Critical Care Medicine最新文献

{"title":"Geographic Access to Care and Mortality in Cardiogenic Shock: A Nationwide Cohort Analysis.","authors":"Ki Hong Choi, Danbee Kang, Junwoo Seo, Ji Hyun Cha, Taek Kyu Park, Joo Myung Lee, Young Bin Song, Joo-Yong Hahn, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Juhee Cho, Jeong Hoon Yang","doi":"10.1097/CCM.0000000000007287","DOIUrl":"10.1097/CCM.0000000000007287","url":null,"abstract":"<p><strong>Importance: </strong>Timely access to advanced care is critical for patients with cardiogenic shock (CS), yet the impact of regional disparities in hospital arrival time on mortality remains unclear.</p><p><strong>Objectives: </strong>To investigate whether regional disparities in hospital arrival time are associated with in-hospital and long-term mortality among patients with CS.</p><p><strong>Design: </strong>Population-based, nationwide cohort study.</p><p><strong>Setting: </strong>Tertiary hospitals in South Korea, using data from the Korean National Health Insurance Service database and regional hospital accessibility indicators from the Korea Transport Institute.</p><p><strong>Participants: </strong>A total of 80,263 adults (≥ 18 yr) admitted to an ICU with a diagnosis of CS between 2017 and 2022. The study population was stratified by estimated hospital arrival time using region-level average daytime travel times (< 10, 10-30, 30-60, and > 60 min) for the present study.</p><p><strong>Interventions: </strong>None.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was all-cause mortality, including in-hospital and post-discharge mortality. Multivariable logistic and Cox regression models were used to assess associations.</p><p><strong>Results: </strong>Median estimated hospital arrival time was 9.15 minutes. In-hospital mortality increased progressively with longer arrival times: 29.6% (< 10 min), 33.5% (10-30 min), 34.9% (30-60 min), and 38.8% (> 60 min). Compared with less than 10 minutes, the adjusted odds ratios for in-hospital mortality were 1.27 (95% CI, 1.23-1.32), 1.24 (95% CI, 1.14-1.35), and 1.51 (95% CI, 1.29-1.75), respectively. At 1-year follow-up, the adjusted hazard ratios for all-cause mortality were 1.16 (95% CI, 1.14-1.19 for 10-30 min), 1.16 (95% CI, 1.09-1.21 for 30-60 min), and 1.31 (95% CI, 1.19-1.43 for > 60 min), relative to less than 10 minutes. These associations were consistent in both de novo and acute-on-chronic CS.</p><p><strong>Conclusions: </strong>Longer hospital arrival times are significantly associated with increased in-hospital and long-term mortality in patients with CS. These findings underscore the need for system-level interventions, such as regionally coordinated shock networks and early prehospital triage, to ensure timely access to definitive care.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"2625-2635"},"PeriodicalIF":7.5,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148683549","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":"Advancing a New Method of Care: The Scientific and Business Development of the eICU","authors":"Brian Rosenfeld","doi":"10.1097/ccm.0000000000007149","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007149","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"8 1","pages":"2517-2520"},"PeriodicalIF":8.8,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149088240","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, Ventilatory Patterns, and Outcomes in Acute Hypoxemic Respiratory Failure Among ICU Patients Requiring Respiratory Support: A Registry-Based Cohort Study.","authors":"Stephan von Düring, Ewan Goligher, Andre Carlos Kajdacsy-Balla Amaral, Gordon D Rubenfeld, Niall D Ferguson, Martin Urner, Eddy Fan","doi":"10.1097/CCM.0000000000007284","DOIUrl":"10.1097/CCM.0000000000007284","url":null,"abstract":"<p><strong>Objectives: </strong>Acute hypoxemic respiratory failure (AHRF) is a leading cause of ICU admission and is associated with significant morbidity and mortality. Yet, epidemiological data on AHRF remain limited, and current management strategies largely derive from studies on acute respiratory distress syndrome (ARDS). We examined the prevalence of AHRF among ICU patients receiving supplemental oxygen or respiratory support for at least 4 hours, as well as initial respiratory support strategies and associated outcomes.