Critical Care最新文献

{"title":"Cardiovascular effects of hypertonic lactate solutions: acid–base or metabolic cause, or both?","authors":"Pedro J. Freire Jorge, Rohan Boer, František Duška, Maarten M. W. Nijsten, Micah L. A. Heldeweg","doi":"10.1186/s13054-025-05463-y","DOIUrl":"https://doi.org/10.1186/s13054-025-05463-y","url":null,"abstract":"<p>It was a pleasure to read the recent publication in <i>Critical Care</i> on the cardiovascular effects of lactate [1]. The authors conducted a randomized comparison between the infusion of hypertonic lactated solution and hypertonic saline solution and their effects on echocardiography measurements. The authors equalized the osmolarity of the solutions to ensure that there were no differences in volume expansion between groups—as evidenced by the preload metrics. The authors assert that the observed hemodynamic differences were primarily attributable to the infusion of hypertonic lactate i.e., lactate anion.</p><p>Increasing evidence supports lactate as a valuable metabolic intermediate and signaling molecule, highlighting its potential future therapeutic role. However, before concluding on the positive effects of exogenous hypertonic lactate solutions, we would like to discuss additional acid–base and metabolic considerations that will contribute in moving the discourse and future investigations forward.</p><p>The first point concerns the confounding acid–base effects secondary to the administration of hypertonic sodium-lactate and sodium-chloride. In the current study, the sodium-lactate and sodium-chloride groups demonstrated significant and substantial differences in pH, chloride, bicarbonate, lactate, and potassium levels. Although the authors stated that there is no hyperchloremic acidosis, we calculated an average difference in the standard base excess of − 7.4 mmol/L (−2.1 versus + 5.3) between the groups. The acid–base difference between groups is virtually entirely—barring a minimal amount of unmeasured anion in the sodium-lactate group—explained by their relative changes in chloride (see supplemental material for full calculation).</p><p>As lactate is metabolized, the strong ion difference in the sodium-lactate group rises, whereas the strong ion difference in the sodium-chloride group decreases due to hyperchloremia. This is a problematic confounder because a hypochloremia with metabolic alkalosis has a positive inotropic effect, whereas a hyperchloraemia with metabolic acidosis causes myocardial depression [2]. Thus, the different cardiovascular effects (reflected in a different stroke volume) between these groups may well be attributed to the electrolyte or acid-base properties of the respective solutions [2]. In fact, previous experiments in hemorrhaging canines also demonstrated the superior cardiovascular effects of hypertonic fluids with either acetate or lactate, versus unbalanced hypertonic saline. The metabolization of acetate, another organic anion, also induces alkalosis in a manner similar to that of lactate. The authors found that acetate may have a superior resuscitative profile due to its strong intrinsic vasodilatory properties and capacity to persistently restore oxygen consumption [3]. Moreover, another study in hemorrhaging dogs showed that infused acetate was rapidly metabolized, whereas equivalent lactate loads","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144176597","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":"Trajectories of fluid management after the initiation of renal replacement therapy in critically ill patients: a secondary analysis of the STARRT-AKI trial","authors":"William Beaubien-Souligny, Ehsan Gamarian, Jean-Maxime Côté, Javier A. Neyra, Frederic Baroz, Neill K. J. Adhikari, Kevin Thorpe, Sean M. Bagshaw, Ron Wald","doi":"10.1186/s13054-025-05447-y","DOIUrl":"https://doi.org/10.1186/s13054-025-05447-y","url":null,"abstract":"Fluid management is an essential component of renal replacement therapy (RRT) in critically ill patients. Both a positive cumulative fluid balance (CFB) and a high net ultrafiltration (NUF) rate have been reported to be associated with adverse outcomes in epidemiological studies, although the overall trajectory of fluid balance after RRT initiation is not well-described. We aimed to characterize trajectories of fluid management parameters during RRT and analyse the effect of CFB/NUF on outcomes as a trajectory rather than single or aggregated time points over the first week after initiation of RRT. This is a secondary analysis using fluid balance data focusing on individuals enrolled in the standard-strategy arm of the STARRT-AKI trial who initiated RRT. Cumulative fluid balance (CFB) following RRT initiation and daily net ultrafiltration (NUF) adjusted for body weight during the first 7 days after initiation of RRT were the main independent exposures. We modeled the trajectory of fluid parameters using spline functions and used latent trajectory analysis methods to identify predominant trajectories to compare patients’ characteristics and outcomes. We employed logistic regression and multivariable joint longitudinal models to compare the odds and determine the time-dependent association between fluid parameters (CFB and NUF) and 90-day mortality