Acute and Critical Care

Editorial

Surgery
The efficacy of intensivist-led closed-system intensive care units in improving outcomes for cancer patients requiring emergent surgical intervention: Eun Young Kim; Acute Crit Care. 2024;39(4):640-642. Published online November 28, 2024; DOI: https://doi.org/10.4266/acc.2024.01256

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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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Abstract 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

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Abstract PDF Supplementary Material: seBackground: Optimal sedation assessment in critically ill children remains challenging due to the subjective nature of behavioral scales and intermittent evaluation schedules. This study aimed to develop a deep learning model based on heart rate variability (HRV) parameters and vital signs to predict effective and safe sedation levels in pediatric patients.
Methods
This retrospective cross-sectional study was conducted in a pediatric intensive care unit at a tertiary children’s hospital. We developed deep learning models incorporating HRV parameters extracted from electrocardiogram waveforms and vital signs to predict Richmond Agitation-Sedation Scale (RASS) scores. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). The data were split into training, validation, and test sets (6:2:2), and the models were developed using a 1D ResNet architecture.
Results
Analysis of 4,193 feature sets from 324 patients achieved excellent discrimination ability, with AUROC values of 0.867, 0.868, 0.858, 0.851, and 0.811 for whole number RASS thresholds of −5 to −1, respectively. AUPRC values ranged from 0.928 to 0.623, showing superior performance in deeper sedation levels. The HRV metric SDANN2 showed the highest feature importance, followed by systolic blood pressure and heart rate.
Conclusions
A combination of HRV parameters and vital signs can effectively predict sedation levels in pediatric patients, offering the potential for automated and continuous sedation monitoring in pediatric intensive care settings. Future multi-center validation studies are needed to establish broader applicability.

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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Abstract PDF Supplementary 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

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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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Abstract 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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Abstract 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.

CPR/Resuscitation
Incidence of hypoglycemia in hyperkalemia patients after treatment with insulin and dextrose in the emergency department of a tertiary care hospital in India: a prospective observational study: Vivek Chaurasia, Nayer Jamshed, Praveen Aggrawal, Sanjeev Bhoi, Meera Ekka, Tej Prakash Sinha, Akshay Kumar, Prakash Ranjan Mishra, Anand Kumar Das; Acute Crit Care. 2024;39(4):499-506. Published online November 22, 2024; DOI: https://doi.org/10.4266/acc.2024.00661

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Abstract PDF: Background
Hypoglycemia is a serious, often overlooked complication of treating hyperkalemia with insulin and dextrose. If not recognized and managed, it can increase morbidity and mortality. This study aimed to estimate the incidence of hypoglycemia in hyperkalemic patients treated with 10 units of intravenous insulin, 50 ml of 50% dextrose, 10 ml of 10% calcium gluconate, and salbutamol nebulization. Additionally, the timing of hypoglycemia onset and its associated factors were studied.
Methods
This prospective observational study included hyperkalemic patients (serum potassium >5.5 mmol/L) who visited the emergency department between January 26, 2020, and August 26, 2021. The primary outcome was hypoglycemia (blood glucose <70 mg/dl) within 3 hours of receiving the standard treatment. Glucose levels were measured hourly for 3 hours. Univariate and multivariate logistic regression identified factors associated with hypoglycemia.
Results
Of 100 patients, 69% were male, and the median age was 46 years (IQR, 30–60 years). Hypoglycemia occurred in 44%, and 10% developed severe hypoglycemia (blood glucose <54 mg/dl). The median time for hypoglycemia onset was 2 hours (IQR, 1–2 hours). Low pretreatment blood glucose (<100 mg/dl) was significantly associated with hypoglycemia, according to both univariate and multivariate analyses.
Conclusions
The study found a higher incidence of hypoglycemia in hyperkalemia treatment than reported in retrospective studies, suggesting the need for standardized management protocols with integrated glucose monitoring.

