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Original Articles
Trauma
Effect of atorvastatin as a renal protective agent in patients with systemic inflammatory response syndrome using the renal arterial resistive index
Mina Maher Raouf, Eslam Antar Shadad, Nagy Sayed Ali
Received October 14, 2024  Accepted October 30, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.003912    [Epub ahead of print]
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AbstractAbstract PDF
Background
Current meta-analyses have yielded inconclusive results regarding the effectiveness of statins in preventing early renal injury in the context of poly-trauma. Notably, renal artery Doppler-derived resistance indices have shown a strong correlation with early detection of renal impairment, underscoring their importance in clinical assessment.
Methods
The study involved 106 adults of both sexes aged 18 years and older who presented with poly-trauma with a two-point or greater increase in the sequential organ failure assessment score within the first 72 hours of hospital admission and who met two or more of the diagnostic criteria of systemic inflammatory response syndrome. Participants were randomly assigned to either the atorvastatin group, which received oral atorvastatin at a dosage of 20 mg every 12 hours for 1 week alongside conventional therapy (antimicrobial agents and balanced crystalloids), or the control group, which received conventional therapy along with a placebo tablet every 12 hours for 1 week.
Results
The atorvastatin group yielded a significantly lower incidence of acute kidney injury (AKI; P<0.001). Additionally, there was significant reduction in renal resistance and pulsatility indices in the atorvastatin group. Furthermore, the atorvastatin group exhibited a shorter intensive care unit (ICU) stay (P=0.004). The renal index had a sensitivity of 90% and specificity of 68% for AKI prediction when the cutoff value was 0.61. Pulsatility index had a sensitivity of 90% and a specificity of 53% when the cutoff value was 1.28.
Conclusions
Atorvastatin was impactful in mitigating the incidence of AKI, improving renal resistive vascular indices, and abbreviating ICU stays in the poly-traumatized population.
Trauma
Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit
Abdulrahman Özel, Esra Nur İlbeği, Servet Yüce
Received August 26, 2024  Accepted November 18, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.003528    [Epub ahead of print]
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AbstractAbstract PDF
Background
This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods
This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results
A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.75) for mortality. Pediatric Risk of Mortality-3 scores showed good predictive ability (AUC, 0.83), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.69). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusion
Initial lactate levels and Pediatric Risk of Mortality score 3 (PRISM-3)scores are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.
Infection
The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
Michael Roimi, Anat Shrot, Roy Ilan, Avraham Tenenbaum, Danny Epstein, Yaron Bar-Lavie
Received February 22, 2024  Accepted November 4, 2024  Published online February 18, 2025  
DOI: https://doi.org/10.4266/acc.000696    [Epub ahead of print]
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AbstractAbstract PDF
Background
The pivotal role of the gastrointestinal (GI) tract in sepsis has long been recognized. This study aimed to evaluate the associations between defecation frequency as a basic assessment of GI function and the clinical outcomes of intensive care unit (ICU) patients with suspected sepsis.
Methods
This retrospective, single-center study included patients suspected of having sepsis >72 hours after ICU admission. The number of defecations and consecutive days without defecation during the 72 hours preceding the suspected infection were assessed as indicators of GI function. The primary outcome was 30-day all-cause mortality. Multivariate regression analysis adjusting for potential confounders was employed to establish the independent associations between GI function and clinical outcomes.
Results
The final analysis included 1,306 patients with a median age of 56.2 years (interquartile range [IQR], 39.6–69.1); 919 (70.4%) were male, and the median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 22.0 (IQR, 17.0–27.0). The median Sequential Organ Failure Assessment (SOFA) score at the time of suspected infection was 5.0 (IQR, 3.0–7.0). Mortality rates were 20.3%, 28.0%, and 34.3% for patients with 0–2, 3–5, and >5 defecations, respectively (P<0.001). There was a strong correlation between the number of defecations and mortality (r=0.7, P=0.01). In multivariate analyses, each defecation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.07; 95% CI, 1.01–1.12; P=0.01), while each consecutive day without a defecation was associated with reduced mortality (aOR, 0.84; 95% CI, 0.73–0.95; P=0.02).