across and within the trajectory classes identified. We included 855 patients in the primary analysis. After excluding erroneous fluid balance data, we identified two distinct CFB/NUF trajectories. Class A (82.8%) was characterized by a slight increase in CFB and low/stable NUF during the week following RRT initiation while class B (17.2%) was characterized by an increasingly negative CFB with initially higher daily NUF during the first 4 days followed by a stabilization after day 4. In an adjusted analysis, individuals classified in class B were at lower risk for 90-day mortality (aOR: 0.48 CI 0.32; 0.70) p < 0.001) compared to class A. Time-dependent analysis revealed higher CFB was associated with mortality only in those with a class A trajectory (aHR 1.29, 95% CI 1.03–1.55, p = 0.03). Distinct CFB/NUF trajectories convey prognostic information beyond single-day fluid balance or NUF values and should be considered when formulating or interpreting fluid management strategies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"51 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144145634","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":"Spontaneous diuresis in combination with furosemide stress test (SD-FST) as predictor for successful liberation from kidney replacement therapy: a prospective observational study","authors":"Lorenz Weidhase, Stephanie Wille, Helene Foede, Fanny Gilch, Meinhard Mende, Christina Scharf-Janßen, Sirak Petros, Jonathan de Fallois","doi":"10.1186/s13054-025-05452-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05452-1","url":null,"abstract":"The optimal time for initiating kidney replacement therapy (KRT) in acute kidney injury (AKI) has been extensively studied in recent years. In contrast, there are currently insufficient data on the best time to discontinue KRT. One diagnostic option to unmask tubular reserve and indirectly estimate the glomerular filtration rate is the furosemide stress test (FST). We conducted a prospective, observational single-center trial. A FST was carried out in patients who developed spontaneous diuresis (SD) during ongoing KRT with a urine output of at least 400 ml in 24 h without any diuretic therapy. A positive FST was defined with urine output > 200 ml within 2 h following intravenous furosemide application. Follow-up was performed for 7 days and the need to restart KRT was assessed daily. After 100 patients were enrolled in the trial, 98 patients were eligible for further evaluation. 76 patients were FST-positive, while 22 patients were FST-negative. Resumption of KRT within the 7-day follow-up was required in only 14.5% of the FST-positive, but 72.7% of the FST-negative patients (p < 0.001). The urine output after FST was also significantly associated with successful release from KRT (AUC 0.87; p < 0.001). In critically ill patients with recovery of SD > 400ml/d during ongoing KRT, the FST helps to identify patients who can be successfully liberated from KRT. By detecting the tubular reserve using FST, the possibility of short-term kidney recovery after AKI can be estimated. German Clinical Trials Registry (DRKS00030560); date of registration 18/11/2022. https://drks.de/search/de/trial/DRKS00030560 .","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"786 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144137145","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":"Phrenic stimulation decreases brain injury biomarkers in sedated mechanically ventilated patients: preliminary observations","authors":"Bassi Thiago, Rohrs Elizabeth, Parfait Melodie, Hannigan Brett, Reynolds Steve, Mayaux Julien, Decavèle Maxens, Demoule Alexandre, Similowski Thomas, Dres Martin","doi":"10.1186/s13054-025-05435-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05435-2","url":null,"abstract":"&lt;p&gt;Astrocytes assist in modulating the breathing cycle. Mechanically ventilated sedated patients have their respiratory drive suppressed, which may affect astrocytes’ function. This pilot study showed that phrenic nerve stimulation may protect astrocyte function and activity, maintaining the integrity of the blood–brain barrier in these patients. &lt;/p&gt;&lt;p&gt;Neural control of respiratory rhythm is a complicated process controlled by both neuron and glia cells across subcortical and cortical networks, sending rhythmic or non-rhythmic inputs to respiratory motoneurons in the spinal cord [1]. Glial cells, specifically astrocytes, also play a major role in controlling blood–brain barrier permeability, acting as “the brain’s gatekeepers” [1]. Cervical vagus nerve stimulation and the use of mechanical ventilation have been shown to modify the blood–brain barrier permeability [2, 3]. Better ventilation distribution and increased alveolar ventilation secondary to diaphragm activity in mechanically ventilated patients could enrich the afferent traffic from the respiratory system to the brain through pulmonary stretch receptors stimulation. This could modulate the activity of the tractus solitarius nucleus directly via the vagal pathway or indirectly via spinal-to-brainstem communication. Phrenic stimulation could thus upregulate astrocyte function and subsequently affect the permeability and integrity of the blood–brain barrier. This dynamic interaction is essential for normal brain function and plays a significant role in neurological health and disease states, which can be affected by deep sedation.