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Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit

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World Journal of Critical Care Medicine 2019年第7期8卷 120-126页

作者： Prabij Dhungana Laura Piccolo Serafim Arnaldo Lopez Ruiz Danette Bruns Timothy J Weister nathan jerome smischney Rahul Kashyap Department of Anesthesiology and Perioperative Medicine Mayo ClinicRochesterMN 55905United States Multidisciplinary Epidemiology and Translational Research in Intensive Care Mayo ClinicRochesterMN 55905United States Department of Medicine Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterMN 55905United States Anesthesia Clinical Research Unit Mayo ClinicMN 55905United States

BACKGROUND With the recent change in the definition(Sepsis-3 Definition)of sepsis and septic shock,an electronic search algorithm was required to identify the cases for data *** supervised machine learning method would help screen a large amount of electronic medical records(EMR)for efficient research *** To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care *** A supervised machine learning method was developed based on culture orders,Sequential Organ Failure Assessment(SOFA)scores,serum lactate levels and vasopressor use in the intensive care units(ICUs).The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical *** was then validated in an independent cohort of 100 *** compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded *** was resolved by a critical care clinician.A SOFA score≥2 during the ICU stay with a culture 72 h before or after the time of admission was *** versions as V1 was defined as blood cultures with SOFA≥2 and Sepsis V2 was defined as any culture with SOFA score≥2.A serum lactate level≥2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 *** In the derivation subset of 100 random patients,the final machine learning strategy achieved a sensitivity-specificity of 100%and 84%for Sepsis-1,100%and 95%for Sepsis-2,78%and 80%for Septic Shock-1,and 80%and 90%for Septic *** overall percent of agreement between two blinded reviewers had a k=0.86 and 0.90 for Sepsis 2 and Septic shock 2 *** validation of the algorithm through a separate 100 random patient subset,the reported sensitivity and specificity for all 4 diagnoses were 100%-100%e

关键词： Machine learning Computable phenotype Critical care Sepsis Septic shock

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Inhaled volatile anesthetics in the intensive care unit

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World Journal of Critical Care Medicine 2024年第1期13卷 28-39页

作者： Erin D Wieruszewski Mariam ElSaban Patrick M Wieruszewski nathan J smischney Department of Pharmacy Mayo ClinicRochesterMN 55905United States Anesthesiology and Perioperative Medicine Mayo ClinicRochesterMN 55905United States Department of Anesthesiology&Perioperative Medicine Mayo ClinicRochesterMN 55905United States

The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th ***,a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres,finding diverse applications in intensive care *** the dynamic landscape of intensive care,volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements,managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus,conditions of high sedative requirements including burns,high opioid or alcohol use and neurological conditions such as status *** anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry,providing intensivists with multiple options to tailor ***,their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy,mitigating risks associated with conventional sedation *** the amounting enthusiasm for the use of these therapies,barriers to widespread utilization include expanding equipment availability,staff familiarity and training of safe *** article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology,administration considerations in intensive care settings,complication considerations,and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.

关键词： Anesthesia Critical care Mechanical ventilation Sedation Volatile anesthetics Sedative

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Endotracheal intubation sedation in the intensive care unit

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World Journal of Critical Care Medicine 2022年第1期11卷 33-39页

作者： Pritee Tarwade nathan J smischney Anesthesiology and Perioperative Medicine Mayo ClinicRochesterMN 55905United States Anesthesiology and Perioperative Medicine Division of Critical Care MedicineMayo ClinicRochesterMN 55905United States

Endotracheal intubation is one of the most common,yet most dangerous procedure performed in the intensive care unit(ICU).Complications of ICU intubations include severe hypotension,hypoxemia,and cardiac *** observational studies have evaluated risk factors associated with these *** the risk factors identified,the choice of sedative agents administered,a modifiable risk factor,has been reported to affect these complications(hypotension).Propofol,etomidate,and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal *** demonstrates rapid onset and offset,however,has drawbacks of profound vasodilation and associated cardiac *** is commonly used in the critically ill ***,it is known to cause reversible inhibition of 11β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 *** added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its *** is known to provide analgesia with sedation and has minimal respiratory and cardiovascular ***,its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant ***,unlike propofol or etomidate,ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ***,a combination of ketamine and propofol,“Ketofol”,has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent ***,the doses of both drugs are *** situations where a difficult airway is anticipated,awake intubation with the help of a fiberoptic scope or video laryngoscope is *** is a commonly used sedative agent for these proce

