Critical Care Medicine最新文献

{"title":"A Failure of Dexmedetomidine to Reduce Vasopressor Resistance in Refractory Septic Shock: Wrong Population or Wrong Hypothesis?","authors":"Zhong Wang, Chuan Zhang, Penglin Ma","doi":"10.1097/CCM.0000000000006723","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006723","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"53 9","pages":"e1842-e1844"},"PeriodicalIF":6.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144945966","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":"The Cost-Effectiveness of Early Active Mobilization During Mechanical Ventilation in the ICU: An Economic Evaluation Alongside the Treatment of Mechanically Ventilated Adults With Early Activity and Mobilization (TEAM) Trial.","authors":"Alisa M Higgins, Yong Yi Lee, Michael Bailey, Rinaldo Bellomo, Kathy Brickell, Tessa Broadley, Heidi Buhr, Belinda J Gabbe, Doug W Gould, Meg Harrold, Sally Hurford, Theodore J Iwashyna, Ary Serpa Neto, Alistair D Nichol, Jeffrey J Presneill, Stefan J Schaller, Janani Sivasuthan, Claire J Tipping, Steven Webb, Paul J Young, Carol L Hodgson","doi":"10.1097/CCM.0000000000006715","DOIUrl":"10.1097/CCM.0000000000006715","url":null,"abstract":"<p><strong>Objectives: </strong>Early mobilization is recommended by the Society of Critical Care Medicine ICU Liberation Bundle. The Treatment of Mechanically Ventilated Adults With Early Activity and Mobilization (TEAM) randomized controlled trial (RCT) compared early active mobilization to usual care mobilization and found no difference in the primary outcome of days alive and out of hospital to day 180; however, it did find an increase in adverse events in the intervention group. To date, no RCT of early mobilization has reported costs or cost-effectiveness. We aimed to determine the cost-effectiveness of early active mobilization from the perspective of the healthcare sector.</p><p><strong>Design: </strong>We conducted a prospective, within-trial cost-effectiveness analysis alongside the TEAM study.</p><p><strong>Setting: </strong>Forty-nine ICUs in six countries (Australia, New Zealand, United Kingdom, Ireland, Germany, and Brazil).</p><p><strong>Patients: </strong>The cost-effectiveness analysis included 733 adult ICU patients who were undergoing invasive mechanical ventilation and enrolled in the TEAM study.</p><p><strong>Interventions: </strong>Early active mobilization or usual care mobilization.</p><p><strong>Measurements and main results: </strong>A significantly higher number of hours were spent by staff in delivering high-dose early active mobilization vs. usual care mobilization; however, incremental costs were not significantly different between the groups ($1,823; 95% CI, -$10,552 to $12,027). EuroQoL-5D 5-level utility scores at 6 months were not significantly different between the groups (0.532 [ se , 0.021] vs. 0.548 [ se , 0.021]; p = 0.585). The probability of early active mobilization being cost-effective is less than 50%, even at a willingness-to-pay threshold of $200,000/quality-adjusted life year (QALY). Sensitivity analyses incorporating meta-analysis data indicated that early active mobilization may be cost-saving; however, this involves the occurrence of lower QALY gains when compared with usual care mobilization.</p><p><strong>Conclusions: </strong>Our trial-based analysis found no evidence that higher-dose early active mobilization is a cost-effective intervention compared with usual care mobilization for mechanically ventilated adult ICU patients; however, results from sensitivity analyses provided some evidence that it may be cost saving if one is willing to accept poorer outcomes. Further research is necessary to determine whether there are scenarios in which early active mobilization provides value for money.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"e1725-e1735"},"PeriodicalIF":6.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12393053/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144207886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Progress, Not Just Predictions: Critical Care Medicine's Vision for Data Science in 2025.","authors":"Patrick G Lyons, David M Maslove","doi":"10.1097/CCM.0000000000006845","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006845","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144945864","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 Course of Morbidity and Mortality Across Echocardiographic Phenotypes in Patients With Sepsis: A Systematic Review and Meta-Analysis.","authors":"Jie Wang, Zewen Tong, Xiaoting Wang, Guangjian Wang","doi":"10.1097/CCM.0000000000006844","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006844","url":null,"abstract":"<p><strong>Objectives: </strong>To determine the temporal evolution of morbidity and mortality across different echocardiographic phenotypes of new-onset myocardial dysfunction in patients with sepsis.