&lt;/p&gt;&lt;p&gt;Deep sedation is one strategy employed in the delivery of invasive mechanical ventilation to ensure patient-ventilator synchrony. Although mechanical ventilation saves lives, it is associated with negative effects on pulmonary air distribution, diaphragm function, cardiac function and an increased likelihood of delirium and cognitive impairment [4, 5]. Increased levels of biomarkers of astrocytes and neuronal injuries have been associated with cognitive impairment and delirium [6]. Calcium binding S100β and glial fibrillary acid protein (GFAP) are examples of astrocyte biomarkers while light chain neurofilament (NfL), tau protein (tau), neuro specific enolase (NSE), and ubiquitin c-terminal hydrolase L-1 (UCHL-1) are neuronal biomarkers [1, 6]. Recently, biomarkers for brain injury have been used to quantify astrocytes and neuronal injury in traumatic brain injured patients. The American Food and Drugs Administration approved the use of biomarkers for astrocytes and neuronal injury to assist in recognizing mild brain injuries (Glasgow coma scale between 14 and 15) that need imagining investigation. Also, S100β, GFAP, NSE and UCHL-1 biomarkers have been used to follow up with the resolution of concussion in traumatic brain injury patients who scored 15 on the Glasgow coma scale [7, 8].&lt;/p&gt;&lt;p&gt;In this research letter, we report the effects of continuous bilate","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"25 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144137143","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":"Novel biomarkers for predicting successful liberation of renal replacement therapy for acute kidney injury: a systematic review","authors":"Qing Xu, Zhifeng Zhou, Lu Jin, Chen Liu, Peiyun Li, Fang Wang, Ling Zhang, Ping Fu","doi":"10.1186/s13054-025-05451-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05451-2","url":null,"abstract":"Renal replacement therapy (RRT) is commonly used in critically ill patients with acute kidney injury (AKI). However, optimal timing of RRT liberation remains controversy. This meta-analysis evaluates novel biomarkers to predict successful RRT liberation in critically ill AKI patients. The systematic review reported following PRISMA guidelines, PubMed, Embase, and Scopus were searched up to May 2, 2025, and were screened using predefined criteria. Methodological quality was assessed using the Newcastle–Ottawa scale. Pooled ROC-AUCs with 95% CIs were calculated; heterogeneity was evaluated using I2 statistics. Sixteen studies (3020 patients) involving 23 biomarkers were included. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) demonstrated fair predictive performance with 4 studies (AUC 0.766, I2 = 39.8%). When excluding a study focused on long-term outcomes, the result showed a better predictive ability with low heterogeneity (AUC 0.801, I2 = 0%). Plasma proenkephalin A (PENK) and serum NGAL also showed potential, but quantitative synthesis was limited by study number and heterogeneity. The cut-off value also varied widely, complicating clinical translation. In addition, multivariable models combining novel biomarkers with clinical indicators have also demonstrated promising predictive potential. However, due to the limited number of studies and inconsistent conclusions, further exploration is needed. uNGAL moderately predicts short-term RRT liberation, while other biomarkers (e.g., PENK) require further validation. Standardizing definitions of successful liberation and integrating dynamic biomarker changed with clinical indicators (e.g., urine output) may enhance predictive accuracy. Further large-scale, prospective, and multicenter studies are needed to validate these findings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"24 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144137147","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":"ORAKLE: Optimal Risk prediction for mAke30 in patients with sepsis associated AKI using deep LEarning","authors":"Wonsuk Oh, Marinela Veshtaj, Ashwin Sawant, Pulkit Agrawal, Hernando Gomez, Mayte Suarez-Farinas, John Oropello, Roopa Kohli-Seth, Kianoush Kashani, John A. Kellum, Girish Nadkarni, Ankit Sakhuja","doi":"10.1186/s13054-025-05457-w","DOIUrl":"https://doi.org/10.1186/s13054-025-05457-w","url":null,"abstract":"Major Adverse Kidney Events within 30 days (MAKE30) is an important patient-centered outcome for assessing the impact of acute kidney injury (AKI). Existing prediction models for MAKE30 are static and overlook dynamic changes in clinical status. We introduce ORAKLE, a novel deep-learning model that utilizes evolving time-series data to predict MAKE30, enabling personalized, patient-centered approaches to AKI management and outcome improvement. We conducted a retrospective study using three publicly available critical care databases: MIMIC-IV as the development cohort, and SiCdb and eICU-CRD as external validation cohorts. Patients with sepsis-3 criteria who developed AKI within 48 h of intensive care unit admission