Conclusions
A higher number of defecations in the 72 hours preceding suspected sepsis is associated with increased 30-day all-cause mortality, suggesting a potential association with GI tract dysfunction.
Review Article
Nursing
Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries
Anabela Carvalho Raposo, Maria Candida Durao, Maria do Rosário Pinto, Helga Rafael Henriques, Joana Ferreira Teixeira
Received November 19, 2023  Accepted November 16, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.005014    [Epub ahead of print]
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AbstractAbstract PDF
Corneal surface injuries occur frequently (59.4%) in critically ill patients, and the average time for their appearance is eight days. Such injuries are primarily related to dry eye, which increases the risk of exposure injury in patients admitted to intensive care units. This can result in a severe ulcer or perforation that results in partial to total loss of vision, decreasing the quality of the patient's life. This is a sensitive nursing care area requiring further investigation. Thus, this review aims to analyse nursing interventions that aim to prevent ocular surface injuries. An integrative literature review was carried out from May to August 2023 in the Medline, CINAHL, Scopus, Web of Science, and PubMed databases using the Whittemore and Knafl methodology. Inclusion and exclusion criteria were subsequently applied to assess the results. After verifying result eligibility, seven documents were identified for data extraction and analysis. The results suggest the importance of recognizing risk factors for ocular injuries in critically ill patients, surveillance as a nursing competency, adequate ocular hygiene and effective lubrication, and managing environmental conditions to prevent corneal injuries. Implementing surveillance and intervention protocols for critically ill patients at risk of corneal injuries requires specialised training for critical care nurses. Specifically, environmental management, including temperature and humidity control, is highlighted as an area that merits further research.
Original Articles
Rapid response system
Resident and nurse attitudes toward a rapid response team in a tertiary hospital in South Korea
Sung Yoon Lim, Ho Geol Woo, Jong Sun Park, Young-Jae Cho, Jae Ho Lee, Yeon Joo Lee
Received November 7, 2024  Accepted December 4, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.004272    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
Residents and nurses who activate rapid response teams (RRTs) are well positioned to offer insights on its effectiveness. Here, we assess such evaluation of RRTs and identify barriers to activation in a 1,400-bed teaching hospital.
Methods
We conducted a 24-item Likert-scale survey from January to May 2017 among residents and ward nurses with RRT experience. Factor analysis was used to identify the barriers.
Results
This study comprised 305 nurses and 53 residents, most of whom were satisfied with their RRT experiences. Factor analysis showed that lack of awareness of activation criteria was a major barrier, with only 21.4% and 22.2% participants, respectively, confident about their knowledge of activation protocols. Of the survey respondents, 85.7% reported first contacting the doctor before activating the RRT. Despite the protocol, 66.7% first discussed the decision with other staff, and 71.5% called the RRT when the patient’s condition worsened despite management.
Conclusions
Nurses and residents value RRTs but face barriers in initiation, primarily due to a lack of confidence in applying the activation criteria. Many prefer to consult a doctor or manage the patient before calling the RRT.
Basic science and research
Impact of tadalafil on cardiovascular and organ dysfunction induced by experimental sepsis
Marcelo Almeida Nakashima, Gabrielle Delfrate, Lucas Braga Albino, Gustavo Ferreira Alves, Junior Garcia Oliveira, Daniel Fernandes
Received June 18, 2024  Accepted November 2, 2024  Published online February 12, 2025  
DOI: https://doi.org/10.4266/acc.002904    [Epub ahead of print]
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AbstractAbstract PDF
Background
Sepsis is a life-threatening condition that affects the cardiovascular and renal systems. Severe hypotension during sepsis compromises tissue perfusion, which can lead to multiple organ dysfunction and death. Phosphodiesterase 5 (PDE5) degrades intracellular cyclic guanosine monophosphate (cGMP) levels which promotes vasodilatation in specific sites. Our previous studies show that inhibiting cGMP production in early sepsis increases mortality, implying a protective role for cGMP production. Then, we hypothesized that cGMP increased by tadalafil (PDE5 inhibitor) could improve microcirculation and prevent sepsis-induced organ dysfunction.
