Critical Care Medicine最新文献

{"title":"Artificial Intelligence Guided Bronchoscopy is Superior to Human Expert Instruction for the Performance of Critical-Care Physicians: A Randomized Controlled Trial.","authors":"Kaladerhan O Agbontaen, Kristoffer M Cold, David Woods, Vimal Grover, Hatem Soliman Aboumarie, Sundeep Kaul, Lars Konge, Suveer Singh","doi":"10.1097/CCM.0000000000006629","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006629","url":null,"abstract":"<p><strong>Objectives: </strong>Bronchoscopy in the mechanically ventilated patient is an important skill for critical-care physicians. However, training opportunity is heterogenous and limited by infrequent caseload or inadequate instructor feedback for satisfactory competencies. A new artificial intelligence (AI) navigational system using augmented reality - the Ambu Broncho Simulator - can guide bronchoscopy training. Is training with the AI system comparable to bedside, expert tutor instruction in improving bronchoscopy performance?</p><p><strong>Design: </strong>A nonblinded, parallel group randomized controlled trial was conducted.</p><p><strong>Setting: </strong>The study was conducted in a simulated setting at an academic university hospital.</p><p><strong>Subjects: </strong>Critical-care physicians were invited to take part in the study.</p><p><strong>Interventions: </strong>Forty participants received 30 minutes of bronchoscopy training, either guided by AI only (artificial intelligence group [AIG]) or by expert tutor feedback (expert tutor group [ETG]). All participants performed a final full navigation bronchoscopy performance test and completed a cognitive load questionnaire, the NASA Task Load Index .</p><p><strong>Measurements and main results: </strong>Mean intersegmental time (MIT = PT/DC), diagnostic completeness (DC), procedure time (PT), structured progress (SP), and number of segments revisited (SR) were measured. The primary outcome measure assessed was MIT, a measure of bronchoscopic performance efficiency. The secondary outcome measures were DC, PT, SP, and SR. Nineteen participants were randomized to the AIG and 21 participants to the ETG. MIT, PT, and SR were significantly better in the AIG compared to the ETG (median difference, p): MIT (-7.9 s, 0.027), PT (-77 s, 0.022), SR (-7 segments, 0.019); all showing moderate effect sizes (0.35, 0.36, and 0.37, respectively) as per Cohen's classification.There was no significant difference between the groups for all other final test measures.</p><p><strong>Conclusions: </strong>Training using an AI system resulted in faster and more efficient bronchoscopy performance by critical-care physicians when compared to expert human tutor instruction. This could change the future of bronchoscopy training in critical care and warrants validation in patients through clinical studies.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143662951","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":"Updating the Understanding of the Association Between Body Mass Index and Survival in Venous-Venous Extracorporeal Membrane Oxygenation.","authors":"Carmen Silvia Valente Barbas","doi":"10.1097/CCM.0000000000006644","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006644","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143656359","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 Antibiotic Initiation and Survival in Hospital-Acquired Pneumonia.","authors":"Subhadra Mandadi, Andre C Kalil","doi":"10.1097/CCM.0000000000006643","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006643","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143656354","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":"Net Fluid Balance Impacts Pediatric Continuous Renal Replacement Therapy Liberation.","authors":"Sameer Thadani, Harsha V Jujjavarapu, Christin Silos, Katja M Gist, Poyyapakkam Srivaths, Katri Typpo, Christopher Horvat, Michael J Bell, Dana Y Fuhrman, Ayse Akcan Arikan","doi":"10.1097/CCM.0000000000006636","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006636","url":null,"abstract":"<p><strong>Objectives: </strong>The optimal fluid management strategy on continuous renal replacement therapy (CRRT) is unknown for critically ill children. The pace of ultrafiltration has been highlighted as a risk predictor for adverse outcomes in adult cohorts. Whether CRRT can cause dialytrauma through excessive ultrafiltration rates (UFRs) in children is undetermined. Although fluid overload (FO) at CRRT start has been associated with adverse outcomes, net fluid balance (NFB) on CRRT has not been investigated as a predictor for renal recovery.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Two quaternary PICUs.</p><p><strong>Patients or subjects: </strong>Children and young adults admitted between 2/2014 and 2/2020 at two quaternary pediatric hospitals who received CRRT.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Three hundred and seventy-one patients were included in this study with the median age of 85 months (interquartile range [IQR] 17-172), 180 (50%) were female. Three hundred and forty-five (96%) had acute kidney injury at CRRT start, 102 (28%) patients had FO > 15%. The median NFB on day 1 was 0.33 mL/kg/hr (-0.43 to 1.18), day 2 was -0.14 mL/kg/hr (-0.72 to 0.52), and day 3 was -0.24 mL/kg/hr (-0.85 to 0.42). Patients with a preserved urine output (UOP) greater than 0.3 mL/kg/hr over the study period had 5.6 more CRRT-free days and had decreased odds of major adverse kidney events at 30 days (MAKE-30). A NFB between -4.46 and -0.305 mL/kg/hr was independently associated with more CRRT-free days (β 2.90 [0.24-5.56]) and decreased odds of MAKE-30 (adjusted odds ratio 0.41 [0.22-0.79]).