</p><p><strong>Data sources: </strong>PubMed, Embase, Web of Science, MEDLINE, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to October 1, 2024.</p><p><strong>Study selection: </strong>All original studies related to new-onset myocardial dysfunction diagnosed by echocardiography in adult patients with sepsis were included.</p><p><strong>Data extraction: </strong>Data were collected according to the predefined outcomes.</p><p><strong>Data synthesis: </strong>This systematic review included 65 studies from 18 regions, involving 17,008 patients with sepsis. The meta-analysis encompassed three echocardiographic phenotypes, namely left ventricular systolic dysfunction (LVSD), left ventricular diastolic dysfunction (LVDD), and right ventricular dysfunction (RVD), as well as four subgroups based on different echocardiographic time points. No patients had cardiac dysfunction at baseline, and the occurrence rate of heart dysfunction declined to a minimal level during the recovery phase. The occurrence rate of LVSD peaked at 33% (95% CI, 27-40%) within 48 hours and declined to 22% (95% CI, 18-25%) within 72 hours. The occurrence rate of LVDD rose to 46% (95% CI, 34-57%) within 48 hours and dropped to 44% (95% CI, 32-56%) within 72 hours. The occurrence rate of RVD peaked at 47% (95% CI, 37-58%) within 48 hours and decreased to 33% (95% CI, 3-75%) within 72 hours. Patients with LVSD, LVDD, or RVD showed a higher risk of death (LVSD: relative risk [RR], 1.57 [95% CI, 1.29-1.91], p < 0.0001; LVDD: RR, 1.36 [95% CI, 1.05-1.75], p = 0.02; and RVD: RR, 1.62 [95% CI, 1.35-1.95], p < 0.0001).</p><p><strong>Conclusions: </strong>This meta-analysis shows a parabolic-like pattern of the occurrence rate of echocardiographic phenotypes (LVSD, LVDD, and RVD) over the time course of sepsis. LVSD, LVDD, and RVD are significant risk factors for mortality in sepsis.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144945795","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":"Prolonged Tele-Critical Care Utilization Is Associated With Improved ICU Outcomes: Evidence From Veterans Affairs Hospitals.","authors":"Mohsen Nabian, Louis Atallah, Ludmila Brochini, Yesha Vora, Joshua Rubenfeld, Ines Berger, Jayashree Raikhelkar, David E Phillips, Ralph J Panos","doi":"10.1097/CCM.0000000000006827","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006827","url":null,"abstract":"<p><strong>Objectives: </strong>To determine the impact of critical care telemedicine (tele-critical care [TCC]) implementation duration on clinical outcomes: ICU mortality, ICU length of stay (LOS), and mechanical ventilation utilization.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Thirty-five U.S. Department of Veterans Affairs (VA) hospitals (444 ICU beds) that used TCC between 2012 and 2020.</p><p><strong>Patients: </strong>One hundred ninety-three thousand three hundred sixty-seven patient stays meeting specific inclusion criteria from 2012 to 2020 were included in the study.</p><p><strong>Interventions: </strong>Critical care telemedicine (TCC) implementation.</p><p><strong>Measurements and main results: </strong>The standardized ICU mortality rate was calculated by comparing patient outcomes to expected outcomes, utilizing critical care prediction models. ICU LOS was standardized for illness severity and case mix. The rate of invasive mechanical ventilation was analyzed, comparing ventilator days against predicted values. Longer TCC utilization was linked with a trend toward lower standardized ICU mortality rates, with statistically significant reductions after a 5-year period. ICU LOS also showed a significant decrease with prolonged TCC deployment. While the rate of invasive mechanical ventilation declined over time, it was not significantly related to the TCC deployment duration.</p><p><strong>Conclusions: </strong>Extended TCC implementation improves ICU mortality rates and reduces ICU LOS. Longer TCC deployment has clear benefits on patient outcomes in the VA healthcare system. Further research should explore long-term effects and factors influencing TCC adoption.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144945826","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":"Venovenous Extracorporeal Membrane Oxygenation Cannulation by Intensivists and Surgeons: A Single-Center Retrospective Noninferiority Analysis of Complications and Outcomes From 2018 to 2023.","authors":"Sagar B Dave, Joshua L Chan, Donald R Maberry, David W Boorman, Mark E Caridi-Scheible, Eric R Leiendecker, Christina Creel-Bulos, Michael J Connor, Jeffrey Javidfar, Mani A Daneshmand, Craig S Jabaley","doi":"10.1097/CCM.0000000000006843","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006843","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the safety and efficacy of venovenous extracorporeal membrane oxygenation (ECMO) cannulation by nonsurgeon intensivists (critical care medicine intensivists [CCM]) compared with cardiothoracic surgeons (CTS).