Unstable Patients Research Articles

Systemic immune inflammatory response index (SIIRI) in acute myocardial infarction.

Different treatment approaches exist for non-ST elevation acute coronary syndrome (ACS) patients. This study assessed the systemic immune inflammatory response index (SIIRI) for its prognostic value and incremental clinical utility in determining optimal timing for percutaneous coronary intervention (PCI) in non-ST elevation myocardial infarction (NSTEMI) patients, particularly when troponin levels are initially negative. This study included 1270 ACS patients: 437 STEMI, 422 NSTEMI, and 411 unstable angina. Patients were stratified by SIIRI levels measured at admission, and coronary artery disease severity was evaluated using the SYNTAX score. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, stroke, and revascularization. Secondary endpoints encompassed individual MACE components and heart failure hospitalisations. The mean age was 54.93 years (83% male). SIIRI levels were significantly higher in STEMI patients (6.83 ± 6.43 × 105) compared to NSTEMI (4.5 ± 5.39 × 105) and unstable angina (3.48 ± 2.83 × 105) (P < 0.001). Area under the curve for SIIRI distinguished NSTEMI and unstable angina from STEMI (0.81 and 0.80), with optimal cut-off points of 4.80 × 105 and 4.25 × 105. In NSTEMI, 24.6% presented within 2 h of symptom onset, were troponin-negative, yet had elevated SIIRI. Post-PCI, SIIRI > 4.93 × 105 correlated with increased MACE at 1 year (17.2% vs 5%). NSTEMI and unstable angina patients with SIIRI values >4.80 × 105 and 4.25 × 105 respectively, may require urgent intervention (<2 h). SIIRI can be of significant utility in patients of NSTEMI who present earlier with negative troponins. SIIRI can also aid in identifying high-risk individuals post-PCI, providing a valuable tool for early and accurate assessment.

Clinical utility of echocardiography in internal medicine: a narrative review

Echocardiography has emerged as an invaluable tool in internal medicine, providing real-time, non-invasive evaluation of cardiac structure and function. Its clinical utility spans a wide range of applications, including the diagnosis and management of heart failure, valvular heart diseases, and cardiomyopathies, as well as systemic conditions like sepsis and chronic kidney disease. The ability to perform bedside echocardiography has made it particularly useful in critical care settings, allowing for rapid assessment of cardiac function in hemodynamically unstable patients. Echocardiography also plays a key role in guiding therapeutic interventions, from fluid management to valvular repair and replacement procedures. Despite its many advantages, echocardiography is not without limitations. Image quality may be compromised in patients with obesity, lung disease, or prior thoracic surgery, necessitating alternative imaging modalities like cardiac magnetic resonance imaging or computed tomography. Operator expertise is another critical factor influencing diagnostic accuracy, underscoring the importance of proper training. Recent advancements, including artificial intelligence integration and portable devices, are expected to further expand the role of echocardiography, making it more accessible in diverse clinical settings. This narrative review highlights the broad clinical utility of echocardiography in internal medicine, its challenges, and the future directions that promise to enhance its role in patient care.

How many is enough? Measuring the number of FAST exams needed by emergency medicine trainees to reach competence

BackgroundFor patients with blunt abdominal trauma, the Focused Assessment with Sonography in Trauma (FAST) exam is the initial imaging modality employed to diagnose and risk stratify. A positive FAST exam in this patient population denotes intraperitoneal hemorrhage. In a hemodynamically unstable patient, it necessitates rapid surgical intervention. Ultrasound is highly dependent on the operator’s ability to obtain quality images for interpretation. Failure to obtain adequate images prevents accurate interpretation and reduce its diagnostic accuracy. Previous studies evaluating whether the FAST exam can be improved solely by experience had conflicting results. None of those studies used an objective method to evaluate the FAST exam’s quality. Our study aimed to objectively determine the number of FAST exams required by an emergency medicine (EM) resident to reach sufficient quality for independent scanning.Methods59 first-year EM residents from a single site were included in this study. All FAST exams that were saved in the Qpath archival system by the 59 EM residents, whether the exam was performed for educational or clinical purposes, were reviewed, and scored using a Task-Specific Checklist (TSC) score. This score is an objective way to assess the proficiency and quality of the FAST scan. The TSC was based on whether the imaging of 24 specific anatomic landmarks, split into four anatomic regions, was completed successfully or not. The AEMUS (Advanced EM Ultrasonography) faculty provided feedback to trainees wither electronically via Qpath or at the bedside. According to the quality of ultrasound imaging and competence (QUICK Score), if the average TSC score for the first 10 exams was 18 or higher, the resident was considered an expert. However, if the resident failed to achieve that score, we skipped the first exam performed by the resident and the average score for the second through eleventh exams was then calculated. If the resident did not achieve the desired result, the first and second exams were skipped and the average score for the remaining 10 exams was determined. This sequence was repeated until the resident achieved an average score of 18 or higher on their TSC score.ResultsIn total, 663 FAST scans performed by EM residents were scored. The average number of FAST exams needed for independent scanning is 11.23 (95% CI, 10.6-11.85). 66.1% of enrolled residents achieved an average score of 18 or higher in their first 10 FAST exams, and 33.8% of residents required more than 10 scans. The average scores for the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvic, and subxiphoid views were 5 (95% CI, 4.88–5.1), 4.7 (95% CI, 4.59–4.8), 5.1 (95% CI, 4.96–5.24), and 3.7 (95% CI 3.6–3.8) respectively.ConclusionThis study demonstrated that when constructive feedback on each FAST exam was given, the average first-year emergency medicine resident achieves competency in performing FAST exams independently after completing 10–12 (average of 11.23) FAST exams. Further research is required to validate the findings.

