Critical Care Medicine最新文献

{"title":"Mortality Effect of Peripheral Perfusion-Guided Resuscitation in Vasodilatory Shock: A Systematic Review and Dual Frequentist-Bayesian Meta-Analysis of Randomized Trials","authors":"Henrique Mendes,João Victor Silva Correia,Mariana Merighi Moreira Salles,Eduardo Kattan,Glenn Hernández,Rafael Hortêncio Melo","doi":"10.1097/ccm.0000000000007364","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007364","url":null,"abstract":"Objectives: To determine the effect of peripheral perfusion-guided resuscitation on 28-day mortality in adults with vasodilatory shock. Data Sources: We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and Scopus from inception to November 2025. Study Selection: We included randomized controlled trials (RCTs) comparing peripheral perfusion-guided resuscitation with standard care or lactate-guided resuscitation; all eligible trials enrolled patients with septic shock. Data Extraction: Trial characteristics, intervention and comparator protocols, and outcomes were extracted. Risk of bias was assessed with the Cochrane Risk of Bias tool for randomized trials 2.0 tool and certainty of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation approach. We conducted a prespecified dual-framework meta-analysis comprising a primary frequentist random-effects model and a Bayesian hierarchical model with alternative prior assumptions. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was preregistered with PROSPERO (CRD420251229564). Data Synthesis: Seven RCTs ( n = 2408) were included. In the primary frequentist analysis, the pooled risk ratio (RR) for 28-day mortality with peripheral perfusion-guided resuscitation was 0.87 (95% CI, 0.76–1.01; p = 0.06; moderate-certainty evidence), with the CI crossing the line of no effect. No heterogeneity was detected ( I 2 = 0%). The two largest and lowest-risk trials were individually nonsignificant. The prespecified Bayesian analysis estimated a 97.2% posterior probability that RR is less than 1 (P [RR < 1]), broadly consistent across alternative prior assumptions. Conclusions: Among adults with septic shock, peripheral perfusion-guided resuscitation yielded a lower 28-day mortality estimate that did not meet statistical significance in the frequentist analysis. The Bayesian component of the dual framework was directionally concordant, estimating a high posterior probability that RR is less than 1, although the magnitude of any effect remains uncertain. Adequately powered trials are needed to confirm whether this signal reflects a clinically meaningful benefit.","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"72 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923280","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":"Operationalizing Alternatives to Prospective Consent in Critical Care Trials","authors":"Petra A. Rantanen,Neal W. Dickert","doi":"10.1097/ccm.0000000000007366","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007366","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"21 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923277","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":"How Early Is Early? Prehospital Management of Septic Shock","authors":"Sandra L. Peake,Anthony Delaney","doi":"10.1097/ccm.0000000000007346","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007346","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"39 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923279","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":"Returning to Driving: Developing a Roadmap to Inform Decision-Making After Critical Illness","authors":"Valerie Danesh,Mark E. Mikkelsen","doi":"10.1097/ccm.0000000000007348","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007348","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"35 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923278","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":"Landscape of Biomarker Use in Critically Ill Patients: Systematic Evidence Map of Acute Kidney Injury and Implications for Practice","authors":"Sandra L. Kane-Gill,Kevin M. Boyer,Ayse Akcan Arikan,Erin F. Barreto,Justin M. Belcher,Nuttha Lumlertgul,John A. Kellum","doi":"10.1097/ccm.0000000000007362","DOIUrl":"https://doi.org/10.1097/ccm.0000000000007362","url":null,"abstract":"Objectives: Create systematic evidence maps of novel biomarkers of kidney injury from a mapping review to guide future implementation in patient care. Data Sources: PubMed/MEDLINE and Embase. Study Selection: Systematic