BACKGROUND: The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria.
METHODS: A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3.
RESULTS: Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups.
CONCLUSIONS: Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Handgrip strength (HGS) is a non-invasive and reliable biomarker of overall health, physical function, mobility, and mortality. This study aimed to investigate the possible relationship between HGS and mortality in older adult patients hospitalized with COVID-19 in the intensive care unit (ICU) by Alpha (B.1.1.7) and Delta (B.1.617.2) variants. This retrospective cohort study was conducted on 472 COVID-19 patients (222 female and 250 male) aged 60-85 years admitted to the ICU. Demographic data, underlying comorbidities, COVID-19-related symptoms, as well as laboratory and computed tomography (CT) findings were obtained from the patient\'s medical records. Using a JAMAR® hydraulic dynamometer, the average grip strength value (kg) after three measurements on the dominant side was recorded for subsequent analysis. Low grip strength (LGS) was defined as an arbitrary cut-off of two standard deviations below the gender-specific peak mean value of normative HGS in Iranian healthy population, i.e. < 26 kg in males and < 14 kg in females. The findings showed lower mean grip strength and high frequency of LGS in the non-survivors patients versus survivors group and in the Delta (B.1.617.2) variant vs. Alpha (B.1.1.7) variant, respectively (both p < 0.01). The binary logistic regression analysis showed that chronic obstructive pulmonary disease (COPD) (adjusted odds ratio [OR] 5.125, 95% CI 1.425-25.330), LGS (OR 4.805, 95% CI 1.624-10.776), SaO2 (OR - 3.501, 95% CI 2.452-1.268), C-reactive protein (CRP) level (OR 2.625, 95% CI 1.256-7.356), and age (OR 1.118, 95% CI 1.045-1.092) were found to be independent predictors for mortality of patients with Alpha (B.1.1.7) variant (all p < 0.05). However, only four independent predictors including COPD (OR 6.728, 95% CI 1.683-28.635), LGS (OR 5.405, 95% CI 1.461-11.768), SaO2 (OR - 4.120, 95% CI 2.924-1.428), and CRP level (OR 1.893, 95% CI 1.127-8.692) can be predicted the mortality of patients with Delta (B.1.617.2) variant (p < 0.05). Along with the well-known and common risk factors (i.e. COPD, CRP, and SaO2), handgrip strength can be a quick and low-cost prognostic tool in predicting chances of mortality in older adults who are afflicted with COVID-19 variants.

UNASSIGNED: The ideal timing for commencing enteral nutrition (EN) in critically ill stroke patients in the intensive care unit (ICU) remains a subject of debate, with ongoing controversy regarding the impact of early EN (EEN) initiation. In this study, we investigated the association between the timing of EN initiation and 28-day mortality using data from the MIMIC-IV database.
UNASSIGNED: This study employed a retrospective cohort design using the MIMIC-IV database to identify stroke patients who received EN during their hospital stay. The main focus of this investigation was to examine 28-day mortality among these patients following hospital admission. Various demographic, clinical, laboratory, and intervention variables were considered as covariates. The Cox regression analysis was employed to assess the correlation between the timing of EN initiation and 28-day mortality, and restricted cubic splines (RCS) analysis was used to test for non-linear correlation. Patients were then stratified into two cohorts depending on the timing of EN initiation: within 2 days (n = 564) and beyond 2 days (n = 433). A multivariate Cox regression analysis was used to investigate the difference in 28-day mortality between the groups.
UNASSIGNED: A total of 997 participants were included in this study, with 318 (31.9%) dying within 28 days. We observed that the timing of EN initiation correlated with 28-day mortality, but this correlation was not significant after adjusting for covariates (crude HR: 0.94, 95% CI: 0.88-1, p = 0.044; adjusted HR: 0.96, 95% CI: 0.9-1.02, p = 0.178). The RCS analysis showed that the correlation was not non-linear. Notably, in the multivariate regression models, early EN initiation was associated with a higher mortality rate compared to late EN initiation [odds ratio (OR) = 1.34, 95% CI: 1.06-1.67, p = 0.012]. After adjusting for various confounding factors in the multivariate Cox regression models, we identified that patients in the early EN group had a 28% higher risk of mortality than those in the reference group (OR = 1.27, 95% CI: 1-1.61, p = 0.048). These associations remained consistent across various patient characteristics, as revealed through stratified analyses.
UNASSIGNED: Early commencement of EN in critically ill stroke patients may be linked to a higher risk of 28-day mortality, highlighting the need for further investigation and a more nuanced consideration of the optimal timing for commencing EN in this patient population.