Methods
Rats were submitted to cecal ligation and puncture (CLP) sepsis model and treated with tadalafil (2 mg/kg, s.c.) 8 hours after the procedure. Hemodynamic, inflammatory and biochemical assessments were performed 24 hours after sepsis induction. Moreover, the effect of tadalafil on the survival of septic rats was evaluated for 5 days.
Results
Tadalafil treatment improves basal renal blood flow during sepsis and preserves it during noradrenaline infusion. Sepsis induces hypotension, impaired response to noradrenaline, and increased cardiac and renal neutrophil infiltration, in addition to increased levels of plasma nitric oxide and lactate. None of these dysfunctions were changed by tadalafil. Additionally, tadalafil treatment did not increase the survival rate of septic rats.
Conclusion
Tadalafil improved microcirculation of septic animals; however, no beneficial effects were observed on microcirculation and inflammation parameters. Then, the potential benefit of tadalafil in the prognosis of sepsis should be evaluated within a therapeutic strategy covering all sepsis injury mechanisms.
Pediatrics
Hyper- and hypomagnesemia as an initial predictor of outcomes in septic pediatric patients in Egypt
Aya Osama Mohamed
Received February 6, 2024  Accepted October 31, 2024  Published online February 4, 2025  
DOI: https://doi.org/10.4266/acc.000480    [Epub ahead of print]
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AbstractAbstract PDF
Background
Critically ill septic children are susceptible to electrolyte abnormalities, including magnesium disturbance, that can easily be neglected. This study examined the potential correlation between serum magnesium levels upon admission to the pediatric intensive care unit (PICU) and the outcomes of critically ill septic patients.
Methods
This prospective study, conducted from May 2023 to November 2023, included 76 children with sepsis who underwent clinical and lab assessments that included initial magnesium levels. The outcome of sepsis was documented. Predictors of mortality were identified through multivariate logistic regression models, with discrimination and calibration assessed using the area under the curve (AUC).
Results
The median magnesium level upon PICU admission was 2.0 mg/dl (range 1.1–4.9), and it was slightly higher in non-survivors than survivors (2.1 mg/dl; interquartile range [IQR], 1.9–2.5 vs. 2.0; IQR, 1.8–2.6, respectively), Hypermagnesemia was observed to have a negative effect on critically ill septic patients. It was also found that hypermagnesemia was associated with low C-reactive protein levels (P=0.043). With a cut-off of 5.5, the pediatric Sequential Organ Failure Assessment score strongly predicted mortality (AUC=0.717, P<0.001), with a sensitivity of 64.3% and specificity of 68.8%.
Conclusion
As an initial predictor of mortality, the serum magnesium level cannot be used alone; however, hypermagnesemia has a negative impact on critically ill septic patients. Thus, healthcare professionals should be cautious with magnesium administration.
Thoracic Surgery
Connective tissue disease is associated with the risk of posterior reversible encephalopathy syndrome following lung transplantation in Korea
Tae Jung Kim, Hyun Joo Lee, Samina Park, Sang-Bae Ko, Soo-Hyun Park, Seung Hwan Yoon, Kwon Joong Na, In Kyu Park, Chang Hyun Kang, Young Tae Kim, Sun Mi Choi, Jimyung Park, Joong-Yub Kim, Hong Yeul Lee
Received September 5, 2024  Accepted November 14, 2024  Published online January 7, 2025  
DOI: https://doi.org/10.4266/acc.003384    [Epub ahead of print]
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AbstractAbstract PDFSupplementary Material
Background
Posterior reversible encephalopathy syndrome (PRES) is a rare complication of lung transplantation with poorly understood risk factors and clinical characteristics. This study aimed to examine the occurrence, risk factors, and clinical data of patients who developed PRES following lung transplantation.
Methods
A retrospective analysis was conducted on 147 patients who underwent lung transplantation between February 2013 and December 2023. The patients were diagnosed with PRES based on the clinical symptoms and radiological findings. We compared the baseline characteristics and clinical information, including primary lung diseases and immunosuppressive therapy related to lung transplantation operations, between the PRES and non-PRES groups.
