Characteristics and predictors of chronic critical illness in the intensive care unit

Risk factors, biomarkers, and mechanisms for persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a systematic review and meta-analysis

INTRODUCTION

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has been proposed as an endotype of chronic critical illness (CCI). The aim of this systematic review is to synthesise the available evidence of risk factors, biomarkers, and biological mechanisms underlying PICS.

METHODS

MEDLINE, CENTRAL, and EMBASE were searched on June 2, 2023. Our population of interest was adult intensive care unit survivors. The exposure group was patients with PICS and the comparator group was patients with no PICS, CCI, or rapid recovery. Mean differences were pooled for each biomarker using a random effects DerSimonian-Laird method. Risk of bias assessment was done using the Newcastle-Ottawa Scale.

RESULTS

Six papers were included. Five were single-centre retrospective cohort studies, and one was a prospective cohort study, with sample sizes ranging from 22 to 391 patients. Two studies showed an increased incidence of PICS with age, and two studies showed an association between PICS and Charlson Comorbidity Index scores. PICS was associated with requiring mechanical ventilation in four studies. Meta-analysis showed a 34.4 mg L-1 higher C-reactive protein (95% confidence interval [CI] 12.7-56.2 mg L-1; P<0.01), a 4.4 g L-1 lower albumin (95% CI 0.5-8.3 g L-1; P<0.01), and a 0.36×109 L-1 lower lymphocyte count (95% CI 0.25-0.47×109 L-1; P=0.01) in the PICS compared with the non-PICS group. There are a large variety of other potential biomarkers but limited validation studies. The overall quality of evidence is limited, and these results should be interpreted accordingly.

CONCLUSIONS

While older patients and those with co-morbidities could be at greater risk for PICS, acquired risk factors, such as injury severity, are potentially more predictive of PICS than intrinsic patient characteristics. There are many potential biomarkers for PICS, but limited validation studies have been conducted. Persistent myeloid-derived suppressor cell expansion, the continual release of danger-associated molecular patterns and pathogen-associated molecular patterns propagating inflammation, and bioenergetic failure are all mechanisms underlying PICS that could offer potential for novel biomarkers and therapeutic interventions.

CLINICAL TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO; CRD42023427749).

PREVALÊNCIA E FATORES ASSOCIADOS À DOENÇA CRÍTICA CRÔNICA EM HOSPITALIZADOS POR TRAUMA EM TERAPIA INTENSIVA

RESUMO Objetivo identificar a prevalência de doença crítica crônica e fatores associados em pacientes hospitalizados por trauma em Unidade de Terapia Intensiva. Método estudo de caso-controle, com dados de prontuários de adultos hospitalizados por trauma em uma Unidade de Terapia Intensiva, entre 2013 e 2019. Os dados foram coletados do livro de admissão de pacientes, do prontuário eletrônico e das fichas do Serviço de Controle de Infecção Hospitalar. A variável dependente foi a ocorrência de doença crítica crônica e as variáveis independentes relacionavam-se às características sociodemográficas, comorbidades, trauma, atendimento pré-hospitalar, índices prognósticos, procedimentos e complicações. Realizou-se análise de regressão logística múltipla, que estimou o Ods Ratio (OR) e respectivos intervalos de confiança (IC). Resultados a doença crítica crônica ocorreu em 150 pacientes (24,2%), dos 619 estudados. Os fatores associados à DCC foram disfunção orgânica (OR=1,09) e complicações gastrointestinais (OR=2,71). Os pacientes com doença crítica crônica, além de demandarem por procedimentos cirúrgicos, desenvolveram disfunções orgânicas em diferentes sistemas, apresentando altas pontuações nos índices de prognósticos, ou seja, um pior prognóstico, além de desenvolverem complicações. Conclusão a identificação das complicações gastrointestinais e o aumento da disfunção orgânica como fatores associados ao paciente crítico crônico tornam-se úteis para compor perfil clínico de pacientes e para planejar a assistência intensiva ao traumatizado, contribuindo, assim, para a prevenção e o manejo desses pacientes pelo enfermeiro.