In 2016, a new, improved and modern intensive care unit was constructed at Kamuzu Central Hospital in Lilongwe, Malawi. Having been operational for about 4 years, there has not been a systematic audit to gauge its performance. Therefore, this quantitative retrospective cohort study aimed at investigating the performance of the intensive care unit at Kamuzu Central Hospital in Lilongwe, Malawi. We analysed the patterns of admission through 250 clinical cases and their respective outcomes spanning from 1st January 2019 to 31st December 2019 using STATA. Descriptive and inferential statistics were computed. We also had a follow-up discussion with the Head of the unit to better understand the unit\'s functioning. Out of the 250 admissions, we evaluated 249 case files. About 30.8% of all patients were referred from the main operating theatre, and 20.7% from the casualty (emergency medicine). Head injury (26.7%) and peritonitis (15.7%) were the commonest causes of admission. The overall mortality was 52.2% with more females (57.5%) dying than males (47.9%). Head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively. In conclusion, despite the new unit registering an improved performance compared to the old unit\'s 2012 mortality of 60.9%, the current mortality rate of 52.2% generally reflects a suboptimal performance. The intensive care unit is still grappling with a number of challenges that need immediate attention including few working beds, shortage of critical care specialists and nursing staff and lack of standard admission criteria.

OBJECTIVE: Healthcare professionals may be able to anticipate more accurately a patient\'s timing of death and assess their possibility of recovery by implementing a real-time clinical decision support system. Using such a tool, the healthcare system can better understand a patient\'s condition and make more informed judgements about distributing limited resources. This scoping review aimed to analyze various death prediction AI (Artificial Intelligence) algorithms that have been used in ICU (Intensive Care Unit) patient populations.
METHODS: The search strategy of this study involved keyword combinations of outcome and patient setting such as mortality, survival, ICU, terminal care. These terms were used to perform database searches in MEDLINE, Embase, and PubMed up to July 2022. The variables, characteristics, and performance of the identified predictive models were summarized. The accuracy of the models was compared using their Area Under the Curve (AUC) values.
RESULTS: Databases search yielded an initial pool of 8271 articles. A two-step screening process was then applied: first, titles and abstracts were reviewed for relevance, reducing the pool to 429 articles. Next, a full-text review was conducted, further narrowing down the selection to 400 key studies. Out of 400 studies on different tools or models for prediction of mortality in ICUs, 16 papers focused on AI-based models which were ultimately included in this study that have deployed different AI-based and machine learning models to make a prediction about negative patient outcome. The accuracy and performance of the different models varied depending on the patient populations and medical conditions. It was found that AI models compared with traditional tools like SAP3 or APACHE IV score were more accurate in death prediction, with some models achieving an AUC of up to 92.9%. The overall mortality rate ranged from 5% to more than 60% in different studies.
CONCLUSIONS: We found that AI-based models exhibit varying performance across different patient populations. To enhance the accuracy of mortality prediction, we recommend customizing models for specific patient groups and medical contexts. By doing so, healthcare professionals may more effectively assess mortality risk and tailor treatments accordingly. Additionally, incorporating additional variables-such as genetic information-into new models can further improve their accuracy.

