Critical Care最新文献

{"title":"The effects of vasopressor choice on renal outcomes in septic shock: a systematic review of randomised trials as a guide for future research","authors":"Rory McDonald, Michael Burns, Adrian Wong, Carolyn Smith, Marlies Ostermann, Sam Hutchings","doi":"10.1186/s13054-025-05573-7","DOIUrl":"https://doi.org/10.1186/s13054-025-05573-7","url":null,"abstract":"Patients with septic shock are high risk for developing acute kidney injury (AKI), with its associated morbidity. This systematic review assessed the evidence for an effect on renal outcomes from choice of vasopressor. Searches were conducted on Medline, Embase, Cochrane Central, congress abstracts and trial registries. The search strategy included septic shock, vasopressor agents and renal impairment. Inclusion criteria were non-crossover randomised controlled trials of adult septic shock comparing individual or combinations of vasopressors and placebo controlled trials. Primary outcome was the incidence of AKI in study participants. Secondary outcomes were AKI duration, renal replacement therapy (RRT) rate, RRT duration, renal failure free days, requirement for long term RRT and Major Adverse Kidney Events (MAKE) at 30 and 90 days. A total of 4259 patients, from 17 studies, were included. Vasopressin and terlipressin studies predominated. In 8 studies reporting AKI rate, no effect was seen relating to vasopressor choice. RRT rate was the most reported secondary outcome. Of five studies that investigated the role of vasopressin, only one showed significant benefit. Alongside limited reporting, no conclusive benefit was demonstrated in other secondary outcomes. No studies reported requirement for long term RRT, MAKE 30 or 90. This is the first systematic review focussed on renal outcomes with differential vasopressor therapy in septic shock. It illustrates the paucity of evidence supporting a particular vasopressor. Also highlighted are problems of population and study heterogeneity, as well as the focus on RRT as a proxy for renal outcomes. Standardised renal outcome reporting, large and appropriately powered trials and focussed sub-population studies are required to further inform renal focussed vasopressor research and practice. This systematic review was prospectively registered on PROSPERO (CRD42023481778).","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"94 7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145203215","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 post-sepsis syndrome: linking cellular dysfunction to the clinical picture","authors":"Gabriel-Petre Gorecki, Andrei Bodor, Marius-Bogdan Novac, Dan-Gabriel Costea, Daniel-Ovidiu Costea, Andreea-Cristina Costea, Cătălin-Nicolae Grasa, Dana-Rodica Tomescu","doi":"10.1186/s13054-025-05491-8","DOIUrl":"https://doi.org/10.1186/s13054-025-05491-8","url":null,"abstract":"Post-sepsis syndrome (PSS) encompasses a range of long-term complications, including immune dysregulation, chronic inflammation, and neuromuscular impairment, that persist beyond the resolution of the acute septic episode. While these clinical phenotypes are increasingly recognized, the underlying molecular mechanisms remain incompletely defined. Mitochondrial dysfunction, particularly in the form of persistent mitochondrial senescence, is emerging as a potential unifying factor driving multiple PSS trajectories. Accumulating evidence suggests that damaged mitochondria not only lose their bioenergetic capacity but also actively contribute to chronic immune and inflammatory signalling. Based on this, we propose a dual-intervention strategy (“mitochondrial flush”) which involves the coordinated elimination of senescent mitochondria and stimulation of mitochondrial biogenesis. The regenerative component, supported by established preclinical research on Peroxisome Proliferator-Activated Receptor Gamma Coactivator 1-Alpha (PGC-1α) activation, represents a partially developed therapeutic arm, while the selective clearance of dysfunctional mitochondria remains an area of active investigation. This concept raises important questions regarding regenerative capacity, therapeutic timing, and cellular resilience following critical illness. We further propose a working definition of PSS as a state of persistent mitochondrial dysfunction, possibly driven by ongoing oxidative stress, which may underlie a broader range of clinical phenotypes than currently recognized. A deeper understanding of mitochondrial quality control may offer a new therapeutic framework for reversing the chronic physiological decline observed in sepsis survivors.