and their families. Several modifiable risk factors, such as duration of sepsis, delirium, and mechanical ventilation, are associated with PICS. However, due to limited awareness about PICS, these factors are often overlooked. The objective of this paper is to highlight the pathophysiology, clinical features, diagnostic methods, and available preventive and treatment options for PICS.

Original Articles

Infection
Comparative evaluation of tocilizumab and itolizumab for treatment of severe COVID-19 in India: a retrospective cohort study: Abhyuday Kumar, Neeraj Kumar, Arunima Pattanayak, Ajeet Kumar, Saravanan Palavesam, Pradhan Manigowdanahundi Nagaraju, Rekha Das; Acute Crit Care. 2024;39(2):234-242. Published online April 1, 2024; DOI: https://doi.org/10.4266/acc.2023.00983

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Abstract PDF: Background
Itolizumab downregulates the synthesis of proinflammatory cytokines and adhesion molecules by inhibiting CD6 leading to lower levels of interferon-γ, interleukin-6, and tumor necrotic factor-α and reduced T-cell infiltration at inflammatory sites. This study aims to compare the effects of tocilizumab and itolizumab in the management of severe coronavirus disease 2019 (COVID-19). Methods: The study population was adults (>18 years) with severe COVID-19 pneumonia admitted to the intensive care unit receiving either tocilizumab or itolizumab during their stay. The primary outcome was clinical improvement (CI), defined as a two-point reduction on a seven-point ordinal scale in the status of the patient from initiating the drug or live discharge. The secondary outcomes were time until CI, improvement in PO2 /FiO2 ratio, best PO2 /FiO2 ratio, need for mechanical ventilation after administration of study drugs, time to discharge, and survival days. Results: Of the 126 patients included in the study, 92 received tocilizumab and 34 received itolizumab. CI was seen in 46.7% and 61.7% of the patients in the tocilizumab and itolizumab groups, respectively and was not statistically significant (P=0.134). The PO2 /FiO2 ratio was significantly better with itolizumab compared to tocilizumab (median [interquartile range]: 315 [200–380] vs. 250 [150–350], P=0.043). The incidence of serious adverse events due to the study drugs was significantly higher with itolizumab compared to tocilizumab (14.7% vs. 3.3%, P=0.032). Conclusions: The CI with itolizumab is similar to tocilizumab. Better oxygenation can be achieved with itolizumab and it can be a substitute for tocilizumab in managing severe COVID-19.

CPR/Resuscitation
Effects of ketamine on the severity of depression and anxiety following postoperative mechanical ventilation: a single-blind randomized clinical trial in Iran: Seyedbabak Mojaveraghili, Fatemeh Talebi, Sima Ghorbanoghli, Shahram Moghaddam, Hamidreza Shakouri, Ruzbeh Shamsamiri, Fatemeh Mehravar; Acute Crit Care. 2024;39(2):243-250. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01186

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Abstract PDF: Background
In this study, we compare the effects of ketamine and the combination of midazolam and morphine on the severity of depression and anxiety in mechanically ventilated patients after discharge from the intensive care unit (ICU). Methods: This randomized single-blind clinical trial included 50 patients who were candidates for craniotomy and postoperative mechanical ventilation in the ICU of 5 Azar Teaching Hospital in Gorgan City, North Iran, from 2021 to 2022. Patients were allocated to two groups by quadruple block randomization. In group A, 0.5 mg/kg of ketamine was infused over 15 minutes after craniotomy and then continued at a dose of 5 µ/kg/min during mechanical ventilation. In group B, midazolam was infused at a dose of 2–3 mg/hr and morphine at a dose of 3–5 mg/hr. After patients were discharged from the ICU, if their Glasgow Coma Scale scores were ≥14, Beck’s anxiety and depression inventories were completed by a psychologist within 2 weeks, 2 months, and 6 months after discharge. Results: The mean scores of depression at 2 months (P=0.01) and 6 months (P=0.03) after discharge were significantly lower in the ketamine group than in the midazolam and morphine group. The mean anxiety scores were significantly lower in the ketamine group 2 weeks (P=0.006) and 6 months (P=0.002) after discharge. Conclusions: Ketamine is an effective drug for preventing and treating anxiety and depression over the long term in patients discharged from the ICU. However, further larger volume studies are required to validate these results.

