Sigh in patients with acute hypoxemic respiratory failure and acute respiratory distress syndrome: the PROTECTION pilot randomized clinical trial

Background: Sigh is a cyclic brief recruitment manoeuvre: previous physiological studies showed that its use could be an interesting addition to pressure support ventilation to improve lung elastance, decrease regional heterogeneity and increase release of surfactant. Research question: Is the clinical application of sigh during pressure support ventilation (PSV) feasible? Study design and methods: We conducted a multi-center non-inferiority randomized clinical trial on adult intubated patients with acute hypoxemic respiratory failure or acute respiratory distress syndrome undergoing PSV. Patients were randomized to the No Sigh group and treated by PSV alone, or to the Sigh group, treated by PSV plus sigh (increase of airway pressure to 30 cmH2Ofor 3 seconds once per minute) until day 28 or death or successful spontaneous breathing trial. The primary endpoint of the study was feasibility, assessed as non-inferiority (5% tolerance) in the proportion of patients failing assisted ventilation. Secondary outcomes included safety, physiological parameters in the first week from randomization, 28-day mortality and ventilator-free days. Results: Two-hundred fifty-eight patients (31% women; median age 65 [54-75] years) were enrolled. In the Sigh group, 23% of patients failed to remain on assisted ventilation vs. 30% in the No Sigh group (absolute difference -7%, 95%CI -18% to 4%; p=0.015 for non-inferiority). Adverse events occurred in 12% vs. 13% in Sigh vs. No Sigh (p=0.852). Oxygenation was improved while tidal volume, respiratory rate and corrected minute ventilation were lower over the first 7 days from randomization in Sigh vs. No Sigh. There was no significant difference in terms of mortality (16% vs. 21%, p=0.342) and ventilator-free days (22 [7-26] vs. 22 [3-25] days, p=0.300) for Sigh vs. No Sigh. Interpretation: Among hypoxemic intubated ICU patients, application of sigh was feasible and without increased risk