</p><p><strong>Design: </strong>Multicenter registry-based cohort study, 2014-2023.</p><p><strong>Setting: </strong>Nine university of Toronto affiliated ICUs.</p><p><strong>Patients: </strong>Adult ICU patients receiving supplemental oxygen or respiratory support who met AHRF criteria, defined as Pa o2 /F io2 less than or equal to 300 mm Hg or, if Pa o2 was not available, peripheral oxygen saturation (SpO 2 )/F io2 less than or equal to 315, within the first 24 hours of ICU admission.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The primary outcome was AHRF prevalence. Secondary outcomes included ICU length of stay, invasive mechanical ventilation (IMV) duration, ventilator-free days, and ICU mortality, stratified by AHRF severity. Of 21,714 patients recorded in the registry, 10,832 (50%) met AHRF criteria, of whom 76% required IMV. Most received lung-protective ventilation. With increasing AHRF severity, ICU length of stay and IMV duration increased, while ventilator-free days and probability of ICU discharge at 30 days decreased. ICU mortality was 23% overall and 47% among patients on IMV with severe AHRF.</p><p><strong>Conclusions: </strong>AHRF is common early after ICU admission among patients requiring supplemental oxygen or respiratory support and is frequently managed using ARDS-based strategies. A pragmatic, standardized, and operationally feasible definition of AHRF may improve patient recognition, enable comparisons across studies, and guide future research.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"2601-2612"},"PeriodicalIF":7.5,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13632807/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148711495","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":"Facilitating Communication for Family Members of Critically Ill Patients During and Following a Hospital Stay: A Randomized Controlled Trial.","authors":"Claire J Creutzfeldt, Lyndia C Brumback, Jennifer Im, Kathryn I Pollak, Ana Gabriela Vasconcelos, Yilin Song, James Sibley, Anna M Ungar, Gigi Garzio, Patsy D Treece, Lisa Maki Hudson, Rebecca Martini, Sandy Hanson, Nita Khandelwal, Erin Abu-Rish Blakeney, Nancy Kentish-Barnes, Elie Azoulay, Elizabeth L Nielsen, Ruth A Engelberg, J Randall Curtis","doi":"10.1097/CCM.0000000000007268","DOIUrl":"10.1097/CCM.0000000000007268","url":null,"abstract":"<p><strong>Objectives: </strong>Families of patients admitted to ICUs experience numerous care transitions, poor communication across these transitions, and emotional distress associated, in part, with the challenges of obtaining care consistent with patients' values. Specialized support from ICU to postacute setting may improve outcomes.</p><p><strong>Design: </strong>Multicenter randomized, controlled trial of a \"communication facilitator\" intervention.</p><p><strong>Setting: </strong>One healthcare system, three hospitals in Seattle, WA.</p><p><strong>Participants: </strong>ICU patients ( n = 449) with chronic life-limiting illness (2-yr median survival, and/or acute, severe illness with greater than 15% hospital mortality risk) and their family members ( n = 505). Patients were the unit of randomization (control, n = 224; intervention, n = 225).</p><p><strong>Interventions: </strong>Nurse communication facilitators trained to support, model, and teach communication strategies to promote goal-concordant care. Facilitators engaged with participants in the ICU and for 3 months postrandomization.</p><p><strong>Measurement and main results: </strong>The primary outcome was family member depression, measured using the Hospital Anxiety and Depression Scale (HADS) at four time points (randomization, 1-, 3-, and 6-mo postrandomization). Among respondents, HADS-depression tended to decrease over time (mean ± sd = 7.2 ± 4.6 for control and 7.2 ± 4.2 for intervention at baseline; 5.9 ± 4.1 for control and 5.9 ± 4.5 for intervention at 6 mo). The difference in mean HADS-depression between intervention and control over 6 mo was not significantly different: -0.07 (95% CI, -0.70 to 0.55). Differences in family-reported secondary outcomes were in the expected direction, including relationship with the healthcare team ( p = 0.0162) and goal concordance ( p = 0.0504), but their effect sizes were small.