Moving Beyond Systemic Inflammatory Response Syndrome and Bacteremia: Are Modern Critical Care Calculators Useful in Predicting Debridement, Antibiotics, and Implant Retention Treatment Outcomes in Periprosthetic Joint Infection?

BackgroundIn critically ill periprosthetic joint infection (PJI) patients, surgeons need to balance the need for aggressive, definitive treatment against the health state of a potentially unstable patient. A clear understanding of the association between treatment outcomes and assessment scores for sepsis would benefit clinical decision-making in these urgent cases. The current study evaluates the effect of critical illness on debridement, antibiotics, and implant retention (DAIR) outcomes, as defined by systemic inflammatory response syndrome (SIRS) and, for the first time, by contemporary markers quick Sequential Organ Failure Assessment (qSOFA) and Modified Early Warning Score (MEWS). MethodsWe retrospectively identified 253 patients who underwent DAIR for PJI at a single institution between 2017 and 2021. The SIRS, qSOFA, and MEWS scores were calculated based on variables on admission. A DAIR treatment failure, defined as reoperation or mortality, was measured at 90 days and two years. Univariate analysis was used to determine the association between elevated critical care scores and DAIR failure. ResultsThe DAIR treatment success was 59% at two years, with hip procedures and Charlson comorbidity index (CCI) ≥ 1 independently associated with higher odds of DAIR failure. There were 43 patients (16%) who presented with SIRS, however, only four (2%) had positive qSOFA scores. Neither SIRS nor qSOFA were predictive of DAIR failure. For knees only, elevated MEWS scores were predictive of 90-day DAIR failure (P = 0.019). ConclusionOver one in six patients undergoing DAIR for PJI presented with SIRS, while only one in 50 had a positive qSOFA. The SIRS and qSOFA scores were not predictive of DAIR failure. Elevated MEWS scores were associated with DAIR failure at 90 days postoperatively in knee PJIs only, and should be confirmed in a larger cohort. Our results suggest that SIRS is not predictive of DAIR outcomes, possibly because it overestimates the proportion of critically ill patients.

FREQUENCY OF GENERALIZED ANXIETY DISORDER IN HOSPITALIZED COVID-19 PATIENT

The COVID-19 pandemic has had a profound impact on mental health, with anxiety disorders being particularly prevalent among hospitalized patients. Identifying and addressing mental health issues like generalized anxiety disorder (GAD) is crucial for improving patient outcomes and providing holistic care. Objective: To determine the frequency of generalized anxiety disorder (GAD) among hospitalized COVID-19 patients at MTI-Hayatabad Medical Complex, Peshawar, and to explore its association with gender and socioeconomic status. Methods: A cross-sectional study was conducted in the Department of Psychiatry at MTI-Hayatabad Medical Complex, Peshawar, over six months, from October 16, 2021, to April 16, 2022. A total of 179 hospitalized COVID-19 patients, aged 25 years and above, were included. Patients presenting with symptoms of anxiety were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale. Unstable patients, who had a history of other mental disorders or were receiving treatment for depression and anxiety were excluded. Data were analyzed using statistical methods to explore associations between GAD and demographic factors such as gender and socioeconomic status. Results: The study included 179 COVID-19 patients, with a mean age of 43.50 ± 10.18 years. Generalized anxiety disorder was identified in 62 patients, representing 34.6% of the total population. GAD prevalence was significantly higher among female patients (p &lt; 0.001) and those from lower socioeconomic backgrounds (p = 0.002). Conclusion: This study highlights a high prevalence of generalized anxiety disorder among hospitalized COVID-19 patients, particularly among females and those of lower socioeconomic status. The findings underscore the need for routine mental health screening and targeted interventions to address anxiety in this vulnerable population.

