Support Organ Function Research Articles

The impact of anemia on prolonged ventilator use in critically ill patients: A literature review

Anemia is a common condition associated with critically ill patients admitted to intensive care unit (ICU), where 60% of ICU patients experience anemia and 61% of anemic and tranfused patients present in the ICU require mechanical ventilation. The presence of anemia in critically ill patients is associated with increased risk of mortality, cardiovascular morbidity, and decreased oxygen-carrying capacity, potentially prolonging the need for mechanical ventilation. Mechanical ventilation is the primary method of supporting organ function for patients receiving treatment in the ICU. According to epidemiological studies, up to 70% of patients hospitalized to the ICU require mechanical ventilation at some time during their stay. Studies regarding the correlation between anemia and the length of ventilator use are rarely known. Therefore, researchers are interested in conducting research on the correlation between anemia and length of ventilator use. This review is expected to be useful for enriching knowledge about the relationship between anemia and length of ventilator use in critically ill patients. However, further research is needed with more comprehensive variables to determine the impact of anemia on prolonged ventilator use, risk factors of weaning failure, pathogenesis of anemia, and treatment used in critically ill patients.

Respiratory support strategies for ARDS related to infection

Sepsis is one of the main causes of acute respiratory distress syndrome (ARDS), which continues to be a common cause of high mortality in intensive care units (ICUs). Despite tremendous advances in basic science and clinical research, the high mortality of ARDS remains a major clinical challenge. Currently, there is a lack of specific and effective therapeutic approaches for ARDS, with treatment primarily focused on supporting organ function. This article provided a comprehensive discussion and summary of respiratory support strategies for sepsis associated with ARDS.

Understanding the Importance of Balanced Nutrition: Steps to Optimal Health

This article underscores the importance of balanced nutrition as the foundation of optimal health in an era of modern lifestyles and varied diets. Proper nutrition contributes to physical and mental health, and prevents chronic diseases such as obesity, diabetes and heart disease. Understanding the essence of balanced nutrition is considered the first step towards optimal health. The proposed research methodology includes literature analysis, population surveys, and interviews with nutritionists to understand the understanding and implementation of balanced nutrition. The results are expected to generate practical guidelines to promote a balanced diet. Balanced nutrition is considered an important foundation for physical and mental health, supporting organ function, healthy growth, a strong immune system, and preventing chronic diseases. It is also important during the growing years of children and adolescents, and plays a role in mental health by reducing the risk of depression and anxiety. Overall, understanding and implementing balanced nutrition is expected to help individuals and communities build healthy and sustainable lifestyles, improving physical, mental health and productivity.

Clinical characteristics and determinants of invasive mechanical ventilation outcome in adult intensive care unit in Northern Ethiopia: A resource-limited setting

Objectives: Mechanical ventilation (MV) is a primary modality of supporting organ function in patients who are treated in intensive care units (ICUs). Although it is lifesaving, it is also associated with life-threatening complications. This study aims to address the existing paucity of evidence on clinical characteristics and determinants of invasive MV outcomes in adult ICU in North Ethiopia. Materials and Methods: The study was conducted in the adult ICU of Ayder Comprehensive Specialized Hospital. A hospital-based prospective study was conducted to collect data using the purposive sampling technique to include all the patients who received invasive MV from January 2017 to October 2017. Data were analyzed using SPSS version 23. Results: MV was utilized in 36.7% (n = 105) of critically ill patients admitted to the ICU. The two most common indications for invasive MV use were hypoxic respiratory failure 44.8% (n = 47) and coma 35.2% (n = 37). The mortality rate among patients who received invasive MV was 28.6%. Age above 60 years and development of septic shock after intubation were significant determinants of invasive MV-related mortality. Conclusion: A significant number of patients admitted to the ICU require respiratory support with invasive MV. Old age and the development of septic shock after intubation were significant determinants of mortality for patients under invasive MV.