</p><p><strong>Conclusions: </strong>For family members of critically ill patients facing a high likelihood of death or serious disability, involving a communication facilitator during and after an ICU stay did not lead to a reduction in depressive symptoms.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"2521-2535"},"PeriodicalIF":7.5,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148548010","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":"Rethinking Muscle Wasting in Critical Illness: A Systematic Review and Meta-Analysis of Myofiber Size and Protein Turnover.","authors":"Felipe González-Seguel, Cayla M Robinson, Camilo Caceres-Parra, Cecilia Villablanca, Catalina Olave, Felipe Muñoz-Muñoz, Owen Gustafson, Madeline Cavallaro, Zoe Calulo Rivera, Selina M Parry, Yuan Wen, Benjamin F Miller, Kirby P Mayer, Esther E Dupont-Versteegden","doi":"10.1097/CCM.0000000000007288","DOIUrl":"10.1097/CCM.0000000000007288","url":null,"abstract":"<p><strong>Objectives: </strong>To identify biological findings underlying skeletal muscle dysfunction in adults with critical illness and meta-analyze myofiber cross-sectional area and protein turnover variables.</p><p><strong>Data sources: </strong>Six databases were electronically searched from inception to January 2025.</p><p><strong>Study selection: </strong>We included original studies reporting biological findings obtained from skeletal muscle biopsies of adults with critical illness.</p><p><strong>Data extraction: </strong>Bibliometrics, characteristics of the patients/controls, and biological findings were extracted in duplicate. Descriptive statistics of biological findings were performed. Random-effects meta-analyses investigated mean differences (MDs) in myofiber cross-sectional area and protein turnover compared with controls.</p><p><strong>Data synthesis: </strong>From 22,035 titles screened, 75 studies ( n = 2,023 patients; n = 642 controls) published between 1988 and 2024 were included, with 48 unique patient datasets. Biopsies were mainly collected from vastus lateralis (64 [85%] studies) during the first ICU week (50% of studies) and post-ICU (9%). Biological findings included predominant type II myofiber atrophy with necrosis and structural degeneration, mitochondrial dysfunction, inflammatory/fibrotic changes, and upregulated ubiquitin-proteasome/autophagy pathways. Data from six studies ( n = 100 patients; 193 controls) indicated that cross-sectional area was 22% lower in patients with critical illness before (MD, -689 µm 2 ; 95% CI, -1265 to -113 µm 2 ; p = 0.02) and after (MD, -775 µm 2 ; 95% CI, -1512 to -37 µm 2 ; p = 0.04) ICU discharge. Across seven studies ( n = 126 patients; 61 controls) protein synthesis was not significantly different in patients with critical illness compared with controls (MD, 0.007%/hr; 95% CI, -0.010 to 0.027; p = 0.36). Protein degradation pathway markers were significantly higher (standardized MD ranging, 0.5-1.7) in data from 11 studies ( n = 439 patients; 163 controls).</p><p><strong>Conclusions: </strong>Muscle wasting during critical illness reflects multifaceted biological disturbances. While myofiber size is significantly lower in patients with critical illness, pooled analyses show no significant differences in muscle protein synthesis compared with non-ICU controls, whereas protein degradation markers are consistently higher.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":"2636-2647"},"PeriodicalIF":7.5,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13632814/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148683725","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":"Diabetes and Atherosclerotic Cardiovascular Disease Modify the Association Between Soluble Tumor Necrosis Factor Receptor 1 and Sepsis Mortality: A Secondary Cohort Analysis.","authors":"Timothy G Gaulton, Rachel Rigsby, Nathan I Shapiro, Eric P Schmidt, Maurizio Cereda","doi":"10.1097/CCM.0000000000007374","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007374","url":null,"abstract":"<p><strong>Objectives: </strong>To determine whether diabetes mellitus or atherosclerotic cardiovascular disease (ASCVD) modify the association between soluble tumor necrosis factor receptor 1 (sTNFR1) and mortality in sepsis.</p><p><strong>Design: </strong>Secondary cohort analysis using the Acetaminophen and Ascorbate in Sepsis: Targeted Therapy to Enhance Recovery Research Materials.</p><p><strong>Setting: </strong>Academic hospitals in the United States.