Results
PRES manifested in 7.5% (n=11) of the patients who underwent lung transplantation, with a median onset of 15 days after operation. Seizures were identified as the predominant clinical manifestation (81.8%, n=9) in the group diagnosed with PRES. All patients diagnosed with PRES recovered fully. Patients with PRES were significantly associated with connective tissue disease-associated interstitial lung disease (45.5% vs. 18.4%, P=0.019, odds ratio=9.808; 95% CI, 1.064–90.386, P=0.044). Nonetheless, no significant variance was observed in the type of immunotherapy, such as the use of calcineurin inhibitors, blood pressure, or acute renal failure subsequent to lung transplantation.
Conclusions
PRES typically manifests shortly after lung transplantation, with seizures being the predominant initial symptom. The presence of preexisting connective tissue disease as the primary lung disease represents a significant risk factor for PRES following lung transplantation.
Editorial
Corrigendum
Infection
Corrigendum to: 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(4):652-653.   Published online November 28, 2024
DOI: https://doi.org/10.4266/acc.2023.00983.e1
Corrects: Acute Crit Care 2024;39(2):234
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Original Articles
Infection
Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia
Priyo Sasmito, Satriya Pranata, Rian Adi Pamungkas, Etika Emaliyawati, Nisa Arifani
Acute Crit Care. 2024;39(4):545-553.   Published online November 27, 2024
DOI: https://doi.org/10.4266/acc.2023.01473
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AbstractAbstract PDF
Background
Good sepsis management is key to successful sepsis therapy and optimal patient outcomes. Objectives: This study aimed to determine obstacles among nurses and doctors to implementing the hour-1 sepsis bundle in a secondary hospital in Indonesia.
Methods
This was a qualitative study with a phenomenological approach. Data were obtained from one-on-one in-depth interviews with 13 doctors and nurses in the intensive care unit and emergency department who were purposively sampled. Data were analyzed using content analysis.
Results
Five main themes were revealed in the analysis: incomplete implementation of the hour-1 sepsis bundle, lack of knowledge about the hour-1 sepsis bundle, cost issues, lack of supporting facilities, and lack of coordination among health workers.
Conclusions
Optimizing regional health laboratories, optimizing the use of quick Sequential Organ Failure Assessment (qSOFA) and SOFA, and creating a series of sepsis protocols within the hospital are some solutions that secondary hospitals can implement to ensure appropriate management of sepsis cases. Involvement of health policyholders and hospital management is needed to address these challenges.
Pediatrics
A deep learning model for estimating sedation levels using heart rate variability and vital signs: a retrospective cross-sectional study at a center in South Korea
You Sun Kim, Bongjin Lee, Wonjin Jang, Yonghyuk Jeon, June Dong Park
Acute Crit Care. 2024;39(4):621-629.   Published online November 25, 2024
DOI: https://doi.org/10.4266/acc.2024.01200
Retraction in: https://doi.org/
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Surgery
Effects of closed- versus open-system intensive care units on mortality rates in patients with cancer requiring emergent surgical intervention for acute abdominal complications: a single-center retrospective study in Korea
Jae Hoon Lee, Jee Hee Kim, Ki Ho You, Won Ho Han
Acute Crit Care. 2024;39(4):554-564.   Published online November 25, 2024
DOI: https://doi.org/10.4266/acc.2024.00808
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AbstractAbstract PDFSupplementary Material
Background
In this study, we aimed to compare the in-hospital mortality of patients with cancer who experienced acute abdominal complications that required emergent surgery in open (treatment decisions made by the primary attending physician of the patient's admission department) versus closed (treatment decisions made by intensive care unit [ICU] intensivists) ICUs.
Methods
This retrospective, single-center study enrolled patients with cancer admitted to the ICU before or after emergency surgery between November 2020 and September 2023. Univariate and logistic regression analyses were conducted to explore the associations between patient characteristics in the open and closed ICUs and in-hospital mortality.
Results
Among the 100 patients (open ICU, 49; closed ICU, 51), 23 died during hospitalization. The closed ICU group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, vasopressor use, mechanical ventilation, and preoperative lactate levels and a shorter duration from diagnosis to ICU admission, surgery, and antibiotic administration than the open ICU group. Univariate analysis linked in-hospital mortality and APACHE II score, postoperative lactate levels, continuous renal replacement therapy (CRRT), and mechanical ventilation. Multivariate analysis revealed that in-hospital mortality rate increased with CRRT use and was lower in the closed ICU.