A study protocol for improving the delivery of acute kidney replacement therapy (KRT) to critically ill patients in Alberta – DIALYZING WISELY

BackgroundAcute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs.MethodsDialyzing Wisely is a registry embedded, stepped-wedge, interrupted time-series evaluation of the implementation of a standardized, stakeholder-informed, and evidence-based acute KRT pathway into Alberta ICUs. The acute KRT pathway will consist of two distinct phases. First, we will implement routine monitoring of evidence-informed key performance indicators (KPIs) of acute KRT. Second, we will provide prescriber and program reports for acute KRT initiation patterns. After the implementation of both phases of the pathway, we will evaluate acute KRT performance quarterly and implement a customized suite of interventions aimed at improving performance. We will compare this with baseline and evaluate iterative post implementation effects of the care pathway.DiscussionDialyzing Wisely will implement, monitor, and report a suite of KPIs of acute KRT, coupled with a care pathway that will transform the quality of acute KRT across ICUs in Alberta. This program will provide a framework for scaling evidence-informed approaches to monitoring and management of acute KRT in other jurisdictions. We anticipate improvements in acute KRT performance, decreased healthcare system costs and improved patient quality of life by decreasing patient dependence on maintenance dialysis.Trial registrationClinicaltrials.gov, NCT05186636. Registered 11, January, 2022.

Characteristics and Outcomes of Mechanically Ventilated Patients at Adult ICU of Selected Public Hospitals in Addis Ababa, Ethiopia.

IntroductionMechanical ventilation is the primary method of supporting organ function for patients admitted to intensive care units (ICU). The information on the characteristics and outcomes of patients requiring mechanical ventilation is essential to understanding the causes of mortality among mechanically ventilated patients. However, the available literature in developing countries, including Ethiopia, is limited.ObjectiveThe objective of this study was to assess the characteristics and outcomes of mechanically ventilated patients in adult intensive care units in selected public hospitals, in Addis Ababa, Ethiopia, from 2019 to 2020.MethodsAn institutional-based cross-sectional study design was employed. All adult patients who were mechanically ventilated and admitted to ICU for at least 24 hours between July 2019 and July 2020 were included in the study. The collected data were evaluated with SPSS version 26 software. Multiple logistic regression models were used to indicate the association between dependent and independent variables. The variables, which have an independent association with poor outcomes, were identified with a p-value less than 0.05.ResultsOf 180 mechanically ventilated patients, 98(54.4%) were male. The main reason for ventilation was respiratory failure. The mean duration of stay on the ventilator was 7.09± 6.06, and the mortality rate in mechanically ventilated patients was 41.7%. The mortality rate was higher in patients with cardiac diseases 43(57.70%). Inotropic use, not taking sedation, and length of stay on a mechanical ventilator were independently associated with mortality.ConclusionThe mortality rate of mechanically ventilated patients in the selected public hospitals was high. The clinicians must strive to balance the necessity and benefit of sedation use with the potential to negatively affect the patient outcome. In addition, the risk:benefit assessment of ventilation must be done for all patients requiring ventilator support.

A Case Report of Sedation Strategy for a Patient With Coronavirus Disease 2019 Supported by Extracorporeal Membrane Oxygenation After Cesarean Section

Pneumonia caused by coronavirus disease 2019 (COVID-19) is a highly contagious disease. Unfortunately, research on extracorporeal membrane oxygenation (ECMO) assisted treatments for patients with COVID-19 infection is limited. In this case study, a patient who was in late pregnancy (35+2 weeks of pregnancy) and suffering from severe COVID-19 was extremely irritable during ECMO-assisted treatment after she underwent a cesarean section. Her Richmond Agitation Sedation Scale (RASS) score reached +3. Nevertheless, the patient successfully was treated with a continuous single/combined application of propofol, midazolam, dexmedetomidine, hibernation mixture, and other drugs for several days (maintaining RASS -2 to -4) and provided with anti-infection, mechanical ventilation, nutritional support, fluid balance under hemodynamic monitoring, liver support, and other organ function support treatments. ECMO-assisted sedation strategy for patients was introduced and discussed in this case to provide a certain reference for the clinical diagnosis and treatment of such patients.