</p><p><strong>Patients: </strong>A total of 466 adults with sepsis and respiratory failure or vasopressor-dependent shock with available baseline sTNFR1 measurements.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We tested the interaction between sTNFR1 and diabetes or ASCVD (defined by Charlson comorbidity categories) on 90-day mortality using Cox regression with restricted cubic splines, adjusted for illness severity, age (in tertiles), and sex. Of 466 patients, 243 patients (52.1%) had diabetes or ASCVD. Despite similar illness severity and mortality between groups, sTNFR1 was higher among patients with diabetes or ASCVD (median, 6547 vs. 4883 pg/mL). Among patients without diabetes or ASCVD, higher sTNFR1 was associated with 90-day mortality (hazard ratio [HR], 2.25 per sd; 95% CI, 1.76-2.88). The association was attenuated among those with diabetes or ASCVD, with a plateau in mortality risk above approximately 12,000 pg/mL (overall HR, 1.04; 95% CI, 0.83-1.30; interaction p < 0.001). This interaction was specific to sTNFR1 and was not observed for interleukin-6 or angiopoietin-2. No effect modification was present among patients with obesity or hypertension without diabetes or ASCVD.</p><p><strong>Conclusions: </strong>Diabetes or ASCVD attenuated the association between sTNFR1 and sepsis mortality. These findings suggest that comorbid conditions may alter the biological relationship between a biomarker and outcome, with implications for biomarker-guided risk stratification and disease mechanisms in sepsis.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149080031","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-Dependent Effects of Inotropic Exposure During Venoarterial Extracorporeal Membrane Oxygenation Support on the Probability of Extracorporeal Membrane Oxygenation Weaning Failure","authors":"Myrthe P.J. van Steenwijk,Lara C.A. Pladet,Atreyu van Esch,Hong Jun Shi,Dirk W. Donker,Yannick Taverne,Jeroen J.H. Bunge,Carlos V. Elzo Kraemer,Jacinta J. Maas,Leon J. Montenij,Luuk C. Otterspoor,Erik Scholten,Laurien van Koppenhagen,Joost van Rosmalen,Diederik Gommers,Alina A. Constantinescu,Rudolf A. de Boer,Jacob E. Møller,Dimitris Rizopoulos,Christiaan L. Meuwese","doi":"10.1097/ccm.0000000000007338","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007338","url":null,"abstract":"Objectives: During venoarterial extracorporeal membrane oxygenation (VA ECMO), organ perfusion no longer entirely depends on native cardiac output, which may reduce the therapeutic advantage of inotropic drugs relative to their risks. We hypothesized that, in this setting, higher cumulative inotropic exposure would be associated with impaired cardiac recovery. Design: Observational cohort study on the effects of longitudinal inotropic exposure during VA ECMO support. Temporal changes in inotropic support during VA ECMO support were evaluated. Cumulative inotropic exposure per day during VA ECMO support was calculated using the area under the curve of a standardized inotropic score. These cumulative inotropic scores were associated with the risk of ECMO weaning failure up to 30 days (a composite of death, ongoing need for ECMO support, or the need for heart replacement therapy), mortality, and complications, using joint modeling techniques. Setting: Six hospitals in the Netherlands. Patients: Adult patients with severe cardiogenic shock (CS) receiving VA ECMO support between 2018 and 2024. Interventions: None. Measurements and Main Results: Out of 440 patients with various causes of CS, 235 patients (53.4%) developed ECMO weaning failure. Inotropic support remained largely unchanged in the days following VA ECMO initiation. Adjusted joint models showed that a higher cumulative inotropic exposure during VA ECMO support was associated with an increased risk for ECMO weaning failure (hazard ratio [HR], 1.04; 95% CI, 1.00–1.07), 30-day mortality (HR, 1.04; 95% CI, 1.01–1.08), arrhythmias (HR, 1.05; 95% CI, 1.01–1.08), and protracted lactate clearance (HR, 0.96; 95% CI, 0.92–0.99). Conclusions: In patients requiring VA ECMO support for refractory CS, inotropic support is often maintained at similar levels after ECMO initiation. Higher cumulative inotropic exposure was associated with an increased risk for ECMO weaning failure. Prospective studies are needed to investigate whether inotropes can be tapered