</p><p><strong>Conclusions: </strong>Ultrafiltration practices in children receiving CRRT are substantially different compared to adult cohorts. Patients with a more positive NFB had fewer CRRT-free days. Preservation of UOP was associated with more CRRT-free days. Whether UFR causes direct dialytrauma in critically ill children through impairment of organ perfusion and hemodynamics require further study to allow personalization of CRRT prescriptions to improve outcomes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143656355","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":"Toward Optimizing Short-Acting Beta-Blockers in Septic Shock.","authors":"Nicholas A Bosch","doi":"10.1097/CCM.0000000000006638","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006638","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143656357","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":"Effect of Monetary Incentives on Peer Review Acceptance and Completion: A Quasi-Randomized Interventional Trial.","authors":"Christopher S Cotton, Abid Alam, Sophie Tosta, Timothy G Buchman, David M Maslove","doi":"10.1097/CCM.0000000000006637","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006637","url":null,"abstract":"<p><strong>Objectives: </strong>Peer review typically relies on experts volunteering their time to review research. This process presents challenges for journals that may face a shortage of qualified referees, resulting in either delay in handling papers or less thorough review than is optimal. We experimentally tested the impact of providing cash incentives to complete peer review assignments at Critical Care Medicine.</p><p><strong>Design: </strong>Quasi-randomized, blinded, interventional study with an alternating treatment design.</p><p><strong>Setting: </strong>Critical Care Medicine (CCM), a peer-reviewed specialty journal.</p><p><strong>Subjects: </strong>All reviewers receiving requests from CCM to review research articles during a 6-month period from September 2023 to March 2024 (excluding a 2-wk holiday window).</p><p><strong>Interventions: </strong>In alternating 2-week blocks, reviewer invitation letters were sent out, including either an offer of $250 for accepting the peer review request (treatment) or the standard letter with no cash offer (control). Reviewers who fulfilled incentivized invitations received a $250 check from the journal.</p><p><strong>Measurements and main results: </strong>Our primary outcome was the rate of invitation-to-completed-review conversion, defined as the number of reviews submitted divided by the number of reviewer invitations sent out. Secondary outcomes included the \"on-time\" conversion rate, invitation acceptance rate, time to invitation acceptance, time to review submission, and review quality. Seven hundred fifteen reviewer invitations were sent out, 414 of which (57.9%) included an incentive offer. Two hundred eighteen (52.7%) of the incentivized invitations were accepted, compared with 144 (47.8%) in the control group. A greater proportion of reviewer invitations led to submitted peer review reports in the incentive group than in the control group (49.8% [206/414] vs. 42.2% [127/301]; p = 0.04). In a \"survival analysis,\" invitations sent with an incentive offer were fulfilled faster on average (Cox proportional hazard ratio, 1.30 [1.04-1.62]; p = 0.02), corresponding to quicker review times of approximately 1 day (11 vs. 12 d). Of the 333 reviewer reports submitted, 205 (61.6%) were assessed by editors, with no difference in review quality noted between study arms.</p><p><strong>Conclusions: </strong>Providing cash incentive for completing peer review reports resulted in a modest increase in the share of invited reviewers who complete reviews for a specialty medical journal.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143566355","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 Performance of Spo2/Fio2 and Pao2/Fio2 Ratio in Mechanically Ventilated Acute Respiratory Distress Syndrome Patients: A Retrospective Study.","authors":"Silvia Coppola, Tommaso Pozzi, Giulia Catozzi, Alessandro Monte, Enrico Frascati, Davide Chiumello","doi":"10.1097/CCM.0000000000006623","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006623","url":null,"abstract":"<p><strong>Objectives: </strong>The present study aims to evaluate the severity classification of acute respiratory distress syndrome (ARDS) in mechanically ventilated patients according to peripheral oxygen saturation by pulse oximetry (Spo2)/Fio2 ratio compared with Pao2/Fio2 ratio and the relationship between Spo2/Fio2 ratio and venous admixture.</p><p><strong>Design: </strong>Retrospective observational study.</p><p><strong>Setting: </strong>Medical-surgical ICU.</p><p><strong>Patients: </strong>A cohort of 258 mechanically ventilated patients with ARDS already enrolled in previous studies.