Pulmonary
Are sodium-glucose co-transporter-2 inhibitors associated with improved outcomes in diabetic patients admitted to intensive care units with septic shock?: Nikita Ashcherkin, Abdelmohaymin A. Abdalla, Simran Gupta, Shubhang Bhatt, Claire I. Yee, Rodrigo Cartin-Ceba; Acute Crit Care. 2024;39(2):251-256. Published online May 14, 2024; DOI: https://doi.org/10.4266/acc.2023.01046

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Abstract PDF: Background
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce organ dysfunction in renal and cardiovascular disease. There are limited data on the role of SGLT2i in acute organ dysfunction. We conducted a study to assess the effect of SGLT2i taken prior to intensive care unit (ICU) admission in diabetic patients admitted with septic shock. Methods: This retrospective cohort study used electronic medical records and included diabetic patients admitted to the ICU with septic shock. We compared diabetic patients on SGLT2i to those who were not on SGLT2i prior to admission. The primary outcome was in-hospital mortality, and secondary outcomes included hospital and ICU length of stay, use of renal replacement therapy, and 28- and 90-day mortality. Results: A total of 98 diabetic patients was included in the study, 36 in the SGLT2i group and 62 in the non-SGLT2i group. The Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation III scores were similar in the groups. Inpatient mortality was significantly lower in the SGLT2i group (5.6% vs. 27.4%, P=0.008). There was no significant difference in secondary outcomes. Conclusions: Our study found that diabetic patients on SGLT2i prior to hospitalization who were admitted to the ICU with septic shock had lower inpatient mortality compared to patients not on SGLT2i.

Cardiology
Implementation of Society for Cardiovascular Angiography and Interventions classification in patients with cardiogenic shock secondary to acute myocardial infarction in a spanish university hospital: Javier Pérez Cervera, Carlos Antonio Aranda López, Rosa Navarro Romero, Javier Corral Macías, Juan Manuel Nogales Asensio, José Ramón López Mínguez; Acute Crit Care. 2024;39(2):257-265. Published online May 13, 2024; DOI: https://doi.org/10.4266/acc.2023.01620

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Abstract PDF Supplementary Material: Background
Killip-Kimball classification has been used for estimating death risk in patients suffering acute myocardial infarction (AMI). Killip-Kimball stage IV corresponds to cardiogenic shock. However, the Society for Cardiovascular Angiography and Interventions (SCAI) classification provides a more precise tool to classify patients according to shock severity. The aim of this study was to apply this classification to a cohort of Killip IV patients and to analyze the differences in death risk estimation between the two classifications. Methods: A single-center retrospective cohort study of 100 consecutive patients hospitalized for “Killip IV AMI” between 2016 and 2023 was performed to reclassify patients according to SCAI stage. Results: Distribution of patients according to SCAI stages was B=4%, C=53%, D=27%, E=16%. Thirty-day mortality increased progressively according to these stages (B=0%, C=11.88%, D=55.56%, E=87.50%; P<0.001). The exclusive use of Killip IV stage overestimated death risk compared to SCAI C (35% vs. 11.88%, P=0.002) and underestimated it compared to SCAI D and E stages (35% vs. 55.56% and 87.50%, P=0.03 and P<0.001, respectively). Age >69 years, creatinine >1.15 mg/dl and advanced SCAI stages (SCAI D and E) were independent predictors of 30-day mortality. Mechanical circulatory support use showed an almost significant benefit in advanced SCAI stages (D and E hazard ratio, 0.45; 95% confidence interval, 0.19–1.06; P=0.058). Conclusions: SCAI classification showed superior death risk estimation compared to Killip IV. Age, creatinine levels and advanced SCAI stages were independent predictors of 30-day mortality. Mechanical circulatory support could play a beneficial role in advanced SCAI stages.

Thoracic Surgery
Catheter detection by transthoracic echocardiography during placement of peripherally inserted central catheters: a real-time method for eliminating misplacement: Yong Chae Jung, Man-shik Shim, Hee Sun Park, Min-Woong Kang; Acute Crit Care. 2024;39(2):266-274. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2024.00150