关键词： Critically ill Endotracheal intubation Etomidate Hypotension Intensive care unit Ketamine Ketofol Propofol Sedation

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Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation

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World Journal of Critical Care Medicine 2019年第6期8卷 87-98页

作者： Barry Burstein Patrick M Wieruszewski Yan-Jun Zhao nathan smischney Division of Pulmonary and Critical Care Medicine Mayo ClinicRochesterMN 55905United States Department of Pharmacy Mayo ClinicRochesterMN 55905United States Department of Anesthesia Mayo ClinicRochesterMN 55905United States

Use of extracorporeal membrane oxygenation to support patients with critical cardiorespiratory illness is *** anticoagulation is an essential element in the care of extracorporeal membrane oxygenation *** unfractionated heparin is the most commonly used agent,unfractionated heparin is associated with several unique complications that can be catastrophic in critically ill patients,including heparin-induced thrombocytopenia and acquired antithrombin *** complications can result in thrombotic events and subtherapeutic *** thrombin inhibitors(DTIs)are emerging as alternative anticoagulants in patients supported by extracorporeal membrane *** evidence supports DTIs use as safe and effective in extracorporeal membrane oxygenation patients with and without heparininduced *** review outlines the pharmacology,dosing strategies and available protocols,monitoring parameters,and special use considerations for all available DTIs in extracorporeal membrane oxygenation *** advantages and disadvantages of DTIs in extracorporeal membrane oxygenation relative to unfractionated heparin will be described.

关键词： Extracorporeal membrane oxygenation Anticoagulants Antithrombins Bivalirudin Argatroban Heparin

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Acute exacerbation of interstitial lung disease in the intensive care unit

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World Journal of Critical Care Medicine 2022年第1期11卷 22-32页

作者： Antonios Charokopos Teng Moua Jay H Ryu nathan J smischney Department of Medicine Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterMN 55905United States Department of Anesthesiology and Perioperative Medicine Division of Critical Care MedicineMayo ClinicRochesterMN 55905United States

Acute exacerbations of interstitial lung disease(AE-ILD)represent an acute,frequent and often highly morbid event in the disease course of ILD *** in the intensive care unit(ICU)is very common and the need for mechanical ventilation arises *** non-invasive ventilation has shown promise in staving off intubation in selected patients,it is unclear whether mechanical ventilation can alter the exacerbation course unless it is a bridge to lung *** stratification using clinical and radiographic findings,and early palliative care involvement,are important in ICU *** this review,we discuss many of the pathophysiological aspects of AE-ILD and raise the hypothesis that ventilation strategies used in acute respiratory distress syndrome might be implemented in *** present possible decision-making and management algorithms that can be used by the intensivist when caring for these patients.

关键词： Interstitial lung diseases Disease exacerbation Mechanical ventilation Intensive care unit Pathophysiological aspect

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Vasopressin in vasoplegic shock:A systematic review

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World Journal of Critical Care Medicine 2020年第5期9卷 88-98页

作者： Andrew J Webb Mohamed O Seisa Tarek Nayfeh Patrick M Wieruszewski Scott D Nei nathan J smischney Department of Pharmacy Oregon Health and Science UniversityPortlandOR 97239United States Robert D and Patricia E Kern Center For The Science of Health Care Delivery Mayo ClinicRochesterMN 55905United States Department of Pharmacy Mayo ClinicRochesterMN 55905United States Department of Anesthesia Mayo ClinicRochesterMN 55905United States

BACKGROUNDVasoplegic shock is a challenging complication of cardiac surgery and is oftenresistant to conventional therapies for shock. Norepinephrine and epinephrine arestandards of care for vasoplegic shock, but vasopressin has increasingly been usedas a primary pressor in vasoplegic shock because of its unique pharmacology andlack of inotropic activity. It remains unclear whether vasopressin has distinctbenefits over standard of care for patients with vasoplegic *** summarize the available literature evaluating vasopressin vs non-vasopressinalternatives on the clinical and patient-centered outcomes of vasoplegic shock inadult intensive care unit (ICU) *** was a systematic review of vasopressin in adults (≥ 18 years) with vasoplegicshock after cardiac surgery. Randomized controlled trials, prospective cohorts,and retrospective cohorts comparing vasopressin to norepinephrine, epinephrine,methylene blue, hydroxocobalamin, or other pressors were included. The primaryoutcomes of interest were 30-d mortality, atrial/ventricular arrhythmias, stroke,ICU length of stay, duration of vasopressor therapy, incidence of acute kidneyinjury stage II-III, and mechanical ventilation for greater than 48 *** total of 1161 studies were screened for inclusion with 3 meeting inclusioncriteria with a total of 708 patients. Two studies were randomized controlled trials and one was a retrospective cohort study. Primary outcomes of 30-d mortality,stroke, ventricular arrhythmias, and duration of mechanical ventilation weresimilar between groups. Conflicting results were observed for acute kidney injurystage II-III, atrial arrhythmias, duration of vasopressors, and ICU length of staywith higher certainty of evidence in favor of vasopressin serving a protective rolefor these *** was not found to be superior to alternative pressor therapy for any ofthe included outcomes. Results are limited by mixed methodologies, small overallsample si