Open Abdomen during Extracorporeal Membrane Oxygenation is a Safe and Effective Treatment for Abdominal Compartment Syndrome

Background/Purpose 
 Historically, decompressive laparotomy and open abdomen for abdominal compartment syndrome has contraindicated Extracorporeal Membrane Oxygenation (ECMO) due to seemingly high risk of bleeding and infection. The literature shows few examples of this treatment, and the existing studies are inconclusive. The purpose of this study was to review the series at Riley Hospital for Children and evaluate the effectiveness of ECMO treatment for patients undergoing decompressive laparotomy with open abdomen to recommend future care guidelines. 
 Methods 
 We reviewed all pediatric (30 days to 18 years) patients treated with ECMO concurrently with decompressive laparotomy and open abdomen at Riley Hospital for Children from 2000-2019. We compared these patients with non-surgical pediatric patients supported with ECMO for respiratory failure at Riley Hospital for Children during the same period. Demographics, ECMO data, and outcomes were assessed. We performed t-test, ROC, and chi-square analyses. We defined significance as p=0.05. 
 Results 
 5 of 82 pediatric respiratory ECMO patients were treated with decompressive laparotomy and open abdomen. Survival among the surgical group was 60%, compared to 57% in the non-surgical group (p=0.9). Surgical patients had a similar incidence of bleeding complications (40%) compared to non-surgical patients (55.8%), p=0.486. Surgical patients had a significantly higher VIS (3126 vs 19.2, p=0.004), PaO2/FiO2 ratio (279.0 vs 72.9, p=0.031), and pump flow rate at 24hrs (112mL/kg/min vs 88.1mL/kg/min, p=0.045) than non-surgical patients, while receiving a similar volume of PRBCs (p=0.581) and requiring ECMO treatment for a similar amount of time (p=0.511). 
 Conclusion/Potential Impact 
 ECMO support in patients with decompressive laparotomy and open abdomen was associated with similar survival and bleeding complications compared to non-surgical ECMO patients. ECMO should be offered to or continued in eligible patients with abdominal catastrophe, as it is effective in supporting organ function while not significantly increasing the risk for complications.

Exploring Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors for Organ Protection in COVID-19.

Hospital admissions and mortality from the Coronavirus disease 2019 (COVID-19) pandemic are spreading throughout the world, and second and third waves are thought to be likely. Risk factors for severe COVID-19 include diabetes, chronic kidney disease and cardiovascular disease. Currently, there is no vaccine and no approved therapy. Therapeutic approaches are aimed at preventing viral replication and spread, limiting the impact of the inflammatory overdrive (cytokine storm), preventing thromboembolic complications and replacing or supporting organ function. However, despite organ support, mortality is currently 65% for those receiving advanced respiratory support and 78% for those requiring renal replacement therapies. Thus, efforts should be made to provide adjuvant organ protection therapy. This may imply novel therapies in clinical development (e.g., the Fas ligand trap asunercept), but uptake of repurposed drugs already in clinical use may be faster. In this regard, sodium glucose co-transporter-2 (SGLT2) inhibitors were recently shown to protect the heart and kidney both within and outside of a diabetic milieu context. Further, preclinical data support a beneficial effect for the lung. We now discuss the potential benefits and risks of SGLT2 inhibitors in COVID-19 and an ongoing clinical trial testing the impact of dapagliflozin on outcomes in COVID-19 patients with respiratory failure.