Trauma
Factors associated with unplanned intensive care unit readmission among trauma patients in Republic of Korea: Yongwoong Lee, Byung Hee Kang; Acute Crit Care. 2024;39(4):583-592. Published online November 22, 2024; DOI: https://doi.org/10.4266/acc.2024.00584

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Abstract PDF: Background
In trauma patients, unplanned intensive care unit (ICU) readmission (UIR) is associated with poor clinical outcomes. In this study, we aimed to analyze associated factors for UIR in trauma patients. Methods: This retrospective study was conducted on trauma patients admitted to the ICU at a trauma center from January 2016 to December 2022. Clinical information at admission, the first ICU hospitalization, first discharge from the ICU, and reasons for readmission were collected. Patients who were successfully discharge from the ICU were compared to UIR patients. Logistic regression was performed to determine the factors with a significant impact on ICU readmission. Results: Here, 5,529 patients were admitted to the ICU over 7 years, and 212 patients (3.8%) experienced UIR. Among patients who experienced UIR, 9 (4.2%) died. In the UIR patients, hospital stay (20 days [interquartile range, 13–35] vs. 45 days [28–67], P<0.001), total ICU stay (5 days [3– 11] vs. 17 days [9–35], P<0.001), and complications during the first ICU hospitalization were significantly higher. The most common reason for UIR was respiratory problem (53.8%). In multivariable analysis, cervical spine operation during the first ICU hospitalization (odds ratio, 6.56; 95% CI, 3.62–11.91; P<0.001), renal replacement therapy (RRT; 3.52, 2.06–5.99, P<0.001), and massive blood transfusion protocol (MTP; 1.74, 1.08–2.81, P=0.023) were most highly related with UIR. Conclusions: Because UIR patients had poor outcomes, trauma patients who underwent cervical spine operation, RRT, or MTP require monitoring in the general ward, especially for respiratory problems.

Neurology
Isolated reversible mydriasis was associated with the use of nebulized ipratropium bromide: a case series using quantitative pupilometer in Korea: Soo-Hyun Park, Tae Jung Kim, Sang-Bae Ko; Acute Crit Care. 2024;39(4):593-599. Published online November 20, 2024; DOI: https://doi.org/10.4266/acc.2024.00983

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Abstract PDF Supplementary Material: Background
Abnormal pupillary reactivity is a neurological emergency requiring prompt evaluation to identify its underlying causes. Although isolated unilateral mydriasis without accompanying neurological abnormalities is rare, it has occasionally been associated with nebulizer use. We aimed to quantitatively assess pupillary changes using a pupillometer in cases of isolated mydriasis, which has not been described in previous studies.
Methods
We retrospectively analyzed patients who developed unilateral mydriasis after using an ipratropium bromide nebulizer using a prospectively collected database in the intensive care unit (ICU) between April 2019 and August 2020. An automated pupillometer (NPi-100 or NPi-200) was used for quantitative pupillary assessment. The Neurological Pupil index (NPi) value at the time of unilateral mydriasis was assessed, and the latency before and after the application of the ipratropium bromide nebulizer was measured.
Results
Five patients with isolated mydriasis were identified (mean age, 68 years; male, 60.0%), none of whom had neurological abnormalities other than pupillary light reflex abnormalities. A quantitative pupillometer examination revealed that the affected pupil was larger (5.67 mm vs. 3.20 mm) and had lower NPi values (0.60 vs. 3.40) than the unaffected side. These abnormalities resolved spontaneously without treatment (pupil size, 3.40 mm; NPi, 3.90). The affected pupil had a prolonged latency of 0.38 seconds (vs. 0.28 seconds), which improved to 0.30 seconds with the resolution of the anisocoria.
Conclusions
In the ICU setting, it is important to keep in mind the ipratropium bromide nebulizer as the benign cause of unilateral mydriasis. Further, an automated pupilometer may be a useful tool for evaluating unilateral mydriasis.

Nutrition
Higher caloric intake through enteral nutrition is associated with lower hospital mortality rates in patients with candidemia and shock in Taiwan: Chen-Yu Wang, Tsai-Jung Wang, Yu-Cheng Wu, Chiann-Yi Hsu; Acute Crit Care. 2024;39(4):573-582. Published online November 20, 2024; DOI: https://doi.org/10.4266/acc.2024.00843