Patient factors associated with complementary and alternative medicine use among cancer patients at a county referral hospital, Kenya

BACKGROUND Despite numerous global reports on the use of complementary and alternative medicine (CAM), no studies have been published regarding its use at Machakos Level 5 Hospital. Therefore, this study aims to identify patient-related factors associated with CAM use among cancer patients at this Level 5 hospital in Kenya. METHODOLOGY A mixed method, cross-sectional design was implemented at Machakos level five hospital in Kenya. A Census was carried out, using a face-to-face researcher-administered questionnaire among 80 cancer patients receiving treatment at the clinic. Critically ill and mentally unstable patients were excluded. A Chi-square test assessed variable associations, considering p &lt; 0.05 as statistically significant. Logistic regression analyzed variable relationships. RESULTS Gender was significantly associated with CAM use (p=0.014). Regression analysis revealed that Male patients were 79% less likely to use CAM (OR=0.21, 95% CI 0.042-1.003, p=0.050). Patients who had received radiotherapy were likely to use CAM (p=0.032), however, on regression analysis there was no significant association. Believes that CAM improves health (χ2=9.231, p-0.010), supports conventional treatment (χ2=15.620, p-0.001), cures cancer (χ2=12.661, p-0.002), manages treatment side effects (χ2=11.045, p-0.004), relieves cancer symptoms (χ2=9.008, p-0.011), promotes self-healing (χ2=16.969, p-0.001), and gives hope (χ2=17.512, p-0.001) were significantly associated with CAM use. CONCLUSION AND RECOMMENDATION. There was a significant association between patient characteristics and CAM use among cancer patients. Improving patient-healthcare worker communication could encourage reporting of CAM usage. Further research is needed to explore the efficacy, safety, and tolerability of CAM in cancer patients.

Case Report: Acute Abdomen Due to Ruptured Ovarian Ectopic Pregnancy at 8 Weeks

Background Ovarian pregnancy is a rare type of ectopic pregnancy, accounting for 0.5% to 1% of all ectopic pregnancies, with an incidence ranging from 1 in 2,100 to 1 in 60,000 pregnancies. Due to its rarity and the lack of common risk factors, diagnosing ovarian pregnancy is often challenging and typically occurs during surgical exploration. Case Presentation We present the case of a 40-year-old woman who experienced severe pelvic pain, light vaginal bleeding, and 8 weeks of amenorrhea. Upon arrival at the hospital, she was hemodynamically unstable, with low blood pressure and a rapid heart rate. An ultrasound revealed an empty uterus, an irregular mass on her right ovary, and free fluid in the pelvis. Her beta-hCG level was elevated, and her hemoglobin level was low. Given the suspicion of an ectopic pregnancy, she underwent emergency surgery. During the operation, the surgical team discovered a large amount of clotted blood and a ruptured mass on her left ovary measuring 10 x 9.5 cm. Due to heavy bleeding, they performed a left oophorectomy and salpingectomy. Histopathological analysis later confirmed the diagnosis of ovarian pregnancy. Conclusion This case underscores the challenges in diagnosing ovarian pregnancy and highlights the necessity for prompt surgical intervention, particularly in unstable patients. Early detection and appropriate management are critical to prevent life-threatening complications.

White Smoke in the Intermediate risk PE debate, could POPE be the solution?

Abstract Introduction In spite of a multitude of innovative therapeutic strategies emerging in the past decade, acute pulmonary embolism (PE) remains a potentially fatal disease. However, mortality varies significantly according to risk stratification, substantiating current recommendations to use reperfusion therapy only in hemodynamically unstable patients. There is an ongoing debate around whether hemodynamically stable patients showing signs of right ventricle dysfunction and myocardial injury (intermediate-high risk acute PE) may also benefit from reperfusion therapy. While the majority of patients in this category typically improve with anticoagulation alone, up to 10% may experience clinical deterioration. Aim We aimed to characterize the clinical in-hospital progression of patients with intermediate-risk PE and to evaluate the discriminative efficacy of PE scores in anticipating unfavorable clinical outcomes. Methods We conducted a retrospective observational study in patients admitted with the diagnosis of PE classified as intermediate risk in a tertiary center. Clinical, laboratory and ECG data were obtained. The BOVA score, the News score and the Pope score were evaluated. A composite endpoint of in-hospital mortality and use of reperfusion therapy due to hemodynamic deterioration was defined. Predictive abilities of these three scores were compared using area under the receiver operating characteristics (AUC-ROC) curve. Results From January 2019 to December 2020, a total of 166 patients were admitted with acute PE, classified as intermediate-risk, in our center. The mean age 71.9 ± 16.2 years and 57.2% were female. 71.1% of the pts showed bilateral PE in chest CT. The composite endpoint of in-hospital mortality and reperfusion therapy due to hemodynamic deterioration occurred in 9.8% of the pts. The median BOVA score was 3 (2-4), the median POPE score was 1 (0-2) and the median News score was 4 (2-6). The ROC curve analysis showed a significant higher discriminative power of POPE score compared to the other scores (AUC 0.856 95%CI 0.79–.92, p&amp;lt;0.001) (Fig1). Compared to patients with a POPE score 1, the composite endpoint was 4,6 times higher in patients with higher scores (OR 4.6 95%CI 1.63- 6914, p=0.029) (Fig2). Conclusion Despite classification as intermediate risk, these patients displayed a non-negligible in-hospital mortality rate. Close clinical monitoring is warranted in this group of pts and there is pressing need for an early identification of those who might benefit from more than just anticoagulation. In our population POPE score showed to be a simple and accurate tool in predicting those with an unfavorable evolution that could have benefitted from more advanced intervention.

