Critical Care Medicine最新文献

{"title":"Early Active Mobilization of the Ventilated Patient-Is It Worth the Cost?","authors":"Donald B Chalfin","doi":"10.1097/CCM.0000000000006814","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006814","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144752634","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Mechanical Power During Prone Positioning and Mortality in Patients With Acute Respiratory Distress Syndrome.","authors":"Yao Wu, Rong Liufu, Yang-Yan-Qiu Wang, Yan Chen, Shan Li, Run Dong, Jun Xu, Hua-Dong Zhu, Yun Long, Chen-Qi Zhu, Yuan Guo, Bin Du, Li Weng","doi":"10.1097/CCM.0000000000006811","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006811","url":null,"abstract":"<p><strong>Objectives: </strong>Optimal parameters for evaluating the effectiveness of prone positioning in acute respiratory distress syndrome (ARDS) remain undefined. This study aims to investigate the relationship between dynamic change in mechanical power during prone positioning and mortality in patients with ARDS.</p><p><strong>Design: </strong>This was a single-center retrospective cohort study.</p><p><strong>Setting: </strong>The Center of Critical Care Medicine of Peking Union Medical College Hospital.</p><p><strong>Patients: </strong>ARDS patients who underwent prone positioning while receiving invasive mechanical ventilation were enrolled.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>A total of 1078 patients (720 [66.8%] male; median age, 63 yr [interquartile range (IQR), 51-72 yr]) were enrolled. The median duration of selected prone position sessions was 15.0 hours (IQR, 9.0-17.0 hr). ICU mortality was 20.9% (225/1078). Mechanical power during prone positioning increased in nonsurvivors compared with survivors (0.8 × 10-2 J/min/kg [IQR, -3.3 to 5.6 × 10-2 J/min/kg] vs. -0.6 × 10-2 J/min/kg [IQR, -4.9 to 3.3 × 10-2 J/min/kg]; p = 0.001). Patients with increased mechanical power during prone positioning had higher ICU mortality (23.9% vs. 17.8%; p = 0.011), in-hospital mortality (25.2% vs. 19.5%; p = 0.018), and 28-day mortality (33.2% vs. 25.4%; p = 0.002). Multivariable time-dependent Cox proportional hazards model confirmed that increased mechanical power was independently associated with higher ICU mortality risk (hazard ratio for each 10-U increase in 10-2 J/kg/min 1.071; 95% CI, 1.020-1.125; p = 0.007). Additionally, increased mechanical power during prone positioning was also independently associated with higher in-hospital mortality risk, 28-day mortality risk, and fewer ventilator-free days.</p><p><strong>Conclusions: </strong>Dynamic increases in mechanical power during prone positioning are linked to higher ICU mortality in ARDS patients. Continuous monitoring of mechanical power may guide patient selection for prone positioning.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144752633","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pharmacological Research Agenda on Adult Extracorporeal Membrane Oxygenation Using the Delphi Method: A Position Article of the Extracorporeal Membrane Oxygenation Pharmacology Network.","authors":"Diana Morales Castro, Abdulrahman Abdullah Al-Fares, Gianluca Paternoster, Haifa Lyster, Benjamin Hohlfelder, Julian Arias Ortiz, Mohd Hafiz Abdul-Aziz, Daniel Herr, Rawan Alraish, Andrés Ferre Contreras, Marcela Palavecino, Luigi Milella, Kevin Watt, Afrah Alkazemi, Federico Carlos Carini, Jason A Roberts, Jordi Riera Del Brio, Alba Pau Parra, Vivek Kakar, Pauline Dureau, Marc-Alexandre Duceppe, Mark Alm, Stephanie Cha, Kiran Shekar, Amy L Dzierba","doi":"10.1097/CCM.0000000000006806","DOIUrl":"10.1097/CCM.0000000000006806","url":null,"abstract":"<p><strong>Objectives: </strong>Extracorporeal membrane oxygenation (ECMO) is a critical intervention for patients with severe cardiac or respiratory failure. However, pharmacological management for ECMO-supported patients presents unique challenges due to alterations in drug pharmacokinetics and pharmacodynamics induced by the ECMO circuit and underlying critical illness. This position paper identifies key research priorities in ECMO pharmacology using a structured Delphi consensus process and provides a focused review of current evidence and knowledge gaps to inform future research and clinical practice.