Journal of Intensive Medicine

JIM│Metabolic and nutritional aspects in continuous renal replacement therapy Author: Guy Fishman and Pierre Singer Link: https://buff.ly/4eYDVLW #AcuteKidneyInjury #ContinuousRenalReplacementTherapy #NutritionIndirectCalorimetry #RestingEnergyExpenditure Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritional consequences. Moreover, renal replacement therapy (RRT), whatever the modality used, also profoundly impacts metabolism. RRT and of the extracorporeal circuit impede ‘effect the evaluation of a patient's energy requirements by clinicians. Substrates added and removed within the extracorporeal treatment are not always taken into consideration, making treatment even more challenging. Furthermore, evidence on nutritional support during continuous renal replacement therapy (CRRT) is scarce, and there are no clinical guidelines for nutrition adaptations during CRRT in critically ill patients. Most recommendations are based on expert opinions. This review discusses the complex interaction between nutritional support and CRRT and presents some milestones for nutritional support in critically ill patients on CRRT.

JIM│ The medical treatment of cardiogenic shock Author: Bruno Levy et al. Link: https://buff.ly/4eR2470 #CardiogenicShock #Etiology #Epidemiology #MedicalTreatment #Monitoring Cardiogenic shock (CS) is a leading cause of mortality worldwide. CS presentation and management in the current era have been widely depicted in epidemiological studies. Its treatment is codified and relies on medical care and extracorporeal life support (ECLS) in the bridge to recovery, chronic mechanical device therapy, or transplantation. Recent improvements have changed the landscape of CS. The present analysis aims to review current medical treatments of CS in light of recent literature, including addressing excitation–contraction coupling and specific physiology on applied hemodynamics. Inotropism, vasopressor use, and immunomodulation are discussed as pre-clinical and clinical studies have focused on new therapeutic options to improve patient outcomes. Certain underlying conditions of CS, such as hypertrophic or Takotsubo cardiomyopathy, warrant specifically tailored management that will be overviewed in this review.

JIM│ Management of renal replacement therapy among adults in French intensive care units: A bedside practice evaluation Author: Jean-Pierre Quenot et al. Link: https://buff.ly/3OmEjZI #RenalReplacementTherapy #AcuteKidneyInjury #ICU #PracticeEvaluation #Bedside Background This study aimed to investigate renal replacement therapy (RRT) practices in a representative nationwide sample of French intensive care units (ICUs). Methods From July 1 to October 5 2021, 67 French ICUs provided data regarding their ICU and RRT implementation. We used an online questionnaire to record general data about each participating ICU, including the type of hospital, number of beds, staff ratios, and RRT implementation. Each center then prospectively recorded RRT parameters from 5 consecutive acute kidney injury (AKI) patients, namely the indication, type of dialysis catheter used, type of catheter lock used, type of RRT (continuous or intermittent), the RRT parameters initially prescribed (dose, blood flow, and duration), and the anticoagulant agent used for the circuit. Results A total of 303 patients from 67 ICUs were analyzed. Main indications for RRT were oligo-anuria (57.4%), metabolic acidosis (52.1%), and increased plasma urea levels (47.9%). The commonest insertion site was the right internal jugular (45.2%). In 71.0% of cases, the dialysis catheter was inserted by a resident. Ultrasound guidance was used in 97.0% and isovolumic connection in 90.1%. Citrate, unfractionated heparin, and saline were used as catheter locks in 46.9%, 24.1%, and 21.1% of cases, respectively. Conclusions Practices in French ICUs are largely compliant with current national guidelines and international literature. The findings should be interpreted in light of the limitations inherent to this type of study.