关键词： Vasopressins Shock Vasoactive agents Treatment outcome Vasoplegia Arginine vasopressin

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Clonidine use during dexmedetomidine weaning:A systematic review

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World Journal of Critical Care Medicine 2023年第1期12卷 18-28页

作者： Sanu Rajendraprasad Molly Wheeler Erin Wieruszewski Joseph Gottwald Lindsey A.Wallace Danielle Gerberi Patrick M Wieruszewski nathan J smischney Department of Pulmonary&Critical Care Mayo ClinicRochesterMN 55905United States Department of Pharmacy Mayo ClinicRochesterMN 55905United States Department of Anesthesiology&Perioperative Medicine Mayo ClinicRochesterMN 55905United States Critical Care Medicine Independent Multidisciplinary Program Mayo ClinicRochesterMN 55905United States Mayo Medical Libraries Mayo ClinicRochesterMN 55905United States

BACKGROUND Dexmedetomidine is a centrally acting alpha-2A adrenergic agonist that is commonly used as a sedative and anxiolytic in the intensive care unit(ICU),with prolonged use increasing risk of withdrawal symptoms upon sudden *** clonidine is an enterally available alpha-2A adrenergic agonist,it may be a suitable agent to taper off dexmedetomidine and reduce withdrawal *** appropriate dosing and conversion strategies for using enteral clonidine in this context are not *** objective of this systematic review is to summarize the evidence of enteral clonidine application during dexmedetomidine weaning for prevention of withdrawal *** To systematically review the practice,dosing schema,and outcomes of enteral clonidine use during dexmedetomidine weaning in critically ill *** This was a systematic review of enteral clonidine used during dexmedetomidine weaning in critically ill adults(≥18 years).Randomized controlled trials,prospective cohorts,and retrospective cohorts evaluating the use of clonidine to wean patients from dexmedetomidine in the critically ill were *** primary outcomes of interest were dosing and titration schema of enteral clonidine and dexmedetomidine and risk factors for dexmedetomidine *** secondary outcomes included prevalence of adverse events associated with enteral clonidine use,re-initiation of dexmedetomidine,duration of mechanical ventilation,and ICU length of *** A total of 3427 studies were screened for inclusion with three meeting inclusion criteria with a total of 88 *** three studies were observational,two being prospective and one *** all included studies,the choice to start enteral clonidine to wean off dexmedetomidine was made at the discretion of the *** time ranged from 13 to 167 h on *** clonidine was started in the prospective studies in a similar protocolized method,with 0.3 mg every 6 *** starti

关键词： Clonidine Dexmedetomidine Intensive care unit Withdrawal Weaning

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Exposure to blast shock waves via the ear canal induces deficits in vestibular afferent function in rats

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Journal of Otology 2020年第3期15卷 77-85页

作者： Yue Yu Jun Huang Xuehui Tang jerome Allison David Sandlin Dalian Ding Yi Pang Chunming Zhang Tianwen Chen nathan Yin Lan Chen William Mustain Wu Zhou Hong Zhu Departmant of Otolaryngology and Communicative Sciences University of Mississippi Medical CenterJacksonMSUSA Department of Neurobiology and Anatomical Sciences University of Mississippi Medical CenterJacksonMSUSA Department of Pediatric University of Mississippi Medical CenterJacksonMSUSA Program in Neuroscience University of Mississippi Medical CenterJacksonMSUSA Center for Hearing and Deafness University at BuffaloBuffaloNYUSA Department of Otolaryngology First Affiliated HospitalShanxi Medical UniversityTaiyuan Shanxi030001China Department of Neurology University of Mississippi Medical CenterJacksonMSUSA