Consensus of Chinese experts on early prevention and blocking of sepsis

Sepsis is an ongoing conundrum and challenge in medical field. With the rapid development and progress of modern medicine, sepsis has been researched and explored in greater depth across different fields. Although "Surviving Sepsis Campaign" (SSC) has been taken to tackle sepsis in the world for years, its incidence and mortality stay high. According to the updated definition of sepsis stated in the current international guidelines, sepsis is defined as the infection-induced host response disorder, which further results in circulation and/or organ dysfunction. The original source of sepsis is infection, and it is a complicated pathophysiological process from infection to sepsis, which involves the invasion of pathogens, release of cytokines, capillary leakage, and microcirculation dysfunction, thus causing organ metabolism disorder and failure. As shown in Sepsis-3, the sepsis diagnosis standard is stipulated as infection plus sequential organ failure assessment (SOFA) score ≥ 2, and the tackling of sepsis mainly lies on the "life-saving" treatment regarding organ functions. After about 20 years' efforts, SSC has not achieved satisfactory results. As a frontier discipline of acute and critical diseases, emergency medical department is able to receive and cure the patients with acute infection at the earliest. The incidence and mortality of sepsis could be greatly reduced if the possibility of sepsis can be predicted from population characteristics, pathogens and locations of infection, and severity of illness at the early stage of infection. Besides, timely discovering "inflammation storm" by cytokine detection and accessing the patients with an effective clinical scoring system should also be helpful to take more active and effective treatment to the high-risk patients, and block the progression from infection to sepsis. On such a basis, Chinese emergency medicine specialists have put forward the concept of "prevention and blocking" of sepsis, and carried out "Preventing Sepsis Campaign in China" (PSCC) throughout China. They have also proposed the principles of performing targeted diagnosis, examination and treatment at the "early stage of sepsis" and "peri-sepsis period", so as to realize the early prevention, early discovery, and early intervention, and reduce the morbidity and mortality of sepsis, thus providing a new concept for diagnosis and treatment of patients with acute severe infection. This consensus is jointly advocated, discussed and written by four academic societies (associations) and five related publishing houses, and formed after several turns of discussions by more than 40 specialists and experts from emergency medicine, critical medicine, infectious medicine, pharmacy, laboratory medicine, and other professional disciplines. This consensus involves determination and recognition of patients with acute infection, anti-infective therapy, screening of high-risk sepsis patients, discovery of and response to "inflammation storm", protection of vascular endothelial cells and regulation of coagulation function, liquid support scheme and organ function protection strategy, etc. This consensus summarizes the commonly used Western medical diagnosis and treatment measures, and also integrates the advantages of traditional Chinese medicine in prevention and treatment of sepsis, so as to provide a comprehensive reference for the clinicians to perform diagnosis and treatment, and provide a reliable basis for reducing progression of infected patients to sepsis.

Hypoproteinemia is an independent risk factor for the prognosis of severe COVID-19 patients.

Severe patients of the coronavirus disease 2019 (COVID-19) may progress rapidly to critical stage. This study aimed to identify factors useful for predicting the progress. 33 severe COVID-19 patients at the intensive care unit were included in this study. During treatment, 13 patients deteriorated and required further treatment for supporting organ function. The remaining 20 patients alleviated and were transferred to the general wards. The multivariate COX regression analyses showed that hypoproteinemia was an independent risk factor associated with deterioration of severe patients (HR, 0.763; 95% CI, 0.596 to 0.978; p = 0.033). The restricted cubic spline indicated that when HR = 1, the corresponding value of albumin is 29.6 g/L. We used the cutoff of 29.6 g/L to divide these patients. Kaplan–Meier curves showed that the survival rate of the high-albumin group was higher than that of the low-albumin group. Therefore, hypoalbuminemia may be an independent risk factor to evaluate poor prognosis of severely patients with COVID-19, especially when albumin levels were below 29.6 g/L.

The mitochondrial epilepsies.