JIM│ Management of renal replacement therapy among adults in French intensive care units: A bedside practice evaluation Author: Jean-Pierre Quenot et al. Link: https://buff.ly/3OmEjZI #RenalReplacementTherapy #AcuteKidneyInjury #ICU #PracticeEvaluation #Bedside Background This study aimed to investigate renal replacement therapy (RRT) practices in a representative nationwide sample of French intensive care units (ICUs). Methods From July 1 to October 5 2021, 67 French ICUs provided data regarding their ICU and RRT implementation. We used an online questionnaire to record general data about each participating ICU, including the type of hospital, number of beds, staff ratios, and RRT implementation. Each center then prospectively recorded RRT parameters from 5 consecutive acute kidney injury (AKI) patients, namely the indication, type of dialysis catheter used, type of catheter lock used, type of RRT (continuous or intermittent), the RRT parameters initially prescribed (dose, blood flow, and duration), and the anticoagulant agent used for the circuit. Results A total of 303 patients from 67 ICUs were analyzed. Main indications for RRT were oligo-anuria (57.4%), metabolic acidosis (52.1%), and increased plasma urea levels (47.9%). The commonest insertion site was the right internal jugular (45.2%). In 71.0% of cases, the dialysis catheter was inserted by a resident. Ultrasound guidance was used in 97.0% and isovolumic connection in 90.1%. Citrate, unfractionated heparin, and saline were used as catheter locks in 46.9%, 24.1%, and 21.1% of cases, respectively. Conclusions Practices in French ICUs are largely compliant with current national guidelines and international literature. The findings should be interpreted in light of the limitations inherent to this type of study.

JIM│ Advances in the knowledge on the role of apoptosis repressor with caspase recruitment domain in hemorrhagic stroke Author: Ye Gong et al. Link: https://buff.ly/3Olcjpa #Apoptosis repressor with caspase recruitment domain (ARC) #HemorrhagicStroke #Neuroinflammation #NeuronalApoptosis The apoptosis repressor with caspase recruitment domain (ARC) plays a critical role in extrinsic apoptosis initiation via death receptor ligands, physiological stress, infection response in a tissue-dependent manner, endoplasmic reticulum (ER) stress, genotoxic drugs, ionizing radiation, oxidative stress, and hypoxia. Recent studies have suggested that regulating apoptosis-related pathways can improve outcomes for patients with neurological diseases, such as hemorrhagic stroke. ARC expression is significantly correlated with acute cerebral hemorrhage. However, the mechanism by which it mediates the anti-apoptosis pathway remains poorly known. Here, we discuss the function of ARC in hemorrhagic stroke and argue that it could serve as an effective target for the treatment of hemorrhagic stroke.

JIM│ Advances in the knowledge on the role of apoptosis repressor with caspase recruitment domain in hemorrhagic stroke Author: Ye Gong et al. Link: https://buff.ly/3Olcjpa #Apoptosis repressor with caspase recruitment domain (ARC) #HemorrhagicStroke #Neuroinflammation #NeuronalApoptosis The apoptosis repressor with caspase recruitment domain (ARC) plays a critical role in extrinsic apoptosis initiation via death receptor ligands, physiological stress, infection response in a tissue-dependent manner, endoplasmic reticulum (ER) stress, genotoxic drugs, ionizing radiation, oxidative stress, and hypoxia. Recent studies have suggested that regulating apoptosis-related pathways can improve outcomes for patients with neurological diseases, such as hemorrhagic stroke. ARC expression is significantly correlated with acute cerebral hemorrhage. However, the mechanism by which it mediates the anti-apoptosis pathway remains poorly known. Here, we discuss the function of ARC in hemorrhagic stroke and argue that it could serve as an effective target for the treatment of hemorrhagic stroke.

JIM│ Recent advances in the study of sepsis-induced depression Author: Ye Gong et al. Link: https://buff.ly/3ZjeoIJ #Sepsis #Sepsis-associatedEncephalopathy #Depression #Mechanism Progress in medicine such as the use of anti-infective drugs and development of the advanced life support equipment has greatly improved the survival rate of patients with sepsis. However, the incidence of sepsis-related diseases is increasing. These include severe neurologic and psychologic disorders, cognitive decline, anxiety, depression, and post-traumatic stress disorder. Cerebral dysfunction occurs via multiple interacting mechanisms, with different causative pathogens having distinct effects. Because sepsis-related diseases place a substantial burden on patients and their families, it is important to elucidate the underlying pathophysiologic mechanisms to develop effective treatments.