</p><p><strong>Design: </strong>Retrospective, single-center observational study using a noninferiority framework to evaluate outcomes across cannulating physician training backgrounds. The primary outcome was the rate of cannulation-related complications. Secondary outcomes included in-hospital mortality and resource utilization. Noninferiority was assessed using a predefined margin corresponding to an odds ratio of 1.55 (15% higher complication rate for CCM vs. CTS).</p><p><strong>Setting: </strong>Quaternary academic medical center with a multidisciplinary ECMO program serving the southeastern United States, including in-center and remote cannulations.</p><p><strong>Patients: </strong>Adults with refractory respiratory failure who underwent venovenous ECMO cannulation and initiation.</p><p><strong>Interventions: </strong>Cannulation and initiation of venovenous ECMO within an established program.</p><p><strong>Measurements and main results: </strong>A total of 533 cannulation events in 231 patients from January 1, 2018, to December 31, 2023, were analyzed. Patient characteristics, pre-cannulation factors, predictive scores, hospital courses, cannulation-related complications, and in-hospital mortality were compared between CCM and CTS groups. At the time of cannulation, CCM-initiated cases had lower rates of vasoactive medication use and mechanical circulatory support and were more often performed in remote settings, reflecting differences in practice patterns. In a generalized linear mixed model adjusting for cannulation site, body mass index, and respiratory failure etiology, CCM was noninferior to CTS for cannulation-related complications, with an adjusted odds ratio of 0.84 (95% CI, 0.47-1.50); the upper confidence limit remained below the predefined noninferiority threshold of 1.55. Complication rates were 12% for CCM and 15% for CTS. In-hospital mortality was 29%, with no significant difference or evidence of noninferiority between groups.</p><p><strong>Conclusions: </strong>Venovenous ECMO cannulation by nonsurgeon intensivists was noninferior to that by CTS with respect to complication rates. These findings support the safety of intensivist cannulation in multidisciplinary ECMO programs and highlight the feasibility of flexible models for ECMO delivery.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144945807","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":"Determination of Cerebral Autoregulation at the Bedside: A Narrative Review.","authors":"Jeffrey R Vitt, Spyridoula Tsetsou, Laura Galarza, Aarti Sarwal, Swarna Rajagopalan","doi":"10.1097/CCM.0000000000006790","DOIUrl":"10.1097/CCM.0000000000006790","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Objectives: &lt;/strong&gt;To summarize the current evidence on cerebral autoregulation (CAR) monitoring techniques in critical care settings, highlighting their advantages, limitations, and practical applications at the bedside to inform understanding and clinical decision-making for various acute brain injuries and systemic illnesses.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Data sources: &lt;/strong&gt;Articles were retrieved using Ovid MEDLINE, PubMed, and Cochrane library using a comprehensive combination of subject headings and key words including \"cerebral autoregulation,\" \"transcranial Doppler,\" \"near-infrared spectroscopy,\" and \"intracranial pressure.\" See Supplemental Appendix A (https://links.lww.com/CCM/H763) for complete list of search terms. Relevant articles as well as those discovered through the review process (e.g., references in selected articles) were incorporated into the article.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Study selection: &lt;/strong&gt;Original research, review articles, commentaries, and guidelines focusing on bedside CAR monitoring methodologies, their validation, and applications in critically ill patients were included. The review encompassed both acute brain injury and systemic critical illness conditions.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Data extraction: &lt;/strong&gt;Data from included publications were evaluated and synthesized into a comprehensive narrative review examining CAR monitoring methods and clinical applications.