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"18 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145203691","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":"Conventional versus pump-controlled retrograde trial off (PCRTO) weaning in V-A ECMO: exploring feasibility, physiological insights and benefits","authors":"Francesca Fiorelli, Christophe Vandenbriele, Hatem Soliman Aboumarie, Georgios Georgovasilis, Tim Jackson, Ana Sofia da Costa Pinto, Olaf Maunz, Fernando Riesgo Gil, Waqas Akhtar, Jonathan Aron, Charlie Cox, Vasileios Panoulas, Donna Hall, Alexander Rosenberg, Maurizio Passariello, Brijesh V. Patel","doi":"10.1186/s13054-025-05655-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05655-6","url":null,"abstract":"<p>Weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and determining the optimal timing for liberation from mechanical circulatory support (MCS) remain critical yet complex. Although multiple weaning protocols exist, focusing on hemodynamic and echocardiographic parameters [1], no direct comparative studies have clarified which approach best reflects true cardiopulmonary reserve. Conventional weaning involves gradually reducing ECMO flow to around 1 L-per-minute (lpm), leaving 1 lpm residual right ventricular (RV) unloading and 1 lpm left ventricular (LV) afterload. In contrast, Pump-Controlled-Retrograde-Trial-Off (PCRTO) introduces controlled retrograde flow through the ECMO-pump, creating a controlled arterio-venous shunt that better mimics native physiology [2,3,4] (Fig. 1).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05655-6/MediaObjects/13054_2025_5655_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"411\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05655-6/MediaObjects/13054_2025_5655_Fig1_HTML.png\" width=\"685\"/></picture><p>Schematic overview indicating the flow during conventional peripheral V-A ECMO-support (left panel) and flow reversal during PCRTO (right panel). RV: right ventricle; LV: left ventricle; V-A ECMO: veno-arterial extracorporeal membrane oxygenation; PCRTO: pump-controlled retrograde trial off; rpm: revolution per minute; MAP: mean arterial pressure; P-return ECMO: return ECMO-cannula pressure</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>We conducted a pilot multicentre evaluation of PCRTO’s feasibility, safety, and physiological insights compared to conventional weaning. The study was registered as service evaluation and conducted across three quaternary high-volume centres. Our cohort included 21 adult patients (mean age 49 ± 16 years; 57% male) supported with V-A ECMO for refractory cardiogenic shock (CS) between March 2023 and September 2024. Our inclusion criteria ensured that only patients demonstrating sufficient cardiopulmonary recovery and stable haemodynamics were considered for weaning. The PCRTO-protocol also incorporated regular echocardiographic assessments and invasive monitoring with a pulmonary artery catheter. Criteria for ‘readiness-to-wean’ required resolution of the underlying cause of CS, evidence of improving end-organ perfusion (renal and hepatic), serum lactate < 2 mmol/L, mean arterial pressure (MAP) > 60 mmHg, arterial pulse pressure > 15 mmHg, improving left ventricular outflow tract velocity-time integral (LVOT VTI), and absence of severe mitra","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145195381","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 detection of critical illnesses using exhaled aldehydes: a non-invasive breath analysis approach","authors":"Shuangying Tian, Longxin Li, Yingzhe Guo, Xiuting Yang, Jianhua Gu, Hui Lin, Yanzhen Wang, Yuan Bian, Keyong Hou, Feng Xu, Yuguo Chen","doi":"10.1186/s13054-025-05529-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05529-x","url":null,"abstract":"<p>Early recognition of critical illness is crucial for timely intervention and improved prognosis. However, conventional diagnostic methods are often invasive and time-consuming, limiting their utility for rapid screening in critical care. Breath analysis has recently emerged as a promising approach in metabolomics due to its non-invasive, repeatable, and rapid-response characteristics. Volatile organic compounds (VOCs), as byproducts of cellular metabolism, dynamically reflect metabolic status, oxidative stress, and pathophysiological changes, offering broad potential for disease monitoring. Prior studies have linked VOC profiles to conditions such as ventilator-associated pneumonia and cognitive impairment [1, 2], but their application in critical illness remains exploratory. Chen et al. demonstrated that aldehyde metabolism is dysregulated in early and progressive stages of critical illness, resulting in toxic aldehyde accumulation, cellular injury, and organ dysfunction, and suggested that monitoring aldehyde fluctuations could guide treatment decisions [3]. Lipid peroxidation products are established markers of oxidative stress and potential non-invasive biomarkers across diseases. Based on the theory of aldehyde dysregulation, we hypothesize that exhaled aldehyde detection may facilitate early identification of critically ill patients.