</p><p><strong>Data sources: </strong>An international panel of 25 ECMO pharmacology experts from 13 countries representing the ECMO Pharmacology Network contributed to this position article. Literature was reviewed to summarize current evidence and identify knowledge gaps in ECMO pharmacology.</p><p><strong>Study selection: </strong>The Delphi process involved iterative, anonymous voting by the expert panel to propose key research priorities. Items selected were based on their perceived importance to improving clinical outcomes and advancing pharmacological management in ECMO-supported patients.</p><p><strong>Data extraction: </strong>Key research priorities were identified, and a detailed literature review was conducted for each, focusing on pharmacokinetics/pharmacodynamics, related therapeutic challenges, and knowledge gaps. Future research directions were outlined.</p><p><strong>Data synthesis: </strong>Six critical ECMO pharmacotherapy research priorities were identified: 1) pharmacokinetics/pharmacodynamics reporting, 2) interactions between ECMO and renal replacement therapy, 3) antimicrobial dosing, 4) analgesia and sedation for pain and agitation, 5) sedation and neuromuscular blocking agents for increased work of breathing, and 6) anticoagulation. The review for the key research priorities highlighted substantial gaps in the existing literature, emphasizing the need for comprehensive studies addressing these issues to enhance pharmacotherapy in ECMO patients, improve clinical outcomes, and contribute to the development of evidence-based guidelines for this complex population.</p><p><strong>Conclusions: </strong>ECMO presents unique challenges to drug pharmacokinetics and pharmacodynamics, complicating pharmacotherapy in critically ill patients. Further research addressing identified gaps is essential to develop evidence-based treatment strategies and enhance patient outcomes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144741438","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Patients' Admission to the ICU and Psychological Disorders in Their Families: A Retrospective Matched-Pair Cohort Study.","authors":"Kasumi Shirasaki, Hiroyuki Ohbe, Toru Hifumi, Masaki Okajima, Norio Otani, Hideo Yasunaga","doi":"10.1097/CCM.0000000000006793","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006793","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to evaluate the impact of a family member's ICU admission on post-intensive care syndrome family (PICS-F).</p><p><strong>Design: </strong>Retrospective, cohort study using a matched-pair, cohort design and a large administrative database reflecting the entire Japanese population.</p><p><strong>Setting: </strong>The data were provided by DeSC Healthcare (Tokyo, Japan); the database comprised administrative claims data of 3.44 million insurance subscribers.</p><p><strong>Patients: </strong>The exposure group was defined as family members of ICU patients from April 1, 2014 to November 30, 2022. Then, families of ICU patients were randomly matched to individuals in the non-exposure group with an exposure to non-exposure ratio of 1:4; matching was performed by age (the same month and year of birth), sex, status of medical insurance, and relationship with the householder.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The primary outcome was the prevalence of psychological disorders associated with a diagnosis of PICS-F that needed medical care at least once within 6 months after the ICU admission date of the matched pair. Multivariable logistic regression analyses and subgroup analyses by relationship to the ICU patient (spouse, parent, or child) were performed.Of the eligible individuals, 35,652 family members of 27,748 ICU patients were matched with 142,463 individuals in the non-exposure group. The prevalence of psychological disorders associated with PICS-F within 6 months from the index date was significantly higher in the ICU patients' families than in the matched individuals (15.1% vs. 13.6%; adjusted odds ratio, 1.08; 95% CI, 1.02-1.15). Similar to the main analyses, ICU patients' spouses had a significantly higher prevalence of psychological disorders associated with PICS-F than matched individuals, but there were no significant differences in ICU patients' parents and children.