Troponin I and coronary anatomy in patients with sudden cardiac arrest

Namen dela: Pri večini bolnikov po srčnem zastoju izven bolnišnice (OHCA) ob sprejemu potrdimo akutno poškodbo miokarda. Namen dela je bil opredeliti dinamiko visoko-občutljivega srčnega troponina I (cTnI) in z njo povezan obseg poškodbe miokarda oziroma miokardnega infarkta po OHCA pri bolnikih z različnimi stopnjami koronarne bolezni. Metode: Vključili smo 159 zaporednih komatoznih bolnikov po srčnem zastoju izven bolnišnice, pri katerih je bila opravljena urgentna koronarografija. Na podlagi koronarografskega izvida smo bolnike razdelili v skupine z akutno trombotično lezijo (skupina A), stabilno obstruktivno koronarno boleznijo (skupina B) ter neobstruktivno boleznijo oz. brez koronarne bolezni (skupina C). Ob sprejemu ter 3, 6, 12, 18, 24, 36 in 48 ur kasneje smo odvzeli vzorec krvi za določitev vrednosti visoko-občutljivega cTnI, izračunali smo površino pod krivuljo in določili optimalno vrednost cTnI za napoved akutne trombotične lezije. Rezultati: Dvig spojnice ST (STEMI) v sprejemnem EKG je bil v skupini A prisoten pri 65 % bolnikov, v skupni B pri 26 % bolnikov in v skupini C pri 11 % bolnikov (p < 0.001). cTnI, ki je bil ob sprejemu v skupinah A, B in C 0,88 ng/ml, 0,44 ng/ml in 0,19 ng/ml (p < 0.001), je v naslednjih urah porasel do največ 63,96 ng/ml, 10,00 ng/ml in 2,35 ng/ml (p < 0.001). Med bolniki v skupini A je bil cTnI pomembno višji pri tistih z akutno popolno zaporo koronarne arterije v primerjavi z bolniki s spontano reperfuzijo v času urgentne koronarografije. Pri bolnikih brez akutne trombotične lezije je najvišja vrednost cTnI korelirala s časom trajanja oživljanja na terenu, številom defibrilacij in celokupnim odmerkom prejetega adrenalina. Ob vrednosti sprejemnega TnI več kot 0,46 ng/ml je bila občutljivost za prisotnost akutne trombotične koronarne lezije 64 %, specifičnost pa 60 %. Sklepi: Pri bolnikih po srčnem zastoju je pomembna akutna poškodba miokarda, ugotovljena z visokimi vrednostmi cTnI, povezana s prisotnostjo akutne trombotične koronarne lezije, še posebej, če je koronarna arterija ob urgentni koronarografiji popolnoma zaprta. Pri bolnikih s stabilno in neobstruktivno koronarno boleznijo ter brez koronarne bolezni so vrednosti TnI bistveno nižje in korelirajo z dolžino in intenziteto oživljanja. Sprejemni TnI je premalo zanesljiv za zanesljivo napovedovanje akutne trombotične lezije.Aim: We investigated dynamics of high-sensitivity troponin I (cTnI) and associated extent of myocardial injury in out-of-hospital cardiac arrest (OHCA) patients with different extent of coronary artery disease. Methods: 159 consecutive patients undergoing immediate coronary angiography after OHCA were included and divided into groups with acute culprit lesion (A), stable obstructive coronary disease (B) and non-obstructive or absent coronary disease (C). Serial measurements of cTnI were obtained at admission and 3, 6, 12, 18, 24, 36 and 48 hours later. Area under cTnI curve was calculated and optimal cut-off value predicting acute coronary lesion was determined. Results: ST-elevation myocardial infarction (STEMI) was documented in 65 % in group A, 26 % in group B, and 11 % in group C (p < 0.001). cTnI, which was 0,88 ng/mL, 0,44 ng/mL and 0,19 ng/mL in groups A, B and C on admission (p < 0.001), increased to a maximum of 63,96 ng/mL, 10,00 ng/mL and 2,35 ng/mL, respectively (p < 0.001). Within the group A, cTnI was significantly larger in patients with acute occlusion than in patients with spontaneous reperfusion at initial angiography. Within groups B and C, peak cTnI correlated with duration of resuscitation, number of defibrillations and cumulative epinephrine dose. If admission cTnI exceeded 0,46 ng/mL, sensitivity for detection of acute culprit lesion was 64 % and specificity 60 %. Conclusions: Significant myocardial injury associated with highest cTnI levels in OHCA patients occurs in the presence of acute culprit lesion, particularly if the infarct-related coronary artery is still occluded at the time of coronary angiography. Extent of myocardial injury in stable or absent coronary disease is significantly smaller and correlates with the duration and intensity of cardiac resuscitation. Admission cTnI have insufficient accuracy to securely predict presence of acute culprit lesion

A matched case-control study on the effectiveness of extracorporeal cytokine adsorption in critically ill patients

Abstract Extracorporeal cytokine adsorption aims to reduce cytokine levels in critically ill patients. However, little convincing data exist to support its widespread use. This retrospective study compared interleukin-6 (IL-6) levels in patients treated with or without cytokine adsorber (CytoSorb®). Intensive care patients between Jan 2017 and Dec 2021 who had at least two IL-6 measurements were included. They were divided into an adsorber group and a standard of care group. We screened 3865 patients and included 52 patients in the adsorber group and 94 patients in the standard of care group. Matching was performed and the groups were compared regarding IL-6, lactate, CRP, procalcitonin, vasopressor requirement, and mortality rate. After matching, there were 21 patients in each group. Patients had similar age, ECMO and renal replacement therapy use, baseline noradrenaline requirement, serum lactate, pH, CRP, and IL-6 levels. There were no significant differences in the time course of IL-6, lactate, CRP, procalcitonin and noradrenaline requirement between groups. Two-day and ICU mortality and Kaplan-Meier estimated survival were also comparable. In this matched case-control study no difference in IL-6, inflammatory parameters, noradrenaline requirement or mortality was observed between patients treated with adsorber or standard of care