or even stopped and whether such a strategy could improve cardiac recovery.","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"17 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149049112","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":"Epilepsy After Antipsychotic Prescription in Survivors of Traumatic Brain Injury: A Population-Based Cohort Study.","authors":"Augusto Ferraris, Alejandro G Szmulewicz, Neill K J Adhikari, Lisa Burry, Alejandro Hernández, Hannah Wunsch, Damon C Scales, Federico Angriman","doi":"10.1097/CCM.0000000000007335","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007335","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate whether the choice of antipsychotic treatment following traumatic brain injury (TBI) hospitalization is associated with the risk of post-traumatic epilepsy in older adults.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Population-based cohort in Ontario, Canada (2009-2021).</p><p><strong>Patients: </strong>We included adults 66 years or older without epilepsy who survived a first TBI admission and filled new prescriptions for antipsychotics within 30 days after discharge.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The exposure groups included patients who were prescribed haloperidol or risperidone, compared separately to quetiapine. The primary outcome was a new diagnosis of epilepsy up to 5 years following discharge. We used inverse probability of treatment weighting of cause-specific Cox models to calculate adjusted hazard ratios (aHR) and 95% CIs based on a robust variance estimator. Of 1204 TBI survivors included, 202 (17%) filled prescriptions for haloperidol, 300 (25%) for risperidone, and 702 (58%) for quetiapine; epilepsy was diagnosed in 6%, 13%, and 14% of these groups, respectively. Mortality by 5 years of follow-up was 89% for haloperidol, 66% for risperidone, and 62% for quetiapine. Compared with quetiapine, a new prescription for haloperidol (aHR = 0.73; 95% CI, 0.39-1.34) or risperidone (aHR = 0.94; 95% CI, 0.65-1.36) was not associated with higher epilepsy risk.</p><p><strong>Conclusions: </strong>We found no clear signal of a differential risk of epilepsy when comparing new prescriptions for haloperidol or risperidone with quetiapine among survivors of TBI. Nonetheless, high mortality limited comparability across groups, CIs were wide, and additional studies should confirm our findings.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149012099","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 Critically Ill Patients With Cirrhosis Undergoing Continuous Renal Replacement Therapy: A Contemporaneous Parallel Analysis of the HRS-HARMONY and CRRTnet Registries.","authors":"Constantine J Karvellas, Joshua Lambert, Tianqi Ouyang, Sean M Bagshaw, Giuseppe Cullaro, Zachary Fricker, Todd Frederick, Stuart L Goldstein, Andrew A House, Luis A Juncos, Michael Heung, Kavish R Patidar, Oleksa G Rewa, Jevon E Robinson, J Pedro Teixeira, Hani Wadei, Javier A Neyra, Andrew S Allegretti","doi":"10.1097/CCM.0000000000007363","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007363","url":null,"abstract":"<p><strong>Objectives: </strong>Describe the epidemiology of patients with cirrhosis/acute-on-chronic liver failure (ACLF) receiving continuous renal replacement therapy (CRRT) pertaining to process factors including renal replacement dose, modality, and circuit anticoagulation.</p><p><strong>Setting: </strong>Academic tertiary care hospitals in the United States and Canada.</p><p><strong>Design and patients: </strong>We performed a parallel study of contemporaneous data from the HARMONY and CRRT network (CRRTnet) databases to describe the epidemiology and process of CRRT care of cirrhosis/ACLF patients receiving CRRT in the ICU. We evaluated clinical and CRRT process factors (dialysis dose, anticoagulation) with the primary outcome of in-hospital mortality.