evidence maps included clinical trials and observational studies in critically ill patients, investigating novel kidney biomarkers for acute kidney injury (AKI). Data Extraction: Six thousand eight hundred five records were screened, and 1116 studies were included that related to one or more novel biomarkers and AKI. Data Synthesis: Adult populations accounted for 78.6% of the studies, and 93.3% used a cohort design to investigate AKI biomarkers. Mixed critically ill populations, cardiac surgery, and sepsis were identified as the most frequently studied clinical contexts in 69.5% of the studies. Systematic evidence maps were synthesized for biomarker studies to predict AKI ( n = 944), prognosticate clinical outcomes ( n = 647), diagnose AKI etiology ( n = 109), enrich clinical trials ( n = 6), and manage AKI ( n = 12). Implementation strategies for patient care included surveilling patients at risk of AKI, including patients undergoing surgery and those exposed to multiple nephrotoxic drugs. Conclusions: Substantial clinical evidence assessing the accuracy of biomarkers compared with diagnosis of AKI exists, with fewer practical trials in clinical use. Still, guidance on implementation approaches can be gleaned from evaluations using biomarkers for the management of critically ill patients, particularly in surgical and nephrotoxin-exposed populations where evidence is available. This review identifies the landscape of current evidence and highlights priorities for future management and enrichment trials needed to bridge the gap between predictive accuracy and clinical decision-making.","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":"18 1","pages":""},"PeriodicalIF":8.8,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148923282","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":"Ethical and Methodological Features of Cluster Randomized Trials in Critical Care Settings: A Systematic Review.","authors":"Eric Walser, Cory E Goldstein, Julia F Shaw, Hana Geres, Alla Iansavitchene, Kusum Menon, Simon Pupulin, Marat Slessarev, Monica Taljaard, Charles Weijer","doi":"10.1097/CCM.0000000000007340","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007340","url":null,"abstract":"<p><strong>Objectives: </strong>Cluster randomized trials (CRTs) are useful for evaluating system-level interventions in critical care but raise complex ethical and methodological issues that are amplified in this setting. We aimed to describe ethical and methodological features of CRTs in critical care settings.</p><p><strong>Data sources: </strong>We performed a systematic literature search in MEDLINE and Embase.</p><p><strong>Study selection: </strong>We included primary reports of CRTs in critical care settings published from 2004 to 2022 in English.</p><p><strong>Data extraction: </strong>Two reviewers independently extracted data from each CRT, resolving any discrepancies by consensus.</p><p><strong>Data synthesis: </strong>Among 102 CRTs, 77 CRTs (78%) reported trial registration and 101 CRTs (99%) reported research ethics committee review; five CRTs (5%) were exempted from review. Common designs were parallel-arm (48, 47%), two-period crossover (23, 23%), stepped-wedge (20, 20%), and multi-period crossover (8, 8%). A justification for using cluster randomization was provided in 47 CRTs (46%). Patients and caregivers were identified as research participants in 99 CRTs (97%). Of these, 74 CRTs (75%) reported on consent, which was most commonly waived consent (36, 49%). Healthcare providers were identified as research participants in 48 CRTs (47%). Of these, 11 CRTs (23%) reported on consent. Most (82, 80%) reported a sample size or power calculation, with 67 CRTs (82%) accounting for the intracluster correlation; 77 CRTs (76%) accounted for the intracluster correlation in the primary analysis. Among 85 CRTs with fewer than 40 clusters, 11 CRTs (13%) reported a small sample correction.</p><p><strong>Conclusions: </strong>Ethical and methodological shortcomings persist in CRTs. Enhanced reporting standards and adherence to established ethical frameworks, including the Ottawa Statement, are needed to ensure both scientific and ethical integrity in this essential design in critical care research.