were identified. Our primary outcome was MAKE30, defined as a composite of death, new dialysis or persistent kidney dysfunction within 30 days of ICU admission. We developed ORAKLE using Dynamic DeepHit framework for time-series survival analysis and its performance against Cox and XGBoost models. We further assessed model calibration using Brier score. We analyzed 16,671 patients from MIMIC-IV, 2665 from SICdb, and 11,447 from eICU-CRD. ORAKLE outperformed the XGBoost and Cox models in predicting MAKE30, achieving AUROCs of 0.84 (95% CI: 0.83–0.86) vs. 0.81 (95% CI: 0.79–0.83) vs. 0.80 (95% CI: 0.78–0.82) in MIMIC-IV internal test set, 0.83 (95% CI: 0.81–0.85) vs. 0.80 (95% CI: 0.78–0.83) vs. 0.79 (95% CI: 0.77–0.81) in SICdb, and 0.85 (95% CI: 0.84–0.85) vs. 0.83 (95% CI: 0.83–0.84) vs. 0.81 (95% CI: 0.80–0.82) in eICU-CRD. The AUPRC values for ORAKLE were also significantly better than that of XGBoost and Cox models. The Brier score for ORAKLE was 0.21 across the internal test set, SICdb, and eICU-CRD, suggesting good calibration. ORAKLE is a robust deep-learning model for predicting MAKE30 in critically ill patients with AKI that utilizes evolving time series data. By incorporating dynamically changing time series features, the model captures the evolving nature of kidney injury, treatment effects, and patient trajectories more accurately. This innovation facilitates tailored risk assessments and identifies varying treatment responses, laying the groundwork for more personalized and effective management approaches.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"15 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144137148","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":"Detection of cytomegalovirus in the lower respiratory tract among patients with critical illness: uncovering enhanced potential benefits","authors":"Zhihui Zhang, Xuesong Liu, Rong Zhang, Dongdong Liu, Chun Yang, Sibei Chen, Yimin Li, Xiaoqing Liu","doi":"10.1186/s13054-025-05456-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05456-x","url":null,"abstract":"&lt;p&gt;We were highly interested in reading the clinical research conducted by Kim et al. [1]. This study is a single-center, retrospective clinical cohort investigation with a large sample size, focusing primarily on the significance of lower respiratory tract (LRT) cytomegalovirus (CMV) positivity in the prognosis of critically ill patients. The research departs from the traditional focus on CMV reactivation in blood samples and examines the epidemiological characteristics of critically ill patients with CMV positivity in the LRT. These findings demonstrate CMV positivity in the LRT as a significant risk factor for mortality in patients with critical illness. However, the detection of CMV positivity in the LRT may hold greater significance, and the comprehensiveness of this study could be further enhanced through additional refinements.&lt;/p&gt;&lt;p&gt;First, the direct definition of CMV detection positivity in the LRT as “reactivation” is debatable. Current CMV-related definitions do not explicitly address this issue [2, 3]. Moreover, the prevailing view is that “reactivation” should be defined based on the premise of CMV seropositivity (IgG) and the detection of a certain CMV viral load in blood samples [2,3,4]. Therefore, the term “CMV detection positivity” is more accurate. Additionally, the CMV viral load may vary among different LRT specimens. Theoretically, the CMV viral load in bronchoalveolar lavage fluid is higher than that in endotracheal aspirates, which may subsequently have different impacts on clinical outcomes. It is necessary to further evaluate the CMV detection positivity and viral load in different LRT specimens and their associations with clinical outcomes.&lt;/p&gt;&lt;p&gt;Second, of particular importance is the observation that CMV detection in the LRT precede its detection in the blood, especially in patients with septic shock [4, 5]. This phenomenon is likely attributed to the high levels of inflammation associated with sepsis. Under conditions of elevated inflammation, latent CMV infection can be reactivated, subsequently leading to CMV-related injury [6]. Notably, clinical studies have demonstrated a close association between CMV reactivation and pulmonary fibrosis in patients with acute respiratory distress syndrome [7], while animal studies have shown that CMV reactivation can induce pulmonary fibroproliferation [8], suggesting that CMV reactivation may trigger lung injury. Therefore, assessing CMV antiviral therapy based on the LRT findings may hold greater value, including both prophylactic and preemptive treatment strategies.