JIM│ Blood–brain barrier dysfunction in intensive care unit Author: Nicolas Weiss et al. Link: https://buff.ly/3YL3NGd #Blood–brainBarrier #ICU hepatic encephalopathy #Delirium #ECMO #AcuteBacterialMeningitis The central nervous system is characterized by a peculiar vascularization termed blood–brain barrier (BBB), which regulates the exchange of cells and molecules between the cerebral tissue and the whole body. BBB dysfunction is a life-threatening condition since its presence corresponds to a marker of severity in most diseases encountered in the intensive care unit (ICU). During critical illness, inflammatory response, cytokine release, and other phenomena activating the brain endothelium contribute to alterations in the BBB and increase its permeability to solutes, cells, nutrients, and xenobiotics. Moreover, patients in the ICU are often old, with underlying acute or chronic diseases, and overly medicated due to their critical condition; these factors could also contribute to the development of BBB dysfunction. An accurate diagnostic approach is critical for the identification of the mechanisms underlying BBB alterations, which should be rapidly managed by intensivists. Several methods were developed to investigate the BBB and assess its permeability. Nevertheless, in humans, exploration of the BBB requires the use of indirect methods. Imaging and biochemical methods can be used to study the abnormal passage of molecules through the BBB. In this review, we describe the structural and functional characteristics of the BBB, present tools and methods for probing this interface, and provide examples of the main diseases managed in the ICU that are related to BBB dysfunction.

JIM│ Nomogram prediction model called “ADPLCP” for predicting linezolid-associated thrombocytopenia in elderly individuals Author: Xiangqun Fang, Lixin Xie et al. Link: https://buff.ly/3AWbTCw #Linezolid-associatedThrombocytopenia #Nomogram #RiskPredictionModel #ElderlyIndividuals Background Linezolid-associated thrombocytopenia (LAT) leads to drug withdrawal associated with a poor prognosis. Some risk factors for LAT have been identified; however, the sample size of previous studies was small, data from elderly individuals are limited, and a simple risk score scale was not established to predict LAT at an early stage, making it difficult to identify and intervene in LAT at an early stage. Methods In this single-center retrospective case-control study, we enrolled elderly patients treated with linezolid in the intensive care unit from January 2015 to December 2020. All the data of enrolled patients, including demographic information and laboratory findings at baseline, were collected. We analyzed the incidence and risk factors for LAT and established a nomogram risk prediction model for LAT in the elderly population. Results A total of 428 elderly patients were enrolled, and the incidence of LAT was 35.5% (152/428). Age ≥80 years old (OR=1.980; 95% CI: 1.179–3.325; P=0.010), duration of linezolid ≥ 10 days (OR=1.100; 95% CI: 1.050–1.152; P <0.0001), platelet count at baseline (100–149×109/L vs. ≥200×109/L, OR=8.205, 95% CI: 4.419–15.232, P <0.0001; 150–199 ×109/L vs. ≥200×109/L, OR=3.067, 95% CI: 1.676–5.612, P <0.001), leukocyte count at baseline ≥16×109/L (OR=2.580; 95% CI: 1.523–4.373; P <0.0001), creatinine clearance <50 mL/min (OR=2.323; 95% CI: 1.388–3.890; P=0.001), and total protein <60 g/L (OR=1.741; 95% CI: 1.039–2.919; P=0.035) were associated with LAT. The nomogram prediction model called “ADPLCP” (age, duration, platelet, leukocyte, creatinine clearance, protein) was established based on logistic regression. The area under the curve (AUC) of ADPLCP was 0.802 (95% CI: 0.748–0.856; P <0.0001), with 78.9% sensitivity and 69.2% specificity (cut-off was 108). Risk stratification for LAT was performed based on “ADPLCP.” Total points of <100 were defined as low risk, and the possibility of LAT was <32.0%. Total points of 100–150 were defined as medium risk, and the possibility of LAT was 32.0–67.5%. A total point >150 was defined as high risk, and the probability of LAT was >67.5%. Conclusions We created the ADPLCP risk score scale to predict the occurrence of LAT in elderly individuals. ADPLCP is simple and feasible and is helpful for the early determination of LAT to guide drug withdrawal or early intervention.

JIM│ Is COVID-19 different from other causes of acute respiratory distress syndrome? Author: François M. Beloncle Link: https://buff.ly/3CzD2fe #MechanicalVentilation #RespiratoryMechanics #GasExchange #Recruitability #DeadSpace Coronavirus disease 2019 (COVID-19) pneumonia can lead to acute hypoxemic respiratory failure. When mechanical ventilation is needed, almost all patients with COVID-19 pneumonia meet the criteria for acute respiratory distress syndrome (ARDS). The question of the specificities of COVID-19-associated ARDS compared to other causes of ARDS is of utmost importance, as it may justify changes in ventilatory strategies. This review aims to describe the pathophysiology of COVID-19-associated ARDS and discusses whether specific ventilatory strategies are required in these patients.