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148900163","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":"Ketamine for Analgosedation in Mechanically Ventilated Adults: A Double-Blind Randomized Trial.","authors":"Andrew J Casamento, Angajendra N Ghosh, Simone Said, Glenn Eastwood, Leah Peck, Helen Young, Madeleine Otto, Hannah McKenna, Meg Stevens, Dinesh Pandey, Hossein Jahanabadi, Daryl A Jones, Stephen Warrillow, Sofia Spano, Akinori Maeda, Jian Wen Chan, Rinaldo Bellomo, Ary Serpa Neto","doi":"10.1097/CCM.0000000000007341","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007341","url":null,"abstract":"<p><strong>Objectives: </strong>The role of ketamine for analgosedation in the ICU remains unclear. This study aimed to assess the efficacy of low-dose ketamine infusion for adjunct analgosedation in adults receiving mechanical ventilation.</p><p><strong>Design: </strong>A prospective, double blind, randomized, placebo-controlled trial.</p><p><strong>Setting: </strong>The study was conducted at two university-affiliated ICUs in Melbourne, Australia, between September 2022 and December 2024.</p><p><strong>Patients: </strong>Adult patients receiving mechanical ventilation in the ICU who were also receiving opioid infusion for analgosedation (excluding cardiac surgical patients).</p><p><strong>Interventions: </strong>Patients were randomized to receive low-dose ketamine infusion (0.15 mg/kg/hr) or placebo during the period of mechanical ventilation.</p><p><strong>Measurements and main results: </strong>The primary outcome was the hourly dose of opioids. Secondary outcomes included, among others, delirium, as well as ventilator, ICU, and hospital-free days to day 28. A total of 538 patients were screened for inclusion. Of these, 413 patients were ineligible based on exclusion criteria. A further five patients had consent withdrawn, leaving 120 patients (59 ketamine and 61 placebo) included for primary analysis. The median (interquartile range) hourly dose of opioids in fentanyl equivalents was 64 µg/hr (36-89 µg/hr) in the ketamine group and 77 µg/hr (47-100 µg/hr) in the placebo group (median difference, -13.0 [95% credible interval, -26.6 to 2.4]; probability of benefit, 95.1%). There were no differences between groups for most of the secondary outcomes, including delirium and significant adverse events.</p><p><strong>Conclusions: </strong>Low-dose ketamine infusion appeared safe and was associated with a reduction in hourly opioid requirements in ICU patients receiving mechanical ventilation. Larger randomized controlled trials are required to assess effects on other patient-centered outcomes.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148900124","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":"Evaluation of a Rapid Immunoassay for Molecular Subphenotype Classification in Pediatric Acute Cardiorespiratory Failure.","authors":"Colin J Sallee, Clove S Taylor, Matt S Zinter, Daniela Markovic, Michelle J Lim, Ana Costa Monteiro, Ruth Cortado, Andreas Schwingshackl, Michael Agus, Michael Matthay, Anil Sapru","doi":"10.1097/CCM.0000000000007339","DOIUrl":"10.1097/CCM.0000000000007339","url":null,"abstract":"<p><strong>Objectives: </strong>Molecular subphenotypes, identified through latent class analysis (LCA) of biomarker profiles, have the potential to guide targeted therapeutics in critical care. We have previously published that intensive insulin management has subphenotype-specific beneficial effects among children with hyperglycemia accompanying cardiorespiratory failure. However, the real-time application of subphenotype-based strategies in clinical settings remains challenging due to the operational aspects of biomarker assays. Our study had three objectives: 1) to compare biomarker measurements from rapid immunoassay and conventional multiplex platforms; 2) to evaluate the cross-platform transportability of a conventional assay-based parsimonious classifier for LCA-derived subphenotypes and compare it with a classifier trained directly on rapid immunoassay data; and 3) to assess the prognostic and predictive significance of rapid immunoassay-based subphenotypes.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Multicenter PICUs.</p><p><strong>Patients: </strong>Two hundred sixty-nine critically ill children with acute cardiorespiratory failure and hyperglycemia (2012-2016).