Cangrelor versus no cangrelor during percutaneous coronary intervention in hemodynamically unstable patients: a cohort study on benefits and risks

Abstract Background Cangrelor is an intravenous P2Y12 inhibitor which, according to the European guidelines, may be considered for administration in acute coronary syndrome during percutaneous coronary intervention (PCI). Little is known regarding benefits and risks of such administration in hemodynamically unstable patients. Purpose To investigate the effects of cangrelor versus no cangrelor during PCI regarding major adverse cardiac events (MACE), in-hospital bleeding, and all-cause mortality in patients with cardiogenic shock and/or cardiac arrest. Methods The study population was extracted from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and included patients with cardiogenic shock or cardiac arrest undergoing PCI during the years 2016-2022. Propensity score matching (PSM) was used to create comparable groups. After matching, all variables used for calculating propensity score were balanced (standardized mean difference&amp;lt;0.1). Outcomes were MACE within 30 days, in-hospital bleeding, and all-cause mortality within 30 days. Risk ratios (RR) with 95% confidence intervals (CI) were calculated. When RR deviated from the null, the risk difference (RD) was determined. Results In all, 2,100 (66%) out of 3,206 patients with cardiogenic shock and/or cardiac arrest were included in the PSM analyses (median age: 69 years; 76% male; 78% ST-elevation myocardial infarction (STEMI)). Comparing cangrelor versus no cangrelor in this matched set of patients, the RR was 0.93 (95% CI: 0.84; 1.04) for MACE; 1.51 (1.02; 2.25) for in-hospital bleeding, with an RD of 1.9 percentage points (0.10; 3.7); and 0.93 (0.82; 1.04) for all-cause mortality (Table). In the PSM analysis regarding patients with cardiogenic shock, 1,098 (60%) out of 1,815 patients were included (median age: 71 years; 68% male; 82% STEMI). For these patients, RR was 0.85 (95% CI: 0.74; 0.97) for MACE, with an RD of -7.5 percentage points (-1.6; -13); 1.31 (0.82; 2.09) for in-hospital bleeding; and 0.83 (0.72; 0.95) for all-cause mortality, with an RD of -8.0 percentage points (-2.2; -14). In the PSM analysis regarding patients with cardiac arrest, 1,388 (76%) out of 1,827 patients were included (median age: 67 years; 81% male; 75% STEMI). RR was 0.98 (95% CI: 0.86; 1.12) for MACE; 1.53 (0.95; 2.49) for in-hospital bleeding; and 0.98 (0.86; 1.13) for all-cause mortality. Conclusion For patients with cardiogenic shock, but not for patients with cardiac arrest, administration of cangrelor versus no cangrelor during PCI was associated with a reduction in both MACE and all-cause mortality, with numbers needed to treat of 14 and 13, respectively. Overall, for patients with cardiogenic shock or cardiac arrest, administration of cangrelor versus no cangrelor during PCI was associated with an increased risk of in-hospital bleeding with a number needed to harm of 53.

Impact of Physical Activity, Sedentary Behavior, and Basal Metabolic Rate on PTSD, Depression, and Emotional Instability

Objective: This study aimed to investigate the potential associations between physical activity, sedentary behavior, and the basal metabolic rate (BMR) with post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and emotional instability (EI) using bidirectional Mendelian randomization (MR). Additionally, it sought to identify key molecular mechanisms underlying emotional instability through a comprehensive bioinformatic analysis. Methods: MR analyses utilizing genome-wide association study (GWAS) data were conducted to estimate the effects of physical activity, sedentary behavior, and the BMR on PTSD, MDD, and EI. Sensitivity analyses were performed to assess the robustness of the findings. Concurrently, a bioinformatic analysis was executed on gene expression datasets (GSE53987 and GSE21138) derived from emotionally unstable patients. This analysis encompassed the differential gene expression analysis to identify differentially expressed genes (DEGs), followed by an functional enrichment analysis to uncover key molecular pathways associated with EI. Results: The MR analysis revealed that increased physical activity may have a protective effect against PTSD, albeit with inconsistent effects on MDD and EI. Sedentary behavior and the BMR demonstrated minimal associations with PTSD, MDD, or EI. The bioinformatic analysis identified 114 DEGs associated with EI, with YWHAB, SRRM2, MST1, HDAC10, and HSPA1A highlighted as significant genes. The functional enrichment analysis of these DEGs unveiled key pathways potentially involved in the molecular pathology of emotional instability. Conclusions: Physical activity appears to protect against PTSD, whereas its effects on MDD and EI are less definitive. The bioinformatic findings offer a deeper molecular understanding of EI, pinpointing specific genes and pathways that may serve as potential therapeutic targets. Further research is warranted to elucidate these intricate interactions and the identified molecular mechanisms.