Conclusions
Compared to an open ICU, a closed ICU was an independent factor in reducing in-hospital mortality through prompt and appropriate treatment.

Citations

Citations to this article as recorded by  
  • The efficacy of intensivist-led closed-system intensive care units in improving outcomes for cancer patients requiring emergent surgical intervention
    Eun Young Kim
    Acute and Critical Care.2024; 39(4): 640.     CrossRef
Meta-analysis
Impact of perioperative high-intensity statin treatment on the occurrence of postoperative atrial fibrillation after coronary artery bypass grafting: a meta-analysis
Yeiwon Lee, Somin Im, Yoonjin Kang, Suk Ho Sohn, Myoung-jin Jang, Ho Young Hwang
Acute Crit Care. 2024;39(4):507-516.   Published online November 25, 2024
DOI: https://doi.org/10.4266/acc.2024.00633
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AbstractAbstract PDF
Background
This meta-analysis was conducted to evaluate the impact of high-intensity statin treatment on new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG).
Methods
Four databases were searched for studies that enrolled patients who underwent CABG and investigated the impact of perioperative use of high-intensity statins on the occurrence rate of POAF. The primary outcome was the incidence of POAF. Secondary outcomes were operative mortality and perioperative myocardial infarction (PMI). Publication bias was assessed using a funnel plot and Egger’s test.
Results
Nine articles (eight randomized controlled trials and one non-randomized study: n=3,072) were selected. Rosuvastatin (20 mg) was used in four studies, while atorvastatin (40–80 mg) was used in the other five studies. Reported incidences of POAF in the included studies ranged from 11% to 48.8%. Pooled analyses showed that the incidence of POAF was significantly lower in patients treated with high-intensity statins than in patients in the control group patients (odds ratio, 0.43; 95% CI, 0.27–0.68; P<0.001). Subgroup analyses showed that the impact of high-intensity statins was significant in studies using atorvastatin but not in studies using rosuvastatin. There was no significant subgroup difference in the primary endpoint between studies using a placebo and those using low-dose statins. Secondary outcomes, including operative mortality and the incidence of PMI, were not affected by high-intensity statin treatment.
Conclusions
Perioperative use of high-intensity statins is associated with a 57% reduction in the occurrence of POAF among patients undergoing CABG.
Pediatrics
Early detection of bloodstream infection in critically ill children using artificial intelligence
Hye-Ji Han, Kyunghoon Kim, June Dong Park
Acute Crit Care. 2024;39(4):611-620.   Published online November 22, 2024
DOI: https://doi.org/10.4266/acc.2024.00752
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AbstractAbstract PDF
Background
Despite the high mortality associated with bloodstream infection (BSI), early detection of this condition is challenging in critical settings. The objective of this study was to create a machine learning tool for rapid recognition of BSI in critically ill children.
Methods
Data were extracted from a derivative cohort comprising patients who underwent at least one blood culture during hospitalization in the pediatric intensive care unit (PICU) of a tertiary hospital from January 2020 to June 2023 for model development. Data from another tertiary hospital were utilized for external validation. Variables selected for model development were age, white blood cell count with segmented neutrophil count, C-reactive protein, bilirubin, liver enzymes, glucose, body temperature, heart rate, and respiratory rate. Algorithms compared were extra trees, random forest, light gradient boosting, extreme gradient boosting, and CatBoost.
Results
We gathered 1,806 measurements and recorded 290 hospitalizations from 263 patients in the derivative cohort. Median age on admission was 43 months, with an interquartile range of 10–118.75 months, and a male predominance was observed (n=160, 55.2%). Candida albicans was the most prevalent pathogen, and median duration to confirm BSI was 3 days (range, 3–4). Patients with BSI experienced significantly higher in-hospital mortality and prolonged stays in the PICU than patients without BSI. Random forest classifier achieved the highest area under the receiver operating characteristic curve of 0.874 (0.762 for the validation set).
Conclusions
We developed a machine learning model that predicts BSI with acceptable performance. Further research is necessary to validate its effectiveness.

ACC : Acute and Critical Care
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