</p><p>From January 2024 to January 2025, we conducted a prospective observational study at Qilu Hospital of Shandong University, enrolling 787 adults (230 ICU patients and 557 healthy controls) and collecting exhaled breath samples. The study was approved by the Ethics Committee of Qilu Hospital of Shandong University (approval number KYLL-202401-047) and adhered to the Declaration of Helsinki. Baseline characteristics are summarized in Table 1. We used photoelectron-induced chemical ionization time-of-flight mass spectrometry (CITOF-MS) to analyze VOCs in exhaled breath; this method requires no preprocessing or enrichment, offers high sensitivity and precision, and acquires each spectrum within one second [4]. Ten aldehyde VOCs were preselected for quantitative analysis and group comparison.</p><figure><figcaption><b data-test=\"table-caption\">Table 1 Demographic characteristics of participants</b></figcaption><span>Full size table</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>Critically ill patients exhibited significantly elevated exhaled aldehyde levels compared to healthy controls (Fig. 1). The heatmap (Fig. 1A) shows uniformly low, tightly clustered aldehyde expression in controls versus marked heterogeneity in patients, indicating metabolic dysregulation. Analysis of ten aldehydes confirmed this pattern (Fig. 1B). Multivariate analyses (PCA, PLS-DA; Fig. 1C–D) demonstrated clear group separation, highlighting the discriminatory capacity of aldehyde pro","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"6 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145195382","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":"Paradigm shift in hypomagnesemia: a prospective observational study of ionized magnesium in the ICU","authors":"Jelle P. Zwart, Mike Zwartkruis, Marcel M. G. J. van Borren, Jan van Vliet, Anna P. Bech","doi":"10.1186/s13054-025-05630-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05630-1","url":null,"abstract":"<p>Hypomagnesemia is frequently encountered in patients admitted to the intensive care unit (ICU) [1, 2]. Several reports have shown that hypomagnesemia on the ICU is associated with critical illness and ICU outcome, but it is unclear whether this concerns a causal relation [1, 3]. While total magnesium is often used in routine care, ionized magnesium appears to be the best possible test [2]. Understanding the underlying mechanism is necessary for moving forward in treatment regimens.</p><p>We therefore performed a prospective study in an ICU of a teaching hospital in the Netherlands. This ICU admits general medical and surgical patients, except acute neurosurgery and cardiothoracic surgery patients. All patients admitted to the ICU receive standard nutritional care, starting on day 1 and with a preference for enteral nutrition. Patients were screened each day for the first 7 days on the ICU for hypomagnesemia (ionized serum magnesium < 0.45mmol/L). Patients with low serum ionized magnesium were included for further screening. We continued the study until a total of 10 patients were included. Magnesium suppletion was given according to the attending clinicians preferences.</p><p>The incidence of ionized hypomagnesemia in our study population was 15% (15/99 patients). The incidence of hypermagnesemia (ionized magnesium > 0.60 mmol/l) was 52% (52/99). All patients who developed ionized hypomagnesemia showed this within 24 h of admittance to the ICU, except one. In all patients magnesium levels rose during their stay on the ICU, even when no suppletion was given (Fig. 1). In general, ionized and total magnesium levels correlated well (R2 = 0.92, <i>p</i> < 0.01) but the amount of mislabeled hypomagnesemia based on total magnesium was relatively high: in 13 out of 29 low total magnesium levels, there was a concomitant normal ionized magnesium (= 45%). Levels of albumin and pH were not different in these patients compared to the overall group. The amount of mislabeled normomagnesemia based on total magnesium was low: there was only one instance of a low ionized magnesium with a normal total magnesium, in contrast to 16 measurements of low ionized magnesium with a concomitant low total magnesium (= 6%).</p><p>Patients with an ionized hypomagnesemia all showed low concentrations of urine magnesium. The mean amount of magnesium in the 24 h urine samples collected on the first day after diagnosis was 1.2 mmol. Compared to the median suppletion of over 2 g of MgSO4 (~ 8mmol of Mg) in the same period, this is also low.