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Abstract PDF Supplementary Material: Background
Although guidelines and protocols are available for central venous access, existing methods lack specificity and sensitivity, especially when placing peripherally inserted central catheters (PICCs). We evaluated the feasibility of catheter detection in the right atrial cavity using transthoracic echocardiography (TTE) during PICC placement. Methods: This single-center, retrospective study included consecutive patients who underwent PICC placement between January 2022 and March 2023. TTE was performed to detect the arrival of the catheter in the right atrial cavity. Catheter misplacement was defined as an aberrant catheter position on chest x-ray (CXR). The primary endpoint was predicting catheter misplacement based on catheter detection in the right atrial cavity. The secondary endpoint was optimizing catheter placement and examining catheter-associated complications. Results: Of the 110 patients identified, 10 were excluded because of poor echogenicity and vein access failure. The remaining 100 patients underwent PICC placement with TTE. The catheter was visualized in the right atrial cavity in 90 patients. CXR exams revealed catheter misplacement in seven cases. Eight patients with catheter misplacement underwent the same procedure in the other arm. In two patients, PICC placement failed due to anatomical reasons. Catheter misplacement was detected using TTE with sensitivity, specificity, positive predictive value, and negative predictive value of 97% confidence interval (CI; 91.31%–99.36%), 90% CI (55.50%–99.75%), 99%, and 75%, respectively. Conclusions: TTE is a reliable tool for detecting catheter misplacement and optimizing catheter tip positioning during PICC placement.

Trauma
Comparison of ropivacaine, bupivacaine, and lignocaine in femoral nerve block to position fracture femur patients for central neuraxial blockade in Indian population: Manik Seth, Santvana Kohli, Madhu Dayal, Arin Choudhury; Acute Crit Care. 2024;39(2):275-281. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2023.01606

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Abstract PDF: Background
Patients with a fractured femur experience intense pain during positioning for neuraxial block for definitive surgery. Femoral nerve block (FNB) is therefore often given prior to positioning for analgesia. In our study, we compare the onset and quality of block of 0.25% bupivacaine, 0.5% ropivacaine, and 1.5% lignocaine for FNB in fracture femur patients. Methods: Seventy-five adult femur fracture patients were equally and randomly divided into three groups to receive 15 ml of either 0.25% bupivacaine (group B), 0.5% ropivacaine (group R), or 1.5% lignocaine (group L) for FNB prior to positioning for neuraxial blockade. Onset and quality of block were assessed, as well as improvement in visual analog scale (VAS) score, ease of positioning, and patient satisfaction. Results: Percentage decrease in VAS was found to be highest in group R (82.8%) followed by groups L and B. Time to achieve a VAS of less than 4 was found to be 26.2±2.4 minutes in group B, 8.5±1.9 minutes in group R, and 4.1±0.7 minutes in group L (P<0.001). In group B, 12 patients required additional fentanyl to achieve a VAS <4. Patient positioning was reported to be satisfactory in all patients in group R and L, while in B it was satisfactory in 13 (52%) patients only. Patient acceptance of FNB was 100% in group R and L, but only 64% in group B. Conclusions: Based on our findings, 0.5% ropivacaine is a favorable choice for FNB due to early onset, ability to yield a good quality block, and good safety profile.

Neurosurgery
The efficacy of therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis: Seungjoo Lee, Moinay Kim, Min-Yong Kwon, Sae Min Kwon, Young San Ko, Yeongu Chung, Wonhyoung Park, Jung Cheol Park, Jae Sung Ahn, Hanwool Jeon, Jihyun Im, Jae Hyun Kim; Acute Crit Care. 2024;39(2):282-293. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2024.00612

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Abstract PDF Supplementary Material: Background
This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus. Methods: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed. Results: The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups. Conclusions: TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.

Ethics
Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea: Claire Junga Kim, Kyung Sook Hong, Sooyoung Cho, Jin Park; Acute Crit Care. 2024;39(2):294-303. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01130

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Abstract PDF Supplementary Material: Background
The decision to discontinue intensive care unit (ICU) treatment during the end-oflife stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization. Methods: We retrospectively reviewed medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not. Results: Among 54,699 hospital admissions, LST was withdrawn in 550 cases (1%). Cancer was the most common diagnosis, followed by pneumonia and cerebral infarction. Among ICU inpatients, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.002), had longer total hospital stays (16 vs. 11 days, P<0.001), and higher ICU readmission rates than the control group. There were no significant differences in the healthcare costs of ICU stay between the two groups. Most LST decisions (86%) were made by family. Conclusions: The decisions to withdraw LST of ICU inpatients were influenced by age, readmission, and disease category. ICU costs were similar between the withdrawal and control groups. Further research is needed to tailor LST decisions in the ICU.