</p><p><strong>Conclusions: </strong>Families of ICU patients, especially spouses, were more likely to seek medical care for psychological disorders associated with PICS-F within 6 months than individuals not exposed to a family member's ICU admission.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144741434","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epidemiology of Substance-Related Admissions to ICUs in the United States.","authors":"Kelsey Hills-Dunlap, Max McGrath, Ryan Peterson, P Michael Ho, Tyree H Kiser, R William Vandivier, Ellen L Burnham, Marc Moss, Sarah E Jolley","doi":"10.1097/CCM.0000000000006803","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006803","url":null,"abstract":"<p><strong>Objectives: </strong>To determine the prevalence, demographic characteristics, and predictors of in-hospital mortality for substance-related ICU admissions in the United States.</p><p><strong>Design: </strong>Multicenter, retrospective cohort study.</p><p><strong>Setting: </strong>U.S. ICUs reporting data to the nationally representative Premier Healthcare Database between 2016 and 2019.</p><p><strong>Patients: </strong>Adult ICU admissions with an International Classification of Diseases, 10th Revision diagnosis of a substance-related disorder not in remission.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Among 4,740,799 ICU admissions, a substance-related diagnosis was present in 760,153 (mean age 51.8 yr, 65.5% male, 73.7% White, 74.5% non-Hispanic), representing 16.0% (95% CI, 16.00-16.07%) of all ICU admissions or approximately one of every six ICU admissions. Alcohol was the most common substance associated with ICU admission (8.9% of all encounters; 95% CI, 8.87-8.92%), followed by opioids and stimulants (4.0%; 95% CI, 3.97-4.01% and 2.9%; 95% CI, 2.91-2.94%, respectively). Rates of nearly all substance-related ICU admissions were higher in patients 55-64 years old and in patients who identified as male, non-Hispanic, and \"Other\" race (not identified as White, Black, or Asian). In comparing White and Black patients, the two largest racial groups within our cohort, opioid-related ICU admission rates were higher in White patients while stimulant-related ICU admission rates were higher in Black patients. Only 6.5% (95% CI, 6.37-6.60%) of opioid-related ICU admissions identified heroin use. In multivariable analysis adjusting for relevant covariates, odds of in-hospital mortality following a substance-related ICU admission were higher for encounters that included alcohol-related diagnoses (adjusted odds ratio [aOR], 1.12; 95% CI, 1.06-1.19), female sex (aOR, 1.07; 95% CI, 1.04-1.09), and non-Hispanic ethnicity (aOR, 1.08; 95% CI, 1.01-1.16).</p><p><strong>Conclusions: </strong>A substantial burden of substance-related diagnoses exists in patients admitted to ICUs. Alcohol use was most common and associated with increased hospital mortality relative to other substances. Rates of substance-related ICU admission differed by age, sex, race, and ethnicity. These findings may have implications for effective allocation of resources toward addiction-related diagnoses, treatment, and secondary prevention for ICU patients.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144741436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epinephrine Before Defibrillation in Children With Initially Shockable In-Hospital Cardiac Arrest.","authors":"Morgan B Swanson, Javier J Lasa, Paul S Chan, Ryan W Morgan, Robert M Sutton, Alexis A Topjian, Dianne L Atkins, Sarah E Haskell, Tia T Raymond, Saket Girotra","doi":"10.1097/CCM.0000000000006804","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006804","url":null,"abstract":"<p><strong>Objective: </strong>Assess prevalence of epinephrine before or during the same minute as defibrillation and association with clinical outcomes in pediatric in-hospital cardiac arrest (IHCA).