</p><p>PTH levels were elevated in these patients with mean levels of 20 pmol/L and calcitriol was decreased, mean 36 pmol/L.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05630-1/MediaObjects/13054_2025_5630_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" h","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"157 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188707","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":"Beyond the bleed: complications after aneurysmal subarachnoid hemorrhage. Pathophysiology, clinical implications, and management strategies: a review","authors":"Katharina M. Busl, Elisa Gouvea Bogossian, Jan Claassen, Raimund Helbok, Jose Javier Provencio, Chiara Robba, Mervyn D. I. Vergouwen, Stefan Wolf, Eliza R. Zanier, Giuseppe Citerio","doi":"10.1186/s13054-025-05640-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05640-z","url":null,"abstract":"Aneurysmal subarachnoid hemorrhage is a critical condition with high case-fatality and lasting impacts on survivors. Acute events that are the direct result of aneurysm rupture, such as acute ischemia, elevated intracranial pressure, cerebral edema, seizures, and hydrocephalus, lead to early brain injury. A delayed cascade of processes, including a prominent systemic inflammatory response, may lead to secondary brain injury and delayed cerebral ischemia, which often further impairs recovery. Systemic complications, including cardiac and pulmonary dysfunction, fever, and electrolyte imbalances, arise in the interplay between early and secondary brain injury and challenge the clinical course. Early management focuses on the prevention of rebleeding mainly through aneurysm securement, amelioration of early brain injury through cerebrospinal fluid drainage, control of intracranial pressure, and organ support to avoid or attenuate secondary brain injury. Nimodipine remains the only pharmacological agent shown to reduce delayed cerebral ischemia, and lumbar drainage of cerebrospinal fluid to reduce subarachnoid blood may improve outcome. Management strategies for hemodynamic interventions, seizures, intracranial pressure control, large artery vasospasm, and electrolytes remain consensus-based and with large variation in practice. Several advances in understanding inflammation and delayed cerebral ischemia, as well as in monitoring and interventions hold promise, but robust trials are needed to refine protocols and improve patient recovery. Understanding and mitigating the cascade of damage from rupture to recovery is essential to reduce the burden of this devastating condition. In this review, we appraise the current understanding of the pathophysiology of post-rupture complications as well as scientific and management data, with a focus on recent advances.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"100 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188706","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":"Severe autoimmune hemolytic anemia in ICU: a place for emergency plasma exchange? A French multicenter retrospective study","authors":"Jean-Baptiste Destival, Tomas Urbina, Wulfran Bougouin, Judith Leblanc, Sacha Seksik, Delphine Gobert, Vincent Bonny, Louai Missri, Jean-Luc Baudel, Juliette Bernier, Hafid Ait-Oufella, Eric Maury, Olivier Fain, Jérémie Joffre","doi":"10.1186/s13054-025-05601-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05601-6","url":null,"abstract":"Autoimmune hemolytic anemia (AIHA) is a rare but potentially life-threatening condition requiring intensive care unit (ICU) admission in severe cases. While corticosteroids and immunosuppressants are standard treatments, their delayed efficacy limits their utility in critical settings requiring rapid hemolysis control. Plasma exchange (PlEx) may offer a rapid intervention, but its effectiveness in severe AIHA remains uncertain. This study aims to assess the clinical characteristics, outcomes, and the potential benefit of PlEx in ICU cases with severe AIHA. We conducted a multicenter retrospective cohort study including patients with severe AIHA admitted to 15 ICUs within the Assistance Publique–Hôpitaux de Paris (AP-HP) network between 2017 and 2024. Clinical, biological, and therapeutic data were collected. A multivariate logistic regression model, an analysis adjusted on a propensity score (PS) and on inverse probability of treatment weighting (IPTW) were used to identify predictors of in-ICU mortality and evaluate the association between PlEx and in-ICU mortality. One hundred forty-eight ICU stays involving severe AIHA