Epidemiology
Mortality rates among adult critical care patients with unusual or extreme values of vital signs and other physiological parameters: a retrospective study: Charles Harding, Marybeth Pompei, Dmitriy Burmistrov, Francesco Pompei; Acute Crit Care. 2024;39(2):304-311. Published online May 13, 2024; DOI: https://doi.org/10.4266/acc.2023.01361

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Abstract PDF: Background
We evaluated relationships of vital signs and laboratory-tested physiological parameters with in-hospital mortality, focusing on values that are unusual or extreme even in critical care settings. Methods: We retrospectively studied Philips Healthcare–MIT eICU data (207 U.S. hospitals, 20142015), including 166,959 adult-patient critical care admissions. Analyzing most-deranged (worst) value measured in the first admission day, we investigated vital signs (body temperature, heart rate, mean arterial pressure, and respiratory rate) as well as albumin, bilirubin, blood pH via arterial blood gas (ABG), blood urea nitrogen, creatinine, FiO2 ABG, glucose, hematocrit, PaO2 ABG, PaCO2 ABG, sodium, 24-hour urine output, and white blood cell count (WBC). Results: In-hospital mortality was ≥50% at extremes of low blood pH, low and high body temperature, low albumin, low glucose, and low heart rate. Near extremes of blood pH, temperature, glucose, heart rate, PaO2 , and WBC, relatively. Small changes in measured values correlated with several-fold mortality rate increases. However, high mortality rates and abrupt mortality increases were often hidden by the common practice of thresholding or binning physiological parameters. The best predictors of in-hospital mortality were blood pH, temperature, and FiO2 (scaled Brier scores: 0.084, 0.063, and 0.049, respectively). Conclusions: In-hospital mortality is high and sharply increasing at extremes of blood pH, body temperature, and other parameters. Common-practice thresholding obscures these associations. In practice, vital signs are sometimes treated more casually than laboratory-tested parameters. Yet, vitals are easier to obtain and we found they are often the best mortality predictors, supporting perspectives that vitals are undervalued.

Nursing
Sleep, anxiety, depression, and stress in critically ill patients: a descriptive study in a Portuguese intensive care unit: Rui Domingues Silva, Abílio Cardoso Teixeira, José António Pinho, Pedro Marcos, José Carlos Santos; Acute Crit Care. 2024;39(2):312-320. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2023.01256

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Abstract PDF: Background
Sleep disorders are common among patients admitted to intensive care units (ICUs). This study aimed to assess the perceptions of sleep quality, anxiety, depression, and stress reported by ICU patients and the relationships between these perceptions and patient variables. Methods: This cross-sectional study used consecutive non-probabilistic sampling to select participants. All patients admitted for more than 72 hours of ICU hospitalization at a Portuguese hospital between March and June 2020 were asked to complete the “Richard Campbell Sleep Questionnaire” and “Anxiety, depression, and Stress Assessment Questionnaire.” The resulting data were analyzed using descriptive statistics, Pearson’s correlation coefficient, Student t-tests for independent samples, and analysis of variance. The significance level for rejecting the null hypothesis was set to α ≤0.05. Results: A total of 52 patients admitted to the ICU for at least 72 hours was recruited. The mean age of the participants was 64 years (standard deviation, 14.6); 32 (61.5%) of the participants were male. Approximately 19% had psychiatric disorders. The prevalence of self-reported poor sleep was higher in women (t[50]=2,147, P=0.037) and in participants with psychiatric problems, although this difference was not statistically significant (t[50]=–0.777, P=0.441). Those who reported having sleep disorders before hospitalization had a worse perception of their sleep. Conclusions: Sleep quality perception was worse in female ICU patients, those with psychiatric disorders, and those with sleep alterations before hospitalization. Implementing early interventions and designing nonpharmacological techniques to improve sleep quality of ICU patients is essential.

Editorial

Ethics
End-of-life care in the intensive care unit: the optimal process of decision to withdrawing life-sustaining treatment based on the Korean medical environment and culture: Ho Jin Yong, Dohhyung Kim; Acute Crit Care. 2024;39(2):321-322. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2024.00675

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PDF

Case Report

Pulmonary
Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit: Shauni Wellekens, Nico Buls, Johan De Mey, Vincent Van Nieuwenhove, Jeroen Cant, Joop Jonckheer; Acute Crit Care. 2024;39(2):323-326. Published online June 10, 2022; DOI: https://doi.org/10.4266/acc.2021.01802

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Abstract PDF: Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized x-ray device was developed. We aimed to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized x-ray device was developed to perform 15 radiographic projections while translating the x-ray tube 25 cm (10 cm ramp up and 15 cm during x-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest x-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest x-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable x-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces while avoiding intrahospital transport and limiting radiation exposure compared to CT.

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