</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>We used 2000-2020 data from the American Heart Association's Get With the Guidelines-Resuscitation Registry.</p><p><strong>Patients: </strong>Children (< 18 yr) with index IHCA with an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least one defibrillation attempt.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The primary exposure was epinephrine administration before or during the same minute as defibrillation. Study outcomes were survival to hospital discharge (primary outcome), return of spontaneous circulation (ROSC) for greater than or equal to 20 min, and survival with favorable neurologic outcome. Propensity-score matching was used for confounding adjustment. Among 492 pediatric IHCA index events with an initial shockable rhythm, median age was 7 years and 351 (71%) were in the ICU. Overall, 232 (47%) children received either epinephrine before defibrillation (29%) or during the same minute as defibrillation (18%). In unadjusted analyses, proportions of survival to hospital discharge (37.1% vs. 51.2%), ROSC (74.6% vs. 84.6%), and survival with favorable neurologic outcome (22.1% vs. 40.4%) were lower in the epinephrine before or during the same minute as defibrillation group. However, in adjusted analyses using propensity score matching with exact matching on time to defibrillation category, epinephrine before or during the same minute as defibrillation was not associated with hospital survival (odds ratio [OR] 0.84, 0.46-1.56), ROSC (OR 0.97, 0.48-1.96), or favorable neurologic outcome (OR 0.52, 0.27-1.00).</p><p><strong>Conclusions: </strong>Contrary to current guidelines, nearly 50% of pediatric IHCA due to an initial shockable rhythm receive epinephrine before, or during the same minute, as first defibrillation. Although survival outcomes were numerically lower in epinephrine before defibrillation group, the association was not statistically significant.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144741437","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Presentation, Laboratory Abnormalities, and Predictors of Outcome in 103 Patients With Acute Paraquat Poisoning: A Prospective Observational Study.","authors":"Alladi Mohan, Janjam Harikrishna, Bayyareddy Venkata Rami Reddy, Gottam Bindhu Madhavi, Lakshmanan Jeyaseelan, Kalpalatha K Guntupalli","doi":"10.1097/CCM.0000000000006807","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006807","url":null,"abstract":"<p><strong>Objectives: </strong>To study the clinical presentation and predictors of mortality in paraquat poisoning.</p><p><strong>Design: </strong>Prospective observational study.</p><p><strong>Setting: </strong>Tertiary care teaching hospital.</p><p><strong>Subjects: </strong>Patients presenting with paraquat poisoning.</p><p><strong>Interventions: </strong>We studied the clinical presentation, laboratory abnormalities, and predictors of mortality in 103 consecutive patients admitted to the medicine wards and medical ICU with acute paraquat self-poisoning from August 2023 to March 2024.</p><p><strong>Measurements and main results: </strong>The mean age of the patients was 29.5 ± 10.5 years, there were 73 males (70.8%). The most common presenting symptom was vomiting (93%) followed by throat pain (85%). Of the 103, 78 patients died (75.7%). On univariate analysis, significantly higher median (interquartile range) amount of poison consumed (45 mL [20-100 mL] vs. 10 mL [5-10 mL]; p < 0.001), serum creatinine (6 mg/dL [3.8-8.9 mg/dL] vs. 1.9 mg/dL [0.8-3.2 mg/dL]; p < 0.001), serum bilirubin (5.9 mg/dL [3.7-9.5 mg/dL] vs. 1.1 mg/dL [0.7-3.3 mg/dL]; p < 0.001), and Acute Physiology and Chronic Health Evaluation II score (15.5 [12-19] vs. 7 [3.5-11]; p < 0.001) and a significantly lower ratio of Pao2/Fio2 at the time of admission (300 [150-400] vs. 420 [396-485]; p < 0.001) were evident in patients who died compared with survivors. An increasing trend in the mortality was observed with increasing International Program on Chemical Safety Poisoning Severity Score grade (p = 0.001). On multivariable analysis, shortness of breath (odds ratio [OR], 0.008; p = 0.072), hepatic dysfunction (OR, 0.012; p = 0.048), duration of hospital stay (OR, 1.030; p = 0.023), and presence of infiltrates on chest radiograph/CT chest (OR, 0.003; p = 0.011) emerged as significant independent predictors of mortality.