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Abstract PDF: Background
Candidemia is associated with markedly high intensive care unit (ICU) mortality rates. Although the Impact of Early Enteral vs. Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA-2) trial indicated that early enteral nutrition (EN) did not reduce 28-day mortality rates among critically ill patients with shock, the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend avoiding EN in cases of uncontrolled shock. Whether increased caloric intake from EN positively impacts clinical outcomes in patients with candidemia and shock remains unclear.
Methods
We retrospectively collected data from a tertiary medical center between January 2015 and December 2018. We enrolled patients who developed shock within the first 7 days following ICU admission and received a diagnosis of candidemia during their ICU stay. Patients with an ICU stay shorter than 48 hours were excluded.
Results
The study included 106 patients, among whom the hospital mortality rate was 77.4% (82 patients). The median age of the patients was 71 years, and the median Acute Physiology and Chronic Health Evaluation II score was 29. The Cox regression model revealed that a higher 7-day average caloric intake through EN (hazard ratio, 0.61; 95% CI, 0.44–0.83) was significantly associated with lower hospital mortality rates. Our findings suggest EN as the preferred feeding route for critically ill patients with shock.
Conclusions
Increased caloric intake through EN may be associated with lower hospital mortality rates in patients with candidemia and shock.

Pediatrics
Post–intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post–intensive-care clinic: Chanapai Chaiyakulsil; Acute Crit Care. 2024;39(4):600-610. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.01011

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Abstract PDF Supplementary Material: Background
Long-term survival data for critically ill children discharged to post-intensive care clinics are scarce, especially in Asia. The main objective of this study was to assess the prevalence of post–intensive-care morbidity among pediatric intensive care unit (PICU) survivors at 1 month and 1 year after hospital discharge and to identify the associated risk factors.
Methods
We conducted a retrospective chart review of all children aged 1 month to 15 years who were admitted to the PICU for >48 hours from July 2019 to July 2022 and visited a post–intensive-care clinic 1 month and 1 year after hospital discharge. Post-intensive care morbidity was defined using the Pediatric Cerebral Performance Category (PCPC). Descriptive statistics, univariate, and multivariate analyses were conducted.
Results
A total of 111 children visited the clinic at 1 month, and 100 of these children visited the clinic at 1 year. Only 39 of 111 children (35.2%) had normal PCPC assessments at 1 month, while 54 of 100 (54.0%) were normal at 1 year. Baseline developmental delays were significantly associated with any degree of disability and at least moderate disability at both time points. Mechanical ventilation for >7 days was associated with at least moderate disability at both time points, while PICU stay >7 days was significantly associated with moderate disability at 1 month and any degree of disability at 1 year.
Conclusions
A substantial percentage of PICU survivors had persistent disabilities even 1 year after critical illness. A structured multidisciplinary post–intensive-care follow-up plan is warranted to provide optimal care for such children.

Review Article

Cardiology
Left ventricle unloading during veno-arterial extracorporeal membrane oxygenation: review with updated evidence: Yongwhan Lim, Min Chul Kim, In-Seok Jeong; Acute Crit Care. 2024;39(4):473-487. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00801

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Abstract PDF: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used to treat medically refractory cardiogenic shock and cardiac arrest, and its usage has increased exponentially over time. Although VA-ECMO has many advantages over other mechanical circulatory supports, it has the unavoidable disadvantage of increasing retrograde arterial flow in the afterload, which causes left ventricular (LV) overload and can lead to undesirable consequences during VA-ECMO treatment. Weak or no antegrade flow without sufficient opening of the aortic valve increases the LV end-diastolic pressure, and that can cause refractory pulmonary edema, blood stagnation, thrombosis, and refractory ventricular arrhythmia. This hemodynamic change is also related to an increase in myocardial energy consumption and poor recovery, making LV unloading an essential management issue during VA-ECMO treatment. The principal factors in effective LV unloading are its timing, indications, and modalities. In this article, we review why LV unloading is required, when it is indicated, and how it can be achieved.

Original Articles

Rapid response system
Development and implementation of an artificial intelligence–enhanced care model to improve patient safety in hospital wards in Spain: Alejandro Huete-Garcia, Sara Rodriguez-Lopez; Acute Crit Care. 2024;39(4):488-498. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00759