Mitochondria are vital organelles within cells that undertake many important metabolic roles, the most significant of which is to generate energy to support organ function. Dysfunction of the mitochondrion can lead to a wide range of clinical features, predominantly affecting organs with a high metabolic demand such as the brain. One of the main neurological manifestations of mitochondrial disease is metabolic epilepsies. These epileptic seizures are more frequently of posterior quadrant and occipital lobe onset, more likely to present with non-convulsive status epilepticus which may last months and be more resistant to treatment from the onset. The onset of can be of any age. Childhood onset epilepsy is a major phenotypic feature in mitochondrial disorders such as Alpers-Huttenlocher syndrome, pyruvate dehydrogenase complex deficiencies, and Leigh syndrome. Meanwhile, adults with classical mitochondrial disease syndrome such as MELAS, MERFF or POLG-related disorders could present with either focal or generalised seizures. There are no specific curative treatments for mitochondrial epilepsy. Generally, the epileptic seizures should be managed by specialist neurologist with appropriate use of anticonvulsants. As a general rule, especially in disorders associated with mutation in POLG, sodium valproate is best avoided because hepato-toxicity can be fulminant and fatal.

Extracellular Determinants of Arterial Morphogenesis, Growth, and Homeostasis.

The extracellular matrix (ECM) is a highly heterogeneous mixture of macromolecules capable of self-assembling into tissue-specific suprastructures that constitute the architectural elements supporting organ function. Contrary to the traditional view of being a static scaffold that supports tissue integrity along with cell adhesion and migration, the ECM is an inherently dynamic system that specifies cellular function and defines the limits and patterns of tissue organization. Throughout evolution, the composition and organization of the ECM have changed to accommodate basic and new tissue functions, both in terms of providing structural support and integrating multivalent signals to cells. In this review, we will highlight some of these bidirectional cell-matrix interactions that guide the development of a mechanically compliant vascular system. Specifically, we will focus on studies that have investigated how ECM composition and physical properties influence cell fate decisions associated with vascular tissue development and homeostasis and implicitly, vascular disease.

Sepsis and septic shock-is a microcirculation a main player?

Shock, defined at a cellular level, is a condition in which oxygen delivery to the cells is not sufficient to sustain cellular activity and support organ function. The central role of microcirculation in providing oxygen to the cells makes it of prime importance in determining organ function. In sepsis and septic shock, macrocirculatory alterations and microcirculatory dysfunction participate concurrently in the pathophysiology of organ failure. Haemodynamic coherence in shock is a condition in which normalization of systemic haemodynamic variables results in simultaneous amelioration in the perfusion of the microcirculation and restoration of tissue oxygenation as a final result. Septic shock is most frequently characterized by a lack of microcirculatory recruitment despite of macrocirculatory successful resuscitation. The lack of haemodynamic coherence between macrocirculation and microcirculation in septic patients results in treatment failure and increased mortality. The monitoring of microcirculation and the effects of its changes are an important area of future clinical research and treatment modification.

Modified Da Chengqi granules improvement in immune function in early severe acute pancreatitis patients.

We investigated the role of modified Da Chengqi granules in improving immune function in early severe acute pancreatitis patients. Early severe acute pancreatitis patients who agreed to receive combined treatment of traditional Chinese and Western medicine were randomly assigned to the experimental or control group. All subjects received conventional therapy to support organ function. The experimental group also received modified Da Chengqi granules. Cytokine (interleukin-6, interleukin-10, and tumor necrosis factor-α) levels, immunological markers (HLA-DR, Treg, and Th1/Th2), urinary lactulose/mannitol ratio, and endotoxin levels were measured at 1, 3, 7, and 14 days after hospital admission. The total mortality rate was 11.69% (9/77), which was significantly lower in the experimental group [4.88% (2/41)] than in the control group [19.44% (7/36); χ(2) = 3.940, P < 0.05]. Serum interleukin-6, interleukin-10, tumor necrosis factor-α and endotoxin levels and the lactulose/mannitol ratio were significantly lower on day 7 and day 14 than on day 1 in experimental and control groups (P < 0.01). Immunological indices were significantly lower in the experimental group than in the control group on day 14 (all P < 0.01 or 0.05). HLA-DR-positive cell ratio gradually increased over 14 days in experimental and control groups (P < 0.01 vs day 1), but was higher in the experimental group than in the control group by day 14 (P < 0.05). Notably, Treg cell prevalence and Th1/Th2 cell ratio deteriorated within 7 days in both groups (P < 0.01 vs day 1), but then returned to day 1 levels (P < 0.01 or 0.05 vs day 1). Significant differences in Treg levels and Th1/Th2 cell ratio between experimental and control groups were observed on day 14 (P < 0.01). These results show that modified Da Chengqi granules can improve immune function in early severe acute pancreatitis patients.