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>The HARMONY cohort (n = 245; median age, 57 yr; 41% female) and CRRTnet cohort (n = 206; 58 yr; 39% female) demonstrated similar overall survival to hospital discharge (HARMONY, 34%; CRRTnet, 30%). In HARMONY, the two most common causes of acute kidney injury (AKI) requiring CRRT were acute tubular necrosis (73%) and hepatorenal syndrome-AKI (13%), with no significant difference between survivors and nonsurvivors (p = 0.24). In HARMONY, higher chronic liver failure-C ACLF scores (hazard ratio, 1.03 [95% CI, 1.01-1.05]; p < 0.001) were independently associated with increased in-hospital mortality. In CRRTnet, the most common CRRT modality was continuous venovenous hemodiafiltration (83.8%), and the most common anticoagulation strategy was regional citrate anticoagulation (58.0%) or no anticoagulation (35.8%). CRRT prescribed dose greater than 30 mL/kg/hr was independently associated with higher in-hospital mortality (multivariable regression; odds ratio, 2.69; 95% CI, 1.3-5.64; p = 0.01). Of survivors in CRRTnet, 64% were transitioned to intermittent hemodialysis (IHD) before hospital discharge.</p><p><strong>Conclusions: </strong>Critically ill cirrhosis/ACLF patients initiated on CRRT in the absence of liver transplantation had high in-hospital mortality. These patients were prescribed higher initial CRRT doses (median total effluent > 30 mL/kg/hr), with higher CRRT dose independently associated with increased in-hospital mortality. Of ICU survivors, 64% were transitioned to IHD at ICU discharge. Despite concerns for citrate toxicity, citrate regional anticoagulation was commonly employed in these patients.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148988492","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":"Comprehensive Driving Assessment to Enable Driving Resumption in Adults Recovering From Critical Illness: A Prospective Cohort Study","authors":"Chloe Apps,Kate Brooks,Gillian Radcliffe,Kieran Mahon,Patricia Helen Morris,Gavin Saunders,Michelle Giles,Leah Homden,Jessica Gregory,Paula O’Shea,Melanie Gager,Liza Keating,Amy Grimadell-Jones,Lucy Pearson,Barnaby Sanderson,Andrew Slack,Helen Vollmer,Katie Susser,Manu Shankar-Hari,Natalie Pattison,Louise Rose,Joel Meyer","doi":"10.1097/ccm.0000000000007316","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007316","url":null,"abstract":"Objectives: Primary objective: To determine the driving ability of adult ICU survivors 2 months after hospital discharge. Secondary objectives: Evaluate driving resumption at 3, 6, and 12 months; factors associated with driving resumption; and acceptability of a comprehensive driving assessment. Design: Observational cohort study. Setting: Certified driving assessment center in the United Kingdom. Patients: Adult ICU survivors who received mechanical ventilation (minimum 72 hr) and/or extracorporeal membrane oxygenation. Interventions: A Driver Vehicle Licensing Agency-approved, driving ability assessment comprising physical and cognitive evaluation, and practical driving skills using a driving simulator, private track in-car assessment, and on-road in-car assessment. Measurements and Main Results: We recruited 40 participants (median age, 53 yr [interquartile range (IQR), 46–64 yr]; 13 [32%] female) from six hospitals. Of these, 33 completed the driving assessment at a median of 12.5 weeks following hospital discharge. Twenty-six participants (79%) were assessed as capable of driving a standard vehicle; however, only 15 (45%) had resumed driving. Seven participants (7/33, 21%) were deemed unable to drive a standard vehicle due to either physical ( n = 4/7, 57%), psychological ( n = 2/7, 29%), or cognitive impairment ( n = 1/7, 14%). Driving resumption following adaptations, retraining, or refresher lessons occurred in four participants ( n = 4/7, 57%) in the 12-month study period. Self-reported driving resumption at 3, 6, and 12 months was observed in 21 (62%), 28 (82%), and 30 (91%) participants, respectively. Time to driving resumption ranged from 7 to 274 days following hospital discharge. Median (IQR) driving confidence (10-point Likert scale) increased from 7 (5–8) pre-assessment to 9 (7–10) post assessment ( p &lt; 0.05). Driving assessment acceptability was rated very good or excellent by 32 participants (97%). Conclusions: Using a comprehensive driving assessment 3 months following hospital discharge, approximately three quarters of this cohort were deemed able to drive a standard vehicle, yet less than half had resumed driving. Of those with a driving-related impairment, most could resume driving following intervention.","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"11 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923281","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}