Defining Postinduction Hemodynamic Instability With an Automated Classification Model.

Postinduction hypotension (PIH) may be associated with increased morbidity and mortality. In earlier studies, the definition of PIH is solely based on different absolute or relative thresholds. However, the time-course (eg, how fast blood pressure drops during induction) is rarely incorporated, whereas it might represent the hemodynamic instability of a patient. We propose a comprehensive model to distinguish hemodynamically unstable from stable patients by combining blood pressure thresholds with the magnitude and speed of decline. This prospective study included 375 adult elective noncardiac surgery patients. Noninvasive blood pressure was continuously measured between 5 minutes before up to 15 minutes after the first induction agent had been administered. An expert panel rated whether the patient experienced clinically relevant hemodynamic instability or not. Interrater correlation coefficient and intraclass correlation were computed to check for consistency between experts. Next, an automated classification model for clinically relevant hemodynamic instability was developed using mean, maximum, minimum systolic, mean, diastolic arterial blood pressure (SAP, MAP, and DAP, respectively) and their corresponding time course of decline. The model was trained and tested based on the hemodynamic instability labels provided by the experts. In total 78 patients were classified as having experienced hemodynamic instability and 279 as not. The hemodynamically unstable patients were significantly older (7 years, 95% confidence interval (CI), 4-11, P < .001), with a higher prevalence of chronic obstructive pulmonary disease (COPD) (3% higher, 95% CI, 1-8, P = .036). Before induction, hemodynamically unstable patients had a higher SAP (median (first-third quartile): 161 (145-175) mm Hg vs 150 (134-166) mm Hg, P < .001) compared to hemodynamic stable patients. Interrater agreement between experts was 0.92 (95% CI, 0.89-0.94). The random forest classifier model showed excellent performance with an area under the receiver operating curve (AUROC) of 0.96, a sensitivity of 0.84, and specificity of 0.94. Based on the high sensitivity and specificity, the developed model is able to differentiate between clinically relevant hemodynamic instability and hemodynamic stable patients. This classification model will pave the way for future research concerning hemodynamic instability and its prevention.

Primary delayed sternal closure in adult cardiac surgery: a systematic review of protocols.

Primary delayed sternal closure (DSC) is a useful tool in the management of certain critically unstable patients after cardiac surgery, but there is a paucity of consensus management guidelines. This review aimed to identify critical key areas in DSC management. Systematic literature search was conducted in January 2023 and performed using Embase and PubMed. For original research articles were included that described outcomes and/or protocols for primary adult DSC patients, excluding articles on pediatric patients and secondary DSC. Eleven retrospective review original articles examined protocols for adult patients undergoing DSC. Hemodynamic instability and uncontrolled bleeding/coagulopathy were the two most common indications. Time to chest closure ranged 22 hours - 8.7 days. A range of dressings were employed, including Esmark and VAC dressings, with about half of authors not disclosing details. VAC was endorsed by several authors specifically for management of uncontrolled hemorrhage/coagulopathy. There was no consensus regarding irrigation solution for mediastinal prepping, with or without antibiotic solution. There was a lack of consensus on antibiotic selection and duration, varying from 2 and 3 multidrug regimens of broad-spectrum antibiotics, with/without antifungals. Mediastinal re-exploration varied from undefined intervals to regimented 24-48-hour interval re-explorations, with final closures in the OR or ICU. The optimum care for the patient with an open chest is evolving, and although there is a lack of a consensus DSC protocol, this review identifies mediastinal management, antimicrobial prophylaxis, and mediastinal re-exploration schedules/protocols as key areas for study to determine optimal care for DSC patients.

Comparison of continuous vital signs data analysis versus venous lactate for the prediction of lifesaving interventions in patients with traumatic shock.