BACKGROUND: Sepsis is a dysregulated host immune response stemming from a systemic inflammatory response to microbial invasion, encompassing bacteria, viruses, and other pathogens. The vascular endothelial growth factor (VEGF) was initially identified for its potent induction of endothelial permeability. Studies have proposed a therapeutic role of dopamine in mitigating VEGF-induced permeability, shedding light on its potential in acute respiratory distress syndrome (ARDS) management.
OBJECTIVE: To determine the effect of dopamine as an inhibitor of VEGF and to prevent the progression of sepsis to acute lung injury (ALI) and ARDS.
METHODS: A total of 154 critical care unit patients with a diagnosis of sepsis were randomized into two groups: Group I (control group) and Group II (Study group). Both received standard treatment, as per ICU protocol. In addition, the study group (Group II) received a dopamine infusion of 2 micrograms/kg/min. Baseline routine investigation, procalcitonin, and chest X-ray were done. Day one and day seven blood samples were stored for analysis of VEGF levels. Murray\'s score and sequential organ failure assessment (SOFA) score (organ dysfunction) were calculated from day one to day seven.
RESULTS: VEGF levels on day seven were significantly lower in the study group compared to the control group (p<0.05). The PaO2/FiO2 ratio at day seven was significantly increased in the study group than in the control group, indicating an improvement in oxygenation status in the study group. There was a mean ICU stay of 9.3 days in the study group versus 11.6 days in the control group (p<0.05). The SOFA score showed a significant improvement in the study group from day five onwards, indicating a therapeutic effect of dopamine on organ dysfunction in sepsis.
CONCLUSIONS: Dopamine reduces VEGF and lung injury mediated by increased endothelial permeability.

BACKGROUND: This study aimed to evaluate the predictive accuracy of the prehospital rapid emergency medicine score (pREMS) for predicting the outcomes of hospitalized patients with traumatic brain injury (TBI) who died, were discharged, were admitted to the intensive care unit (ICU), or were admitted to the operating room (OR) within 72 h.
METHODS: A retrospective cohort analysis was performed on a sample of 513 TBI patients admitted to the emergency department (ED) of Besat Hospital in 2023. Only patients of both sexes aged 18 years or older who were not pregnant and had adequate documentation of vital signs were included in the analysis. Patients who died during transport and patients who were transferred from other hospitals were excluded. The predictive power of the pREMS for each outcome was assessed by calculating the sensitivity and specificity curves and by analyzing the area under the receiver operating characteristic curve (AUROC).
RESULTS: The mean pREMS scores for hospital discharge, death, ICU admission and OR admission were 11.97 ± 3.84, 6.32 ± 3.15, 8.24 ± 5.17 and 9.88 ± 2.02, respectively. pREMS accurately predicted hospital discharge and death (AOR = 1.62, P < 0.001) but was not a good predictor of ICU or OR admission (AOR = 1.085, P = 0.603). The AUROCs for the ability of the pREMS to predict outcomes in hospitalized TBI patients were 0.618 (optimal cutoff point = 7) for ICU admission and OR and 0.877 (optimal cutoff point = 9.5) for hospital discharge and death at 72 h.
CONCLUSIONS: The results indicate that the pREMS, a new preclinical trauma score for traumatic brain injury, is a useful tool for prehospital risk stratification (RST) in TBI patients. The pREMS showed good discriminatory power for predicting in-hospital mortality within 72 h in patients with traumatic brain injury.

Background/Objectives: The aim of this study was to investigate the feasibility and safety of neuromuscular electrical stimulation (NMES) in patients on extracorporeal membrane oxygenation (ECMO) and thoroughly assess any potential adverse events. Methods: We conducted a prospective observational study assessing safety and feasibility, including 16 ICU patients on ECMO support who were admitted to the cardiac surgery ICU from January 2022 to December 2023. The majority of patients were females (63%) on veno-arterial (VA)-ECMO (81%), while the main cause was cardiogenic shock (81%) compared to respiratory failure. Patients underwent a 45 min NMES session while on ECMO support that included a warm-up phase of 5 min, a main phase of 35 min, and a recovery phase of 5 min. NMES was implemented on vastus lateralis, vastus medialis, gastrocnemius, and peroneus longus muscles of both lower extremities. Two stimulators delivered biphasic, symmetric impulses of 75 Hz, with a 400 μsec pulse duration, 5 sec on (1.6 sec ramp up and 0.8 sec ramp down) and 21 sec off. The intensity levels aimed to cause visible contractions and be well tolerated. Primary outcomes of this study were feasibility and safety, evaluated by whether NMES sessions were successfully achieved, and by any adverse events and complications. Secondary outcomes included indices of rhabdomyolysis from biochemical blood tests 24 h after the application of NMES. Results: All patients successfully completed their NMES session, with no adverse events or complications. The majority of patients achieved type 4 and 5 qualities of muscle contraction. Conclusions: NMES is a safe and feasible exercise methodology for patients supported with ECMO.