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Abstract PDF: MoreBackground: Early detection of critical events in hospitalized patients improves clinical outcomes and reduces mortality rates. Traditional early warning score systems, such as the National Early Warning Score 2 (NEWS2), effectively identify at-risk patients. Integrating artificial intelligence (AI) could enhance the predictive accuracy and operational efficiency of such systems. The study describes the development and implementation of an AI-enhanced early warning system based on a modified NEWS2 scale with laboratory parameters (mNEWS2-Lab) and evaluates its ability to improve patient safety in hospital wards.
Methods
For this retrospective cohort study of 3,790 adults admitted to hospital wards, data were collected before and after implementing the mNEWS2-Lab protocol with and without AI enhancement. The study used a multivariate prediction model with statistical analyses such as Fisher's chi-square test, relative risk (RR), RR reduction, and various AI models (logistic regression, decision trees, neural networks). The economic cost of the intervention was also analyzed.
Results
The mNEWS2-Lab reduced critical events from 6.15% to 2.15% (RR, 0.35; P<0.001), representing a 65% risk reduction. AI integration further reduced events to 1.59% (RR, 0.26; P<0.001) indicating a 10% additional risk reduction and enhancing early warning accuracy by 15%. The intervention was cost-effective, resulting in substantial savings by reducing critical events in hospitalized patients.
Conclusions
The mNEWS2-Lab scale, particularly when integrated with AI models, is a powerful and cost-effective tool for the early detection and prevention of critical events in hospitalized patients.

Surgery
Performance evaluation of non-invasive cardiac output monitoring device (HemoVista) based on multi-channel thoracic impedance plethysmography technology: Jaehee Park, Byung-Moon Choi; Acute Crit Care. 2024;39(4):565-572. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00731

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Abstract PDF: Background
A non-invasive method of measuring cardiac output (CO) can be beneficial in the care of critically ill patients. HemoVista (BiLab Co., Ltd.) is a medical device that measures CO non-invasively using multi-channel impedance plethysmography technology. The purpose of this study was to exploratively evaluate the performance of HemoVista in critically ill patients undergoing CO monitoring with the FloTrac (Edwards Lifesciences).
Methods
After non-invasively installing the HemoVista sensor in critically ill patients whose CO was monitored with the FloTrac, CO values measured by both devices were collected for 30 minutes. Cardiac output measured by both devices was selected every 10 seconds, creating approximately 360 data pairs per patient. Linear correlation analysis with Pearson correlation coefficients, Bland-Altman analysis, and four-quadrant plot analysis were performed to evaluate the performance of HemoVista.
Results
A total of 7,138 pairs of CO data from the 20 patients were included in the analysis. A significant correlation was observed between the two methods of measuring CO (Pearson's r=0.489, P<0.001). The mean bias was 1.03 L/min, the 95% CI for the limit of agreement was –1.83 L/min to 3.93 L/min and the percentage error was 55.8%. The concordance rate of time-dependent CO between the two devices was 14.6%.
Conclusions
It was observed that the current version of HemoVista has unsuitable performance for use in intensive care units. To be used for critically ill patients, the algorithm must be improved and reevaluated with an enhanced version.

Epidemiology
Long-term mortality of adult patients with carbon monoxide poisoning presenting to the emergency department in Korea: a population-based cohort study: Sang Hwan Lee, Soo Rack Ryu, Kyung Hun Yoo, Juncheol Lee, Yongil Cho, Tae Ho Lim, Hyunggoo Kang, Jaehoon Oh, Byuk Sung Ko; Acute Crit Care. 2024;39(4):526-534. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00199

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Abstract PDF Supplementary Material: Background
Carbon monoxide (CO) poisoning can lead to significant morbidity and mortality. However, relatively few studies have investigated its long-term mortality impact. This nationwide population-based cohort study examined the association between CO poisoning and long-term mortality.
Methods
This retrospective study utilized data from the National Health Insurance Service database in South Korea. We compared the patients with CO poisoning to those without CO poisoning. Inverse probability treatment weights were applied to both groups to control for potential confounding factors. Subsequently, mortality was assessed using the incidence rate and Cox proportional hazard ratios.
Results
This study included 23,387 patients with CO poisoning and 359,851 without it. Over a median follow-up period of 7.6 years after CO poisoning diagnosis, the mortality risk was 2.6 times higher in patients with CO poisoning compared to that in the control group. In a long-term follow-up of patients surviving beyond 30 days, mortality remained 2.18 times higher. Additionally, a higher mortality risk was observed in the relatively younger age group (18–39 years) and the group with fewer underlying diseases, as indicated by a Charlson Comorbidity Index score of 0.
Conclusions
CO poisoning is associated with an elevated long-term mortality rate particularly in a relatively young and healthy population.

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