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Gas exchange, Spo2, and respiratory mechanics were measured on ICU admission and during the positive end-expiratory pressure (PEEP) trial. Radiological data from CTs were used to compute lung recruitability and to assess different lung compartments. A nonlinear association was found between Spo2/Fio2 and Pao2/Fio2. Considering the possible confounding factors of the pulse oximeter on the relationship between Spo2/Fio2 and Pao2/Fio2 ratio, arterial pH, and Paco2 had no effect. Spo2/Fio2 and Pao2/Fio2 ratio demonstrated a moderate agreement in classifying ARDS severity (intraclass correlation coefficient = 0.63). Between the correspondent classes according to Spo2/Fio2 vs. Pao2/Fio2 ratio-derived severity classifications, there was no difference in terms of respiratory mechanics, gas exchange, lung radiological characteristics and mortality in ICU, and within two levels of PEEP. A Spo2/Fio2 ratio less than 235 was able to detect 89% of patients with a venous admixture greater than 20%, similarly to a Pao2/Fio2 ratio less than 200.</p><p><strong>Conclusions: </strong>Spo2/Fio2 ratio can detect oxygenation impairment and classify ARDS severity similarly to Pao2/Fio2 ratio in a more rapid and handy way, even during a PEEP trial. However, our results may not be applicable to different patient populations; in fact, the pulse oximeter is merely a monitoring device and the information should be personalized by the physician on the patient's characteristics and conditions.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143540471","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":"Omega-3 Polyunsaturated Fatty Acids in Sepsis: From Prevention to Early Treatment.","authors":"Evangelos J Giamarellos-Bourboulis","doi":"10.1097/CCM.0000000000006626","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006626","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143540472","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":"Time to Renal Replacement Therapy Initiation in Critically Ill Patients With Acute Kidney Injury: A Secondary Analysis of the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial.","authors":"Rachel Jeong, Sean M Bagshaw, Ehsan Ghamarian, Andrea Harvey, Michael Joannidis, Brian Kirkham, Danny McAuley, Marlies Ostermann, Jean-Pierre Quenot, Paul J Young, Ron Wald","doi":"10.1097/CCM.0000000000006616","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006616","url":null,"abstract":"<p><strong>Objectives: </strong>Among critically ill patients with severe acute kidney injury (AKI) who lack emergent indications for renal replacement therapy (RRT), a strategy of preemptive RRT initiation does not lead to improved outcomes. However, for patients with persistent AKI and without urgent indications for RRT, the safety of prolonged delays in RRT initiation is unclear. We sought to assess the association between progressively longer delays in RRT initiation and clinical outcomes.</p><p><strong>Design: </strong>A post hoc secondary analysis.</p><p><strong>Setting: </strong>The multinational STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial.</p><p><strong>Patients: </strong>Participants allocated to the standard strategy of the STARRT-AKI trial.</p><p><strong>Interventions: </strong>The exposure was time from randomization to RRT initiation, evaluated in quartiles and as a continuous variable.</p><p><strong>Measurements and main results: </strong>The primary outcome was all-cause mortality at 90 days. Secondary outcomes were RRT dependence, RRT-free days, and hospital-free days, all at 90 days, as well length of ICU and hospital stay. Of the 1462 participants allocated to the standard strategy group, 903 (62%) received RRT. Median time (interquartile range) to RRT initiation was 12.1 hours (8.3-13.8 hr), 24.5 hours (21.8-26.5 hr), 46.8 hours (35.2-52.1 hr), and 96.1 hours (76.7-139.2 hr) in quartiles 1-4, respectively. Prolonged time to RRT initiation was associated with a lower risk of death at 90 days (quartile 4 vs. 1: adjusted odds ratio, 0.63 [95% CI, 0.42-0.94]); further analyses using cubic splines and inverse probability weighting to account for immortal time bias showed no association with the risk of death. There was no association between time to RRT initiation and RRT-free days, hospital-free days, or lengths of ICU or hospital stay. Longer delay to RRT initiation had a linear association with RRT dependence at 90 days.</p><p><strong>Conclusions: </strong>Among patients with no urgent indications and who received RRT in the standard strategy of the STARRT-AKI trial, longer deferral of RRT initiation was not associated with a higher risk of mortality.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143540473","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":"A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.","authors":"Kimberley Lewis, Michele C Balas, Joanna L Stollings, Molly McNett, Timothy D Girard, Gerald Chanques, Michelle E Kho, Pratik P Pandharipande, Gerald L Weinhouse, Nathan E Brummel, Linda L Chlan, Makayla Cordoza, Jeremiah J Duby, Céline Gélinas, Erin L Hall-Melnychuk, Anna Krupp, Patricia R Louzon, Judith A Tate, Bethany Young, Ron Jennings, Anitra Hines, Chris Ross, Kallirroi Laiya Carayannopoulos, J Matthew Aldrich","doi":"10.1097/CCM.0000000000006574","DOIUrl":"10.1097/CCM.0000000000006574","url":null,"abstract":"<p><strong>Rationale: </strong>Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.</p><p><strong>Objectives: </strong>The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.</p><p><strong>Panel design: </strong>The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.</p><p><strong>Methods: </strong>The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.</p><p><strong>Results: </strong>The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.</p><p><strong>Conclusions: </strong>The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"e711-e727"},"PeriodicalIF":7.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143467085","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}