</p><p><strong>Conclusions: </strong>Paraquat is a lethal poison associated with a high mortality. Identification of predictors of mortality can facilitate early aggressive attempts at initiating appropriate treatment.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144741435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Trends of Physical and Occupational Therapy Utilization in ICU Patients Undergoing Mechanical Ventilation in the United States: 2008-2021.","authors":"Joel Mintz, Mohammed Mustafa, Rose M Puthumana, Juan P Uribe, Christopher M Mallow, Hayley B Gershengorn","doi":"10.1097/CCM.0000000000006795","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006795","url":null,"abstract":"<p><strong>Background: </strong>Physical and occupational therapy (PT/OT) during invasive mechanical ventilation (IMV) may improve outcomes, however, utilization patterns are understudied.</p><p><strong>Objectives: </strong>Determine trends over time and by hospital in PT/OT utilization.</p><p><strong>Design: </strong>Retrospective study.</p><p><strong>Setting: </strong>Premier Healthcare Database hospitals (2008-2021).</p><p><strong>Patients: </strong>Adults beginning IMV by hospitalization day 3 and receiving IMV continuously for 3-14 days.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The primary outcome was PT/OT usage within the first 3 days of IMV (early PT/OT). Cochran-Armitage tests were used to evaluate unadjusted trends across discharge years. A multilevel multivariable logistic regression model was then created with discharge hospital as a random effect and clinical, sociodemographic, and hospital characteristics as covariables. The median odds ratio (mOR) was calculated to quantify the association of discharge hospital with PT/OT utilization. Across 814 hospitals, 1,228,909 early IMV hospitalizations were identified. Of those, 118,662 (9.7%) had early PT/OT. Frequency of early PT/OT rose from 2008 to 2019 (8.5-10.8%; ptrend < 0.001) before declining in 2020 (9.5%) and 2021 (8.9%). Across hospitals, median early PT/OT usage was 5.4% (interquartile range, 2.9-11.0%). After multivariable adjustment, patients were increasingly more likely to get early PT/OT every year until 2016 (adjusted odds ratio [aOR] for 2016 vs. 2008, 1.52; 95% CI, 1.46-1.59). Use then remained relatively flat until 2020 when it began to decline (aOR for 2020, 1.23; 95% CI, 1.18-1.29 and aOR for 2021, 1.20; 95% CI, 1.15-1.26). The odds of receiving early PT/OT in higher use hospitals was nearly three-fold higher than in lower use hospitals (mOR, 2.82; 95% CI, 2.67-2.97).</p><p><strong>Conclusions: </strong>Early PT/OT usage rose during the early period, before declining significantly in 2020 and 2021. However, use in 2020 and 2021 remained higher than in 2008. Individual hospital of discharge was an important factor in determining who got PT/OT during IMV.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144689094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessment of Tissue Perfusion Pressure in Patients With Septic Shock: Beyond Mean Arterial Pressure.","authors":"Carlos Sanchez E, Ahmed Taha, Yasser Tolba, Glenn Hernandez, Michael R Pinsky","doi":"10.1097/CCM.0000000000006805","DOIUrl":"10.1097/CCM.0000000000006805","url":null,"abstract":"<p><strong>Objectives: </strong>Optimization of macrohemodynamics is just the starting point in the management of hemodynamics in patients with septic shock. We describe the interaction between the various determinants of arterial pressure and tissue perfusion, how to optimize them and their estimations at the bedside. This is a concise definitive review of the assessment of tissue perfusion pressure (TPP) in patients with septic shock beyond just mean arterial pressure (MAP).</p><p><strong>Data sources: </strong>Original publications were retrieved through a PubMed and MEDLINE databases with search terms related to septic shock, arterial blood pressure, critical closing pressure (Pcc), mean systemic filling pressure (Pmsf), and TPP. Supporting evidence was also retrieved from PubMed and MEDLINE when indicated.