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>LCA was previously used to derive hyperinflammatory and hypoinflammatory classes using a conventional multiplex assay of 13 plasma biomarkers. After feature selection, a parsimonious classifier using interleukin (IL)-6, IL-8, and soluble tumor necrosis factor receptor 1 (sTNFR-1) was developed to predict LCA-derived subphenotypes. We applied this classifier to rapid immunoassay biomarker measurements, yielding an area under the receiver operating characteristic curve (AUROC) of 0.90 (95% CI, 0.85-0.95). However, calibration was poor due to systematic underestimation of sTNFR-1 concentrations by the rapid platform. We then derived and internally validated via bootstrapping a de novo classifier using rapid immunoassay data, achieving an AUROC of 0.90 (95% CI, 0.86-0.95) and excellent calibration. Using a probability threshold of ≥ 0.5, the de novo classifier matched LCA-derived classifications in 241 of 269 cases (accuracy 89.6%). Rapid immunoassay-based subphenotypes demonstrated differences in mortality (33.3% in hyperinflammatory vs. 11.8% in hypoinflammatory; p = 0.009) and differential response to intensive insulin management (interaction p = 0.024).</p><p><strong>Conclusions: </strong>A parsimonious, rapid immunoassay-based classifier can approximate LCA-derived molecular subphenotypes while preserving their prognostic and predictive significance, with the potential to inform future subphenotype-based precision trials.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148900190","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":"Healthcare Encounters in the Week Preceding a Sepsis Hospitalization in Pediatric Patients.","authors":"Julia D Cartwright, Moshiur Rahman, Blythe Pollack, Stephen M Gorga, Kristen A Smith, Hallie C Prescott, Erin F Carlton","doi":"10.1097/CCM.0000000000007336","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007336","url":null,"abstract":"<p><strong>Objectives: </strong>Sepsis is a leading cause of morbidity and mortality for critically ill children, yet the pattern of healthcare use before admission for sepsis remains unknown. We measured the proportion and characteristics of healthcare encounters within 7 days before sepsis hospitalizations.</p><p><strong>Design: </strong>Using the Merative MarketScan administrative claims database, we conducted a retrospective observational cohort study to quantify pre-admission healthcare encounters among children hospitalized with sepsis.</p><p><strong>Setting: </strong>The Merative MarketScan database includes inpatient, outpatient, and emergency medical claims from employer-based insurance plans and Medicaid data from approximately 7 million healthcare consumers across multiple states.</p><p><strong>Patients: </strong>Included patients were 0-18 years old and hospitalized with sepsis between January 1, 2016, and December 31, 2022. Children were required to have 30 days of continuous insurance enrollment before admission.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Our primary outcome was the occurrence of any healthcare encounter in the 7 days before sepsis hospitalization, including outpatient, emergency department, or inpatient visits. Of those encounters, we identified the proportion that were related to infection. We compared hospitalization characteristics, including mechanical ventilation, ICU use, and length of stay, among those with vs. without pre-sepsis healthcare utilization. We identified 6928 pediatric sepsis hospitalizations, of whom 64.3% (4452/6928) had a complex chronic condition with a median age of 10 years (interquartile range, 3-15 yr). Overall, 53.5% (3707/928) of sepsis hospitalizations had a healthcare encounter within 7 days of admission, including 33.7% (2338/6928) with an outpatient visit, 28.2% (1956/6928) with an emergency department visit, and 6.2% (431/6928) with an inpatient hospitalization. Among sepsis hospitalizations with any pre-admission encounter, 38.9% (1445/3707) had an infection-related diagnosis documented at the encounter. There was no difference in mechanical ventilation, ICU use, or length of stay between those with vs. without pre-sepsis healthcare encounters.</p><p><strong>Conclusions: </strong>Over half of children hospitalized with sepsis were evaluated in the outpatient or emergency department setting in the week preceding admission, with one in five evaluated for infection. Further understanding of these pre-admission encounters may allow for earlier sepsis identification and possibly intervention in the prehospital setting.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148890990","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 Where Gender Gaps in Critical Care Authorship Really Lie.","authors":"Fatima Sheikh, Kirsten M Fiest","doi":"10.1097/CCM.0000000000007347","DOIUrl":"https://doi.org/10.1097/CCM.0000000000007347","url":null,"abstract":"","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148891004","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}