The ears are air-filled structures that are directly impacted during blast *** addition to hearing loss and tinnitus,blast victims often complain of vertigo,dizziness and unsteady posture,suggesting that blast exposure induces damage to the vestibular end organs in the inner ***,the underlying mechanisms remain to be *** this report,single vestibular afferent activity and the vestibuloocular reflex(VOR)were investigated before and after exposure to blast shock waves(~20 PSI)delivered into the left external ear canals of anesthetized *** vestibular afferent activity was recorded from the superior branch of the left vestibular nerves of the blast-treated and control rats one day after blast *** exposure reduced the spontaneous discharge rates of the otolith and canal *** exposure also reduced the sensitivity of irregular canal afferents to sinusoidal head rotation at *** exposure,however,resulted in few changes in the VOR responses to sinusoidal head rotation and *** the best of our knowledge,this is the first study that reports blast exposure-induced damage to vestibular afferents in an animal *** results provide insights that may be helpful in developing biomarkers for early diagnosis of blast-induced vestibular deficits in military and civilian populations.

关键词： Primary blast injury Vestibular end organ Vestibulo-ocular reflex Vestibular afferent Vestibular hair cell

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AME证据系列001--转化医学协会:脓毒症诊断和早期识别的临床实践指南

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临床与病理杂志 2016年第10期36卷 1467-1476页

作者： Zhongheng Zhang nathan J.smischney Haibo Zhang Sven Van Poucke Panagiotis Tsirigotis Jordi Rello Patrick M.Honore Win Sen Kuan Juliet June Ray Jiancang Zhou You Shang Yuetian Yu Christian Jung Chiara Robba Fabio Silvio Taccone Pietro Caironi David Grimaldi Stefan Hofer George Dimopoulos Marc Leone Sang-Bum Hong Mabrouk Bahloul Laurent Argaud Won Young Kim Herbert D.Spapen Jose Rodolfo Rocco 张建成(译) 尚游(译) 钟鸣(校) Department of Emergency Medicine Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhou 310016 Department of Critical Care Medicine Jinhua Hospital of Zhejiang UniversityJinhua Zhejiang 321000 Department of Anesthesiology Mayo ClinicRochesterMNUSA Keenan Research Center for Biomedical Science of St.Michael's Hospital Departments of Anesthesia and PhysiologyInterdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoONCanada Departments of Anesthesiology Critical CareEmergency Medicine and Pain TherapyZiekenhuis Oost-Limburgy GenkBelgium 2nd Department of Internal Medicine Attikcon University HospitalMedical SchoolNational and Kapodistrian University of AthensAthensGreece CIBERES Vall d'Hebron Institut of ResearchUniversitat Autonoma de BarcelonaSpain Universitair Ziekenhuis Brussely Vrije Universiteit Brussel Brussels BrusselsBelgium Emergency Medicine Department National University HospitalNational University Health SystemSingapore and the Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore DeWitt Daughtry Family Department of Surgery Jackson Memorial HospitalUniversity of Miami Leonard M.Miller School of MedicineMiamiFLUSA Department of Critical Care Medicine Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhou 310016 Department of Critical Care Medicine Union HospitalTongji Medical CollegueHuazhong University of Science and TechnologyWuhan 430022 Department of Critical Care Medicine Renji HospitalShanghai Jiao Tong University School of MedicineShanghai 200001 University Hospital Dusseldorf Heinrich-Heine-University DusseldorfMedical FacultyDivision of CardiologyPulmonology and Vascular MedicineDusseldorfGermany Neurosciences Critical Care Unit Addenbrooke's HospitalCambridgeUK Department of Intensive Care Hopital ErasmeUniversite Libre de Bruxelles(ULB)BrusselsBelgium Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti Fondazione IRCCS Ca'Granda-Ospedale

脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊... 详细信息

脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊断需要不断改变来满足临床和研究的要求。然而,尽管有许多新型的生物标记和筛选工具去预测脓毒症发生的风险,但是这些措施的诊断价值和有效性不足以让人满意,并且没有充分的证据去建议临床使用这些新技术。因此,脓毒症的临床诊断标准需要定期更新去适应不断产生的新证据。这篇综述旨在呈现当前脓毒症的诊断和早期识别方面的最新研究证据。临床运用不同的诊断方法的推荐意见依赖于推荐、评价、发展和评估分级体系(Grades of Recommendation Assessment,Development and Evaluation,GRADE),因为大部分的研究是观察性研究,并没有对这些方法进行可靠评估,采用的是两步推理方法。未来需要更多研究来确认或者反驳某一特殊的指标检测,同时应该直接采用相关病人的结果数据。

关键词：脓毒症早期识别诊断

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