UNASSIGNED: Percutaneous dilatational tracheostomy (PDT), a bedside procedure in intensive care, enhances respiratory support for critically ill patients with benefits over traditional tracheostomy, such as improved safety, ease of use, cost-effectiveness, and operational efficiency by eliminating patient transfers to the operating room. It also minimizes complications including bleeding, infection, and inflammation. Despite decades of PDT evolution and device diversification, adaptations primarily cater to larger Western patients rather than smaller-statured Korean populations. This study assesses the efficacy and appropriateness of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IN, USA), augmented with ultrasound, flexible bronchoscopy, and microcatheter techniques, for Korean patients with short stature.
UNASSIGNED: We conducted PDT on 183 intubated adults (128 male/55 female) with severe respiratory issues at a single medical center from January 2010 to December 2022. Patients were divided into two groups for retrospective analysis: a modified group (n=133) underwent PDT with ultrasound-guided flexible bronchoscopy and microcatheter puncture, and a conventional group (n=50) received PDT using only the Ciaglia Blue Rhino device. We assessed clinical and demographic characteristics, outcomes, and complications such as pneumothorax and emphysema. The study also evaluated the suitability and effectiveness of the devices for Korean patients with short stature.
UNASSIGNED: Demographic characteristics including sex, body weight, height, body mass index, obesity status, and underlying diseases showed no significant differences between the two groups. However, the modified group was older (69.5±14.2 vs. 63.5±14.1 years; P=0.01). The sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS) II score was slightly higher in the modified groups, but no statistically significant differences were observed (7.1±2.3 vs. 6.7±2.3, P=0.31 and 46.7±9.0 vs. 44.0±9.1, P=0.08, respectively). The duration of hospital and ICU stays, as well as days post-PDT, were longer in the conventional group, yet these differences were not statistically significant (P=0.20, P=0.44, P=0.06). Total surgical time, including preparation, ultrasound, bronchoscopy, and microcatheter puncture, was significantly longer in the modified group (25.6±7.5 vs. 19.9±6.5 minutes; P<0.001), and the success rate of the first tracheal puncture was also higher (100.0% vs. 92.0%; P=0.006). Intra-operative bleeding was less frequent in the modified group (P=0.02 for tracheostomy site bleeding and P=0.002 for minor bleeding).
UNASSIGNED: PDT, performed at the bedside in intensive care settings, proves to be a swift and dependable method. Utilizing the Ciaglia Blue Rhino device, combined with ultrasound guidance, flexible bronchoscopy, and 4.0-Fr microcatheter puncture, PDT is especially effective for intubated patients who cannot be weaned from ventilation. This technique results in fewer complications than traditional tracheostomy and is particularly beneficial for patients with respiratory issues and smaller-statured Koreans, potentially reducing morbidity and mortality.

Endocrine disorders pose significant challenges in the management of critically ill patients, contributing to morbidity and mortality in intensive care settings. Timely detection of these disorders is essential to optimizing patient outcomes. Biomarkers, as measurable indicators of biological processes or disease states, play a crucial role in the early identification and monitoring of endocrine dysfunction. This comprehensive review examines the role of biomarkers in the early detection of endocrine disorders in critical illnesses. We provide an overview of common endocrine disorders encountered in the intensive care unit (ICU) and discuss the impact of endocrine dysregulation on patient outcomes. Additionally, we classify biomarkers and explore their significance in diagnosing and monitoring endocrine disorders, including thyroid dysfunction, adrenal insufficiency, and hypopituitarism. Furthermore, we discuss the clinical applications of biomarkers, including their utility in guiding therapeutic interventions, monitoring disease progression, and predicting outcomes in critical illnesses. Emerging trends and future directions in biomarker research are also highlighted, emphasizing the need for continued investigation into novel biomarkers and technological advancements. Finally, we underscore the potential of biomarkers to revolutionize the early detection and management of endocrine disorders in critical illnesses, ultimately improving patient care and outcomes in the ICU.