PREVALENCE AND FACTORS ASSOCIATED WITH CHRONIC CRITICAL DISEASE IN HOSPITALIZED FOR TRAUMA IN INTENSIVE CARE

ABSTRACT Objective to identify the prevalence of chronic critical disease and associated factors in patients hospitalized for trauma in the Intensive Care Unit. Method case-control study, with data from medical records of adults hospitalized for trauma in an Intensive Care Unit, between 2013 and 2019. Data were collected from the patient admission book, the electroni cmedical records and the records of the Hospital Infection Control Service. The dependent variable was the occurrence of chronic critical disease, and the independent variables were related to sociodemographic characteristics, comorbidities, trauma, pre-hospital care, prognostic indices, procedures and complications. Multiple logistic regression analysis was performed, which estimated the Ods Ratio (OR) and respective confidence intervals (CI). Results chronic critical disease occurred in 150 patients (24.2%), of the 619 patients studied. The factors associated with CCD were organic dysfunction (OR=1.09) and gastrointestinal complications (OR=2.71). Patients with chronic critical disease, in addition to proseeding for surgical procedures, developed organic dysfunctions in different systems, presenting high scores in prognostic indexes, i.e., a worse prognosis, in addition to developing complications. Conclusion the identification of gastrointestinal complications and the increase in organic dysfunction as factors associated with chronic critical patients become useful to compose the clinical profile of patients and to plan intensive care for the traumatized patients, thus contributing to the prevention and management of these patients by nurses.

Efficacy of Bifidobacterium Triple Viable Enteric-Coated Capsules Combined with Enteral Nutrition on Patients with Chronic Critical Illness and Influence on Immune and Coagulation Function

OBJECTIVE

To investigate the efficacy of enteric-coated Bifidobacterium triple viable capsules combined with enteral nutrition in the treatment of patients with chronic critical illness (CCI) and their effects on the immune and coagulation function of patients.

METHODS

106 CCI patients admitted to the intensive care unit of our hospital from December 2018 to March 2020 were selected as the research objects, and they were randomly divided into the control group (n = 53) and the observation group (n = 53). The control group was given symptomatic treatment, etiological treatment, clinical nursing, enteral nutrition support, and other conventional treatment methods according to the patient's condition. On this basis, the observation group was treated with enteric-coated Bifidobacterium triple viable capsules, and both groups were treated for 14 days. All patients were followed up for 3 months after treatment, and their death/cure prognosis was recorded. The acute physiological and chronic health (APACHE II) scoring system was used to evaluate the acute physiological and chronic health status of the two groups before and after treatment, and the organs of the patients were scored with sepsis-related organ failure assessment (SOFA) score. T lymphocyte subsets (CD3+, CD4+, CD8+, and CD4+/CD8+), prothrombin time (PT), activated partial thrombin time (APTT), fibrinogen (FIB), and D-dimer (DD) were measured before and after treatment.

RESULTS

The cure rate of the observation group was slightly higher than that of the control group, and the mortality rate was slightly lower than that of the control group, but the difference was not statistically significant (P < 0.05). After treatment, the APACHE II and SOFA scores of the two groups were lower than before treatment, and the APACHE II and SOFA scores of the observation group were lower than those of the control group, and the differences were both statistically significant (P < 0.05). After treatment, the levels of CD3+, CD4+, and CD4+/CD8+ in the two groups were higher than those before treatment, and the levels of CD8+ were lower than before treatment. The CD3+, CD4+, and CD4+/CD8+ levels of the observation group were higher than those of the control group, and the CD8+ levels were lower than the control group, and the differences were both statistically significant (P < 0.05). After treatment, the PT and APTT levels of the two groups of patients were higher than those before treatment, and the levels of FIB and DD were lower than those before treatment. The PT and APTT levels of the observation group were higher than those of the control group, and the FIB and DD levels were lower than those of the control group, and the differences were both statistically significant (P < 0.05).

CONCLUSION

The combination of enteric-coated Bifidobacterium triple viable capsules and enteral nutrition for CCI has high cure rate, which can not only improve the patients' physiological health status and organ dysfunction but also effectively improve the patients' immune and coagulation function, which is worthy of promotion.