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Data synthesis: &lt;/strong&gt;Three commonly used bedside approaches for assessing CAR were identified. Transcranial Doppler ultrasound measures vessel flow velocity response to blood pressure changes, either through vasopressor administration or monitoring spontaneous fluctuations. Near-infrared spectroscopy evaluates regional cerebral oxygenation changes in response to hemodynamic alterations through continuous, noninvasive forehead sensors. Intracranial pressure monitoring enables assessment of pressure reactivity index through analyzing the correlation between intracranial and arterial blood pressure. CAR impairment is common across critical illness, from acute brain injury to systemic conditions like sepsis, cardiac surgery, and hepatic failure, where dysregulation can lead to secondary brain injury and worse outcomes. While each technique offers unique insights into CAR status, they vary in invasiveness, continuous monitoring capability, and technical requirements. Evidence suggests these methods can help to detect impaired CAR, identify optimal perfusion targets, and may guide individualized management strategies.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Bedside CAR monitoring represents a promising approach for personalizing hemodynamic management in critically ill patients. While current evidence supports its role in prognostication and management decisions, further research is needed to standardize assessment methods and validate CAR-guided therapy across different critical care conditions. Multimodal monitoring approaches may provide complementary in","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144871849","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 Relative Hypotension Below Noninvasive Cerebral Oximetry-Derived Optimal Blood Pressure Thresholds in Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.","authors":"Vishank A Shah, Mariyam Humayun, Batya Radzik, Ryan Healy, Caitlin Palmisano, Mirinda Anderson-White, Eusebia Calvillo, Romergryko Geocadin, Charles Brown, Charles Hogue, Wendy Ziai, Sung-Min Cho, Jose I Suarez, Lucia Rivera-Lara","doi":"10.1097/CCM.0000000000006826","DOIUrl":"10.1097/CCM.0000000000006826","url":null,"abstract":"<p><strong>Objectives: </strong>Impairment in cerebral autoregulation (CA) after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI) and poor outcomes. We assessed: 1) feasibility of defining CA-based optimal mean arterial pressure (MAPOpt) thresholds using noninvasive cerebral oximetry and 2) associations of relative hypotension below MAPOpt in the early brain injury (EBI) and pre-DCI phase with DCI and long-term outcomes after aSAH.</p><p><strong>Design: </strong>Pilot observational study on a prospective cohort.</p><p><strong>Setting: </strong>Single-center Neuro-ICU.</p><p><strong>Patients: </strong>aSAH patients with altered consciousness.</p><p><strong>Interventions: </strong>Continuous noninvasive cerebral oximetry neuromonitoring.</p><p><strong>Measurements and main results: </strong>Daily MAPOpt was defined as observed MAP (MAPObs) corresponding to lowest cerebral oximetry-derived autoregulation index. Outcomes included DCI and 1-year modified Rankin Scale (mRS). Mixed-effects linear regression assessed MAPOpt trajectories. Multivariable generalized estimating equation models assessed associations between daily %time below MAPOpt ± 5 mm Hg (MAPOpt range) and DCI and poor 1-year mRS (mRS 4-6). We included 118 daily MAPOpt measurements (118/128 epochs = 92.2% feasibility) estimated from 35 aSAH patients receiving cerebral oximetry monitoring for median duration of 4 days (interquartile range [IQR], 3-4 d), beginning on median of hospital day 2 (1-3). Median (IQR) age was 64 years (52-69 yr), World Federation of Neurological Surgeons grade 4 (2-5), and modified Fisher Scale 4 (3-4). DCI and poor 1-year outcome occurred in 15 (42.9%) and 20 (57.1%) patients, respectively. Patients that developed DCI had higher median MAPOpt (102.5 vs. 85 mm Hg; p = 0.03), upward trajectory of MAPOpt (β-coefficient = +19 mm Hg; p = 0.04 vs. +4 mm Hg; p = 0.56), and greater %time with MAPObs below MAPOpt range (39.7% vs. 12.7%; p = 0.01) in the early phase. In covariate-adjusted models, %time below MAPOpt range was independently associated with DCI and poor 1-year mRS (adjusted odds ratio, 1.02; 95% CI, 1.002-1.03; p = 0.03).</p><p><strong>Conclusions: </strong>Defining individualized MAPOpt thresholds using noninvasive cerebral oximetry was feasible. Relative hypotension below oximetry-based MAPOpt in the EBI and pre-DCI phase (days~2-6) was associated with DCI and poor long-term functional outcome, supporting further exploration of individualized hemodynamic optimization in the early phase of aSAH.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144871850","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":"Functional Status After Delirium in the ICU: A 1-Year Follow-Up of the Agents Intervening Against Delirium in the ICU (AID-ICU) Trial.","authors":"Lone M Poulsen, Camilla B Mortensen, Nina C Andersen-Ranberg, Anders Granholm, Marie O Collet, Lars P K Andersen, Stine Estrup, Bodil S Rasmussen, Ole Mathiesen","doi":"10.1097/CCM.0000000000006842","DOIUrl":"10.1097/CCM.0000000000006842","url":null,"abstract":"<p><strong>Objectives: </strong>To assess the effect of haloperidol compared with placebo on functional status in adult ICU patients with delirium, 1 year after inclusion in the Agents Intervening against Delirium in the ICU (AID-ICU) trial.