The prehospital environment is fraught with operational constraints, making it difficult to assess the need for resources such as lifesaving interventions (LSI) for adults with traumatic injuries. While invasive methods such as lactate have been found to be highly predictive for estimating injury severity and resource requirements, noninvasive methods, to include continuous vital signs (VS), have the potential to provide prognostic information that can be quickly acquired, interpreted, and incorporated into decision making. In this work, we hypothesized that an analysis of continuous VS would have predictive capacity comparable to lactate and other laboratory tests for the prediction of injury severity, need for LSIs and intensive care unit (ICU) admission. In this pre-planned secondary analysis of 300 prospectively enrolled patients, venous blood samples were collected in the prehospital environment aboard a helicopter and analyzed with a portable lab device. Patients were transported to the primary adult resource center for trauma in the state of Maryland. Continuous VS were simultaneously collected. Descriptive statistics were used to describe the cohort and predictive models were constructed using a regularized gradient boosting framework with 10-fold cross-validation with additional analyses using Shapley additive explanations (SHAP). Complete VS and laboratory data from 166 patients were available for analysis. The continuous VS models had better performance for prediction of receiving LSIs and ICU length of stay compared to single (initial) VS measurements. The continuous VS models had comparable performance to models using only laboratory tests in predicting discharge within 24 hours (continuous VS model: AUROC 0.71; 95% CI, 0.68-0.75 vs. lactate model: AUROC 0.65; 95% CI, 0.68; 95% CI, 0.66-0.71). The model using all laboratory data yielded the highest sensitivity and sensitivity (AUROC 0.77; 95% CI, 0.74-0.81). The results from this study suggest that continuous VS obtained from autonomous monitors in an aeromedical environment may be helpful for predicting LSIs and the critical care requirements for traumatically injured adults. The collection and use of noninvasively obtained physiological data during the early stages of prehospital care may be useful for in developing user-friendly early warning systems for identifying potentially unstable trauma patients.

Artificial intelligence applied to development of predictive stability model for intracranial aneurysms

BackgroundWe aimed to develop multiple machine learning models to predict the risk of early intracranial aneurysms (IAs) rupture, evaluate and compare the performance of predictive models.MethodsInformation related to patients diagnosed with IA by CT angiography and clinicians in Central hospital of Dalian University of Technology from January 2010 to June 2022 was collected, including clinical characteristics, blood indicators and IA morphological parameters. IA with rupture or maximum growth ≥ 0.5 mm within 1 month of first diagnosis was considered unstable. The relevant factors affecting IA stability were screened and predictive models were developed based on the above three levels, including random forest (RF), support vector machine (SVM), and artificial neural network (ANN). Sensitivity, specificity, accuracy and area under curve (AUC) value were used to evaluate the predictive models.ResultsA total of 989 IA patients were included in the study, including 561 stable patients and 428 unstable patients. For RF models, the training set showed that sensitivity, specificity, accuracy and the AUC values were 72.8–83.7%, 76.9–86.9%, 75.1–84.1% and 0.748 (0.719–0.778)–0.839 (0.814–0.864), respectively; after test set validation, the results were 71.9–78.8%, 75.0–84.0%, 73.6–81.1% and 0.734 (0.688–0.781)–0.809 (0.768–0.850), respectively. For SVM models, the training set were 66.0–80.2%, 76.5–85.5%, 71.7–82.3%, 0.712 (0.682–0.743)–0.913 (0.884–0.924), respectively; the test set were 44.2–78.3%, 63.4–84.4%, 57.9–80.9%, 0.699 (0.651–0.747)–0.806 (0.765–0.848), respectively. For ANN models, the training set were 66.8–83.0%, 75.3–82.3%, 71.6–82.1%, 0.783 (0.757–0.808)–0.897 (0.879–0.914); the test set were 63.1–76.3%, 65.5–84.0%, 64.4–80.6%, 0.680 (0.593–0.694)–0.860 (0.821–0.899). The results of variable importance showed that age, white blood cell count (WBC) and uric acid (UA) played an important role in predicting the stability of IA.ConclusionsThe predictive stability models of IA based on three artificial intelligence methods shows good clinical application. Age, WBC and UA played an important role in predicting the IA stability, and were potentially important predictors.

Intensive care unit continuous kidney replacement therapy: time to change dosage recommendations?

Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney support used for hemodynamically unstable adult ICU patients with severe AKI (KDIGO stage 3). The success of CKRT depends on the achieved doses. Practice patterns worldwide are highly variable. A contemporary understanding of treatment adequacy is essential. The KDIGO AKI clinical guidelines recommend delivering effluent volumes of 20-25ml/kg/hour for CKRT in the ICU setting, with the caveat that higher prescribed doses (25-30ml(kg/h) may be necessary to achieve adequate delivered CKRT doses. The reference landmark trials provide definitive evidence that increases of delivered CKRT doses beyond the recommended dose are not beneficial for unselected ICU patients with severe AKI. However, the minimum delivered CKRT intensity at which underdosing becomes harmful remains unknown. The answer to this question has clinical relevance (dosing of critically ill patients with obesity or Covid-19 disease, minimizing adverse effects of CKRT) and a relevant impact on the costs of CKRT. The delivered dose of CKRT for Japanese ICU patients with severe AKI has been generally smaller (median 15ml/h/kg) than the recommended delivered KDIGO dose. The most recently published retrospective cohort study by Okamoto et al. demonstrated that low delivered CKRT doses were associated with a higher mortality among critically ill patients with severe AKI. These data challenge the nation-wide accepted hypothesis that a lower limit of delivered CKRT (< 20ml/ kg/h) may adequately control uremia/volume overload. Thus, there is an unmet clinical need for prospective randomized trials defining the minimal effective dose of CKRT. Given the dynamic nature of the precipitating critical illness and the natural course of most episodes of AKI, CKRT dose targets are likely to vary. Doses should be tailored to the needs of the individual patient within the limits of the KDIGO guideline recommendations. The Japanese experience with low-dose CKRT is not practice changing.

Peri-operative strategy in resuscitation of unstable injured surgical patients: a primer.

Trauma remains a leading cause of death, both for individuals under 40 in North America, and globally, where it contributes to ~10% of deaths annually. Thoughtful, timely, balanced resuscitation, especially in the peri-operative period for unstable injured surgical patients, is vital for optimizing outcomes. The advanced trauma life support protocol plays a pivotal role in early evaluation and management, emphasizing hemorrhage control and resuscitation strategies. This narrative review provides a structured, evidence-based framework aimed at enhancing the educational experience of surgical trainees. It outlines key principles in peri-operative trauma resuscitation, emphasizing timely intervention, goal-directed fluid therapy, and damage control surgery (DCS) to improve patient outcomes. A comprehensive Scale for Quality Assessment of Narrative Review Articles -guideline compliant literature search was conducted using PubMed and Google Scholar for English-language articles published between January 2000 and February 2024. The search included relevant medical subject headings terms. Additional studies were identified from reference lists. Extracted data were reviewed and organized using thematic analysis, focusing on historical perspectives, evidence-based practices, and the concept of DCS. Key findings from the 55 relevant studies selected underscore the importance of balanced fluid and blood product administration, the use of permissive hypotension in hemorrhagic shock, and the application of DCS principles. This review highlights educational strategies that foster a deeper understanding of trauma resuscitation practices, offering practical insights through case studies and technological innovations. This review serves as an educational resource for surgical trainees, equipping them with a robust understanding of evidence-based trauma resuscitation. By integrating historical context, modern practices, and emerging technologies, the review aims to enhance both the theoretical knowledge and practical skills necessary for managing unstable trauma patients. Emphasis is placed on interdisciplinary teamwork, continuous education, and personalized resuscitation strategies to improve clinical outcomes.

Contrast-enhanced Ultrasound as a Method of Splenic Injury Assessment

Abstract Splenic injuries are common in abdominal trauma, as the spleen is one of the most often harmed organs. The treatment of splenic injuries underwent major changes during the past decades, shifting from a surgical approach to nonoperative management. This change of the proceedings results from a constantly growing awareness of the spleen’s crucial hematological and immunological function and was possible owing to the advances in radiological techniques. In a setting of high-energy trauma in hemodynamically stable patients, computed tomography (CT) remains the gold standard. Where ultrasonography (US) is of major importance is in cases of unstable patients undergone high-energy trauma or in patients after low-energy trauma. Nevertheless, baseline US’s sensitivity is not sufficient to detect splenic traumatic injuries; hence, a new method was developed involving ultrasound contrast agents (UCAs), called contrast-enhanced ultrasound (CEUS). In a low-energy trauma setting, it facilitates the diagnosis of abdominal lesions with a sensitivity close to that of CT, without the disadvantages of the latter. In addition, CEUS can be used in the follow-up of abdominal traumatic injuries. The fact that CEUS preserves CT’s sensitivity while not carrying the risk of radiation-induced cancer makes it feasible for children and pregnant women. This review aims to discuss the technical aspects of CEUS, the limitations, and possibilities regarding this modality, present the appearance of both a healthy and injured spleen, and compare CEUS’s effectiveness to that of CT through an analysis of retrievable studies.

Impact of non-invasive oxygen reserve index versus standard SpO2 monitoring on peripheral oxygen saturation during endotracheal intubation in the intensive care unit: Protocol for the randomized controlled trial NESOI2.