</p><p><strong>Study selection: </strong>English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies.</p><p><strong>Data extraction and data synthesis: </strong>Data from relevant publications were reviewed, selected, and summarized by the authors and applied as indicated.</p><p><strong>Conclusions: </strong>The relationship between arterial pressure and outcomes in septic shock is complex and heterogeneous. Focusing on critical parameters-such as TPP, the vascular waterfall, and individual treatment effects-enables a more personalized approach, focused on perfusion rather than pressure alone. Persistent hypoperfusion despite adequate macrocirculatory targets marks a pivotal moment when microcirculatory assessment becomes essential to guide therapy and avoid potentially harmful escalation of fluids or vasopressors. Bedside measurements of systolic arterial pressure, MAP, diastolic arterial pressure, Pcc, and Pmsf offer practical tools for monitoring and tailoring treatment. Future clinical trials are needed to validate these metrics and refine resuscitation strategies in septic shock.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144642028","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early Vasopressor Utilization in Critically Ill Patients With Acute Traumatic Spinal Cord Injury: A Retrospective Cohort Study.","authors":"Mona Hashemaghaie, Tetsu Ohnuma, Ruba Sajdeya, Shreya Khandelwal, N David Yanez, Vijay Krishnamoorthy, Karthik Raghunathan, Michael J Devinney, Aparna Depuru, Miriam M Treggiari","doi":"10.1097/CCM.0000000000006791","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006791","url":null,"abstract":"<p><strong>Objectives: </strong>Evidence regarding vasopressor support for acute spinal cord injury (SCI) is lacking. We report early vasopressor use and hospital outcomes in patients with SCI.</p><p><strong>Design: </strong>Propensity-score standardized mortality ratio-weighted retrospective cohort study.</p><p><strong>Setting: </strong>U.S. hospitals participating in the Premier Healthcare Database, 2016-2020.</p><p><strong>Patients: </strong>Adults 18 years old or older with acute traumatic SCI at T8 level or above who received vasopressors within 48 hours of hospitalization.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Of 3636 patients included (mean [sd] age, 56 [19]; 2757 [75%] males), 2055 (57%) received phenylephrine, 548 (15%) received norepinephrine, 110 (3%) received other single vasopressor, and 923 (25%) received multiple vasopressors. Baseline cervical SCIs, higher Injury Severity Scores, neurogenic shock, and mechanical ventilation were more likely with norepinephrine administration. The primary outcome was death/hospice/skilled nursing facility vs. home/inpatient care facility/rehabilitation facility. Compared with the phenylephrine group, the norepinephrine group was more likely to have a discharge disposition of death/hospice/or skilled nursing facility (odds ratio [OR], 1.50; 95% CI, 1.14-1.99), and adverse events, including urinary tract infections (OR, 1.66; 95% CI, 1.17-2.35), cardiac arrest (OR, 2.70; 95% CI, 1.74-4.19), acute kidney injury (OR, 1.91; 95% CI, 1.32-2.77), tracheostomy (OR, 1.39; 95% CI, 1.04-1.86), death (OR, 2.04; 95% CI, 1.42-2.93), and longer hospital length of stay (estimate, 3.68 d; 95% CI, 1.63-5.74 d). We observed no differences in pneumonia, thromboembolic events, or cerebrovascular accidents.</p><p><strong>Conclusions: </strong>Phenylephrine and norepinephrine were the most used vasopressors in SCI patients, with norepinephrine more frequently selected in patients with higher injury severity. While indication bias and residual confounding may explain our findings, these data raise the question whether phenylephrine and norepinephrine have different efficacy and safety profiles. Future research should focus on comparative trials of these two commonly prescribed agents.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144689093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}