</p><p><strong>Design: </strong>This was a preplanned 1-year follow-up of the randomized, placebo-controlled, blinded AID-ICU trial.</p><p><strong>Setting and patients: </strong>A total of 632 Danish patients enrolled in the AID-ICU trial at three selected Danish sites.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Functional status was evaluated using the Lawton-Brody Instrumental Activities of Daily Living (IADL) score, the Barthel-20 Activities of Daily Living (ADL) score, the Clinical Frailty Scale (CFS), and grip strength. Nonsurvivors were assigned the worst possible values, and missing data were managed with multiple imputation. Results were presented as mean differences and ratios of means with 95% CIs, adjusted for age, and sex. Of the original cohort of 632 patients enrolled in the AID-ICU trial at the three Danish sites, 75 participants in the haloperidol group, and 69 in the placebo group were available for follow-up. In 28.5% of responders (41/144), follow-up was performed by telephone. The proportion of relatives answering the questionnaire at 1-year follow-up on behalf of the participants was 4.2% (6/144). At 1 year, the adjusted mean differences between IADL, ADL, CFS, and grip strength in the haloperidol and placebo group were 0.1 (95% CI, -0.5 to 0.7; p = 0.687), 0.2 (95% CI, -1.3 to 1.7; p = 0.773), 0.0 (95% CI, -0.4 to 0.5; p = 0.862), and -2.9 (95% CI, -7.1 to 1.2; p = 0.175), respectively.</p><p><strong>Conclusions: </strong>Among adult ICU patients with delirium, treatment with haloperidol vs. placebo did not result in statistically significant differences in functional status at 1-year follow-up. However, due to the uncertainty of the estimates, clinically important differences cannot be excluded.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144871851","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":"Enhancing Quality of Care Assessments: Managing Atypical Patients in ICU Benchmarking in The Netherlands.","authors":"Mohammad Azizmalayeri, Sylvia Brinkman, Nicolette F de Keizer, Fabian Termorshuizen, Dave A Dongelmans, Ameen Abu-Hanna, Giovanni Cinà","doi":"10.1097/CCM.0000000000006828","DOIUrl":"https://doi.org/10.1097/CCM.0000000000006828","url":null,"abstract":"<p><strong>Objectives: </strong>Benchmarking the quality of care in ICUs contributes to ensuring that patients receive high-quality care. However, the performance metrics in benchmarks may be influenced by atypical patients, those with characteristics that deviate from the typical ICU population. This study aims to provide a framework to identify and reduce the impact of atypical patients in ICU benchmarking, leading to more meaningful ICU performance assessments.</p><p><strong>Design: </strong>The proposed framework compares patients from each ICU to the aggregated data from the rest of the ICUs to identify patients in the isolated ICU with an atypical clinical data pattern. To benchmark ICU quality of care, we used the standardized mortality ratio (SMR) derived from the Acute Physiology and Chronic Health Evaluation (APACHE)-IV model to evaluate mortality outcomes across ICUs in The Netherlands from 2018 to 2023. We subsequently assessed the impact of excluding these atypical patients on the performance of the APACHE-IV model (expressed as the Brier score) and recalculated the SMRs.</p><p><strong>Setting: </strong>Three hundred forty-four thousand four hundred fifty-two patients admitted to 75 ICUs across The Netherlands.</p><p><strong>Patients: </strong>Adult patients admitted to the ICU fulfilling the APACHE-IV inclusion criteria.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Within the total population, the Brier score of the APACHE-IV prediction model worsened from 0.02 in typical admitted patients to 0.13 in atypical patients. Excluding the top 5% atypical patients from benchmarking analysis altered conclusions for 13 ICUs over the full study period, causing them to move from expected quality range to unexpected quality or vice versa. Furthermore, our analysis identified 6 of the 75 ICUs as admitting the most atypical patients, 5 of which were academic hospitals.</p><p><strong>Conclusions: </strong>The results highlight how atypical patients negatively affect mortality prediction accuracy and influence ICU quality assessments. Therefore, it is essential to identify and account for these cases when evaluating ICU care by incorporating the proposed framework into routine benchmarking, thereby enhancing the reliability and fairness of performance evaluations.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0,"publicationDate":"2025-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144854710","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}