In critically ill patients, endotracheal intubation (ETI) is lifesaving but carries a high risk of adverse events, notably hypoxemia. Preoxygenation is performed before introducing the tube to increase the safe apnea time. Oxygenation is monitored by pulse oximeter measurement of peripheral oxygen saturation (SpO2). However, SpO2 is unreliable at the high oxygenation levels produced by preoxygenation and, in the event of desaturation, may not decrease sufficiently early to allow preventive measures. The oxygen reserve index (ORI) is a dimensionless parameter that can also be measured continuously by a fingertip monitor and reflects oxygenation in the moderate hyperoxia range. The ORI ranges from 0 to 1 when arterial oxygen saturation (PaO2) varies between 100 to 200 mmHg, as occurs during preoxygenation. No trial has assessed the potential effects of ORI monitoring to guide preoxygenation for ETI in unstable patients. We designed a multicenter, two-arm, parallel-group, randomized, superiority, open trial in 950 critically ill adults requiring ETI. The intervention consists in monitoring ORI values and using an ORI target for preoxygenation of at least 0.6 for at least 1 minute. In the control group, preoxygenation is guided by SpO2 values recorded by a standard pulse oximeter, according to the standard of care, the goal being to obtain 100% SpO2 during preoxygenation, which lasts at least 3 minutes. The standard-of-care ETI technique is used in both arms. Baseline parameters, rapid-sequence induction medications, ETI devices, and physiological data are recorded. The primary outcome is the lowest SpO2 value from laryngoscopy to 2 minutes after successful ETI. Secondary outcomes include cognitive function on day 28. Assuming a 10% standard deviation for the lowest SpO2 value in the control group, no missing data, and crossover of 5% of patients, with the bilateral alpha risk set at 0.05, including 950 patients will provide 85% power for detecting a 2% between-group absolute difference in the lowest SpO2 value. Should ORI monitoring with a target of ≥0.6 be found to increase the lowest SpO2 value during ETI, then this trial may change current practice regarding preoxygenation for ETI. Trial registration: Registered on ClinicalTrials.gov (NCT05867875) on April 27, 2023.

RUSH to the Diagnosis: Identifying Occult Pathology in Hypotensive Patients

Case Presentation: A 63-year-old female presented to our emergency department with altered mental status and hypotension. She was transferred from the outpatient interventional radiology suite after becoming unresponsive during the removal of an inferior vena cava filter. The patient arrived somnolent with no other history available. Her physical exam was unremarkable. We used point-of-care-ultrasound to perform a rapid ultrasound for shock and hypotension (RUSH) exam. A large pericardial effusion along with signs of cardiac tamponade were identified. The cardiothoracic surgery team was notified, and the patient was taken to the operating room where pericardial blood and a large hematoma were evacuated. She recovered uneventfully and was discharged one week later. Discussion: The above case describes a very unstable patient whose diagnosis was obtained using the RUSH exam. History and physical did not point to a clear etiology. Options were very limited. She was too unstable to go for computed tomography, and other tests such as electrocardiogram, chest radiograph, and lab work would have been non-diagnostic. It was only after the cardiac view of the RUSH exam was obtained that a pericardial effusion and developing tamponade were identified, facilitating timely management. The RUSH exam, like the extended focused assessment with sonography for trauma, is used to help determine pathologies that need immediate intervention. Incorporation in the evaluation of critically ill patients reduces the time to diagnosis. Our case is a unique example of how point-of-care ultrasound can be used to urgently identify a life-threatening pathology.

Prognostic thresholds of outcome predictors in severe accidental hypothermia.

Hemodynamically unstable patients with severe hypothermia and preserved circulation should be transported to dedicated extracorporeal life support (ECLS) centers, but not all are eligible for extracorporeal therapy. In this group of patients, the outcome of rewarming may sometimes be unfavorable. It is, therefore, crucial to identify potential risk factors for death. Furthermore, it is unclear what criterion for hemodynamic stability should be adopted for patients with severe hypothermia. The aim of this study is to identify pre-rewarming predictors of death and their threshold values in hypothermic patients with core temperature ≤ 28°C and preserved circulation, who were treated without extracorporeal rewarming. We conducted a multicenter retrospective study involving patients in accidental hypothermia with core temperature 28°C or lower, and preserved spontaneous circulation on rewarming initiation. The data were collected from the International Hypothermia Registry, HELP Registry, and additional hospital data. The primary outcome was survival to hospital discharge. We conducted a multivariable logistic regression and receiver operating characteristic curve (ROC) analysis. In the multivariate analysis of laboratory tests and vital signs, systolic blood pressure (SBP) adjusted for cooling circumstances and base excess (BE) were identified as the best predictor of death (OR 0.974 95% CI 0.952-0.996), AUC ROC 0.79 (0.70-0.88). The clinically relevant cutoff for SBP was identified at 90mmHg with a sensitivity of 0.74 (0.54-0.89) and a specificity of 0.70 (0.60-0.79). The increased risk of death among hypothermic patients with preserved circulation occurs among those with an SBP below 90mmHg and in those who developed hypothermia in their homes.