hemolytic crises were analyzed. The median age at ICU admission was 61 {48–71} years, with a balanced sex ratio (51% male). Admission median hemoglobin was 5.2 g/dL {4.2–7.2} and in-ICU mortality was 17.6%. Risk factors for in-ICU mortality included age > 60 years, renal replacement therapy, mechanical ventilation, and high-dose intravenous methylprednisolone (HDIM). Therefore, ICU mortality was mainly driven by organ dysfunction rather than anemia severity. Standard corticosteroid therapy (1–2 mg/kg) (OR:0.19 [0.03–0.94], P = 0.05) and PlEx (OR:0.04 [0.004–0.4], P = 0.008) were associated with improved survival. The association between PlEx and outcome persisted after PS (OR: 0.04 [0.001–0.39]; P = 0.012) and IPTW (OR: 0.13 [0.02–0.55]; P = 0.011) adjustment. In this large ICU cohort, severe AIHA was associated with high mortality, driven by organ failure rather than anemia severity. PlEx are associated with survival, suggesting its potential role as a bridge to immunosuppressive therapy in selected cases. Prospective studies are needed to confirm these findings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188760","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":"Observational studies of early versus late salvage therapies in critical care exhibit intrinsic selection bias: two meta-analyses","authors":"Elizabeth Landzberg, Alexis Ogdie, Christopher Yarnell, Michael O. Harhay, Nadir Yehya","doi":"10.1186/s13054-025-05663-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05663-6","url":null,"abstract":"It is difficult to determine the optimal timing of salvage therapies, such as initiation of renal replacement therapies (RRT), using non-experimental designs. Therefore, using timing of RRT as a motivating example, we performed meta-analyses comparing observational and experimental studies assessing timing of RRT and timing of invasive mechanical ventilation (IMV). We performed two meta-analyses of observational and experimental studies testing the association of early versus late initiation of RRT and IMV on mortality. We included 72 studies for RRT (57 observational, 15 experimental) and 50 for IMV (48 observational, 2 experimental). For RRT, observational studies showed mortality benefit with early RRT (OR 0.52, 95% CI 0.42-0.63) that was not seen in experimental studies (OR 0.94, 95% CI 0.76-1.17). For IMV, observational studies demonstrated harm with early IMV (OR 1.25, 95% CI 1.03-1.52), although not to the degree of experimental studies (OR 1.86, 95% CI 0.90-3.86). When observational studies were restricted to subjects who all received IMV, conclusions were further biased towards benefit favoring early IMV (OR 0.75, 95% CI 0.55-1.02). Studies that also included subjects who were never intubated showed harm with early IMV (OR 1.63, 95% CI 1.30-2.04). There were significant differences in the results of observational and experimental studies looking at timing of salvage therapies, partly due to selection bias in observational studies. This issue was worsened by only including subjects who receive the therapy. Randomized trials using objective eligibility criteria remain the best method to determine optimal timing of salvage therapies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"37 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188761","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":"Comparison of two transpulmonary pressure-based positive end-expiratory pressure titration strategies in acute respiratory distress syndrome: a randomized crossover study","authors":"Dara Chean, Antonin Courtais, Bertrand Pavlovsky, Elise Yvin, Christophe Desprez, Mathilde Taillantou-Candau, Lise Piquilloud, Jean-Christophe Richard, Alain Mercat, François M. Beloncle","doi":"10.1186/s13054-025-05626-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05626-x","url":null,"abstract":"Esophageal pressure monitoring, which enables the estimation of transpulmonary pressure, has been proposed to personalize ventilator settings, particularly positive end-expiratory pressure (PEEP), in patients with acute respiratory distress syndrome (ARDS). Two conceptually different transpulmonary pressure-based PEEP titration strategies have thus been described but have never been compared. This study aims to compare the PEEP levels obtained with these two distinct strategies and their physiological effects. This was a randomized crossover physiological study. Twenty patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included in an academic intensive care unit. The two transpulmonary pressure-based PEEP titration strategies were applied for 45 min each in a randomized order, separated by a 45-minute washout period. In the directly measured expiratory