Fine-tuning Metabolic Switches

Fine-tuning Metabolic Switches

Mechanical ventilation in ICUs in Poland: A multi-center point-prevalence study

BackgroundMechanical ventilation is the primary method of supporting organ function in patients treated in intensive care units (ICUs). Lung damage from mechanical ventilation can be avoided by using the correct ventilation modes. This study was designed to assess the epidemiology and treatment strategies of patients receiving mechanical ventilation in ICUs in Poland.Material/MethodsThis study was done using a point-prevalence methodology. Questionnaires requesting demographic data, indications for ventilation, variables involved in ventilation, airway access, methods of sedation, and mode of weaning were sent to 148 ICUs.ResultsEighty-three ICUs took part in the study. The rate of ventilated patients was 73.6%. The indications for mechanical ventilation were: acute respiratory failure (40%), coma (40%), chronic obstructive pulmonary disease (COPD) exacerbation (14%), and neuromuscular diseases (5%). Patients were ventilated by orotracheal tube (58%), tracheostomy tube (41%), and mask/helmet (1%). The mean tidal volume was 8 ml/kg and positive end-expiratory pressure was commonly used. The mean oxygen concentration was 40%. Synchronized intermittent mandatory ventilation with pressure support was the most frequently used ventilatory mode. Benzodiazepine and opioids were used for sedation in 91% of centers. A systematic testing of the depth of sedation was performed at 48% surveyed ICUs. Ventilation monitoring with biomechanical methods was used at 53% of centers.ConclusionsMechanical ventilation is commonly used in ICUs in Poland. Almost half of the ventilated patients had extrapulmonary indications. Patients were ventilated with low concentrations of oxygen, and positive end-expiratory pressure (PEEP) was commonly employed.

Clinical Management of the Organ Donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

Sedation in the critically ill patient

The goal of critical care medicine is to support organ function and maintain homeostasis until healing can occur. Sedation and analgesia may blunt the physiologic and psychologic sequelae of intensive care unit stress, and support homeostasis. Although a wide variety of agents have been used empirically, the recognition of analgesia, amnesia, and hypnosis as discrete elements comprising the sedated state has facilitated an individualized approach to therapy. Because intensive care unit patients are a highly heterogeneous population with varying levels of end-organ compromise, the development of specific, easily titratable, parenteral agents has made intensive care unit sedation safer. A trend toward refining dosage regimens in order to minimize the total dose of drug administered and to reduce the occurrence of residual sedation is driven by utilization and cost concerns. The capability for simple bedside electrophysiologic monitoring of the level of sedation is expected to improve the ability to provide optimal therapy.

Clinical trials of new and novel therapeutic agents.

Throughout this issue of World Journal of Surgery are recommendations and descriptions of therapy to prevent the development of multiple organ failure (MOF). The subjects include advances in monitoring; circulatory, pulmonary, and gut support; blood treatment; immune modulation; and control of the inflammatory process. Additional methods of organ support include recommendations for resuscitation and initial care and for early definitive operations. New therapeutic agents such as growth factors, glucan, ketaconazole, and antithrombin III are described. Finally, methods to support organ function before it fails (circulation, lungs, and kidneys) are described.