transpulmonary pressure (PL, exp) strategy, PEEP was set to target a PL, exp using a PL, exp/FiO2 table. In the calculated inspiratory transpulmonary pressure (PL, insp) strategy, PEEP was set to maintain PL, insp estimated using the lung/respiratory system elastance ratio between 20 and 22 cmH2O. Gas exchange, hemodynamics and partitioned respiratory mechanics were assessed at the end of each PEEP application period. Median PEEP levels determined by the two strategies were not different; however, individual values were uncorrelated, with a difference of at least 3 cmH2O in 14 (70%) patients. The PL, insp strategy resulted in higher PEEP levels than the PL, exp strategy in the non-obese patients but not in the obese patients. The effects on gas exchange, hemodynamics, and respiratory mechanics did not differ between the two strategies considering the entire study population or the obese and non-obese patients separately. Recruitment with PEEP (assessed by the recruited lung volume from PEEP 5 cmH2O), PL, insp, transpulmonary driving pressure and lung strain did not differ between the two strategies. The two transpulmonary pressure-based titration strategies result in different PEEP levels in most patients. Neither strategy is associated with higher recruited lung volume or lower estimated Stress and Strain. #NCT03281473 Clinicaltrials.gov. Registered 12 September 2017.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188796","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":"Outcome and critical care resources utilised by do not attempt cardiopulmonary resuscitation (DNACPR) patients admitted to the ICU at a tertiary hospital in Saudi Arabia: a retrospective review of the critical care database","authors":"Asiah Rugaan, Muath Mobarki, Soltan Mohammad Hamida, Masood Iqbal, Manar Alotibi, Tafe Abdulelah Howsawi, Sulafah Reda, Hanan Abdullah Alzhrani, Asmaa Saeed Almadani, Adeel Ahmed Khan","doi":"10.1186/s13054-025-05656-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05656-5","url":null,"abstract":"The Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order. aims to prevent the initiation of inappropriate, aggressive interventions in patients with a poor prognosis, highlighting the need to assess intensive care unit (ICU) resource utilization in such cases. Therefore, our study aimed to evaluate the resources utilized by DNACPR patients and compare them with those utilized by non-DNACPR patients in the intensive care unit to explore the outcomes of these patients. A retrospective cohort study of 7104 patients admitted to the ICU in King Abdullah Medical City, Makkah, Saudi Arabia, was performed. Patients were segregated into DNACPR cases and non-DNACPR cases. Data were extracted from the critical care registry from January 2016 to June 2023. A descriptive analysis was performed. Multivariate analysis was used to adjust for the severity of illness between groups and compare outcomes for resources utilized by the study population after the DNACPR decision was made, between DNACPR patients and non-DNACPR patients. Over eight years, a total of 7,104 patients were admitted to the ICU, with 988 classified as DNACPR (13.9%) and 6,116 (86.1%) classified as non-DNACPR patients. DNACPR patients utilized a substantial amount of critical care resources, including mechanical ventilation (88.9% vs. 41.4%, AOR 7.8, 95% CI (6.1–9.9), P < 0.001) and continuous renal replacement therapy (CRRT) (28.6% vs. 6.7%, AOR 4.4, 95% CI (3.6–5.4), p < 0.001). All radiological imaging was significantly utilized by DNACPR versus non-DNACPR patients (P < 0.001). Additionally, blood product transfusions were significantly consumed by DNACPR versus non-DNACPR patients (P < 0.001). On the other hand, the mortality rate for DNACPR patients was markedly higher (76.7%) than that for non-DNACPR patients (7.7%) (P < 0.0001). The mean ICU length of stay for DNACPR patients was 20.4 days, whereas it was 8.0 days for non-DNACPR patients (P < 0.001). In subgroup analysis of only emergent admissions, the utilization of ICU interventions, such as mechanical ventilation, CRRT, radiological imaging, and blood transfusion, was significantly higher among DNACPR patients versus non-DNACPR patients, with P < 0.001. DNACPR patients consumed a significant amount of ICU resources after the DNACPR decision was made. The findings underscore significant disparities in both resource consumption and clinical outcomes, highlighting the need for optimized care strategies for terminally ill patients in the ICU setting.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"78 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145188767","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}