&lt;/p&gt;&lt;p&gt;Third, subgroup analyses should be conducted to distinguish patients with different immune statuses, including immunosuppressed and non-immunosuppressed individuals, because the incidence of active CMV infection varies across different immune backgrounds, particularly with a higher rate observed in immunosuppressed patients [2,3,4, 9]. Sepsis patients, who are in an acute state of immunosuppression, merit spec","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"18 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144122992","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":"Application of one-way speaking valves in adult tracheostomy patients: the time should be earlier","authors":"Shi-Min Zhang, Yi-qi Qian, Yaxiaerjiang Muhetaer, Min-jie Ju, Kai Liu","doi":"10.1186/s13054-025-05425-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05425-4","url":null,"abstract":"&lt;p&gt;One-way speaking valves (OWV) can be used in tracheostomy patients. Their design enables inhalation via the tracheostomy tube due to an open diaphragm, that closes immediately before or during exhalation, thus restoring normal physiological exhalation pathways. This mechanism provides multiple physiological and psychological benefits, including enabling voice, re-establishes subglottic pressure, enhances peak expiratory flow rate, improved swallowing, and reduced aspiration risk [1, 2]. Additionally, OWV reestablish physiological expiratory positive pressure, which strengthens respiratory muscles, enhances lung capacity, and supports early mobilization [3].&lt;/p&gt;&lt;p&gt;Unlike intubated patients, adult tracheostomy patients experience asynchronous weaning and decannulation processes, often requiring a stepwise approach [4]. Accordingly, the timing of OWV intervention can be divided into three distinct phases: during mechanical ventilation, during a trial of unassisted or spontaneous breathing, and after successful weaning. While most studies focus on the use during spontaneous breathing or after successful weaning, research on its application during mechanical ventilation remains relatively limited [5, 6]. This comment aims to emphasize the importance of early initiation of OWV use and its potential to accelerate weaning and decannulation, and to provide criteria for early use and clinical practice considerations.&lt;/p&gt;&lt;p&gt;The use of OWV during mechanical ventilation not only offers unique advantages compared to their application during trials of unassisted/spontaneous breathing or after successful weaning but also demonstrates comparable safety [7]. Sutt et al. demonstrated through electrical impedance tomography that the use of OWV in mechanically ventilated patients significantly increased end-expiratory lung impedance without inducing regional hyperinflation, meanwhile, oxygen saturation and end-tidal carbon dioxide remained stable, and respiratory rate significantly decreased during OWV use [8, 9]. These findings provide physiological evidence for the use of OWV in line with the ventilator circuit in mechanically ventilated patients. Research by Freeman-Sanderson et al. demonstrated that under specific conditions early intervention with OWV in the ventilator circuit during mechanical ventilation significantly accelerates voice recovery, enhances communication and patient satisfaction, improves psychological health, and facilitates earlier decannulation in tracheostomy patient [10]. Additionally, a randomized controlled trial (RCT) compared the early use of OWV (within 12 ~ 24 h post-percutaneous tracheostomy) with standard use (48 ~ 60 h post-percutaneous tracheostomy. The study found that patients in the early intervention group tolerated the valve for longer periods and achieved higher decannulation rates at discharge [11]. These findings confirm that the use of OWV during mechanical ventilation can be initiated as early as 48 h post-tracheostomy","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"140 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144122917","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":"Computed tomography perfusion assessment of poor neurological outcome in comatose cardiac arrest patients (CANCCAP): a prospective study","authors":"Jai Shankar, Susan Alcock, Evan Wiens, Marco Ayroso, JaeYeon Park, Navjit Singh, Benjamin Blackwood, Reva Trivedi, Roman Marin, Namita Sinha, Anurag Trivedi, Iain Kirkpatrick, Marco Essig, Stephen Schaffer","doi":"10.1186/s13054-025-05454-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05454-z","url":null,"abstract":"Computed tomography perfusion (CTP) of the brain, are increasingly being employed for the assessment of critically ill patients admitted to intensive care units (ICU), including comatose cardiac arrest patients (CCAP). The purpose of our study was to validate the use of CTP in predicting in-hospital mortality in CCAPs. This prospective cohort study enrolled newly admitted adult CCAP, with an out of hospital cardiac arrest (OHCA) and were scheduled for admission to the ICU for further management. Just before ICU admission, CCAP underwent a routine CT scan of the head and CTP of whole head. The treating physicians remained blinded to the CTP results and all patients received standard management. The CTP maps were evaluated to determine a binary outcome of non-survivable brain injury (NSBI), by two independent neuroradiologists, blinded to each other’s assessment and to the clinical history of the patients. A total of 91 patients were enrolled and 90 (Male-78; mean age-62 years) were included in the final analysis. One patient declined consent. Of these, 42 individuals (47%) had in-hospital mortality. Patients with in-hospital mortality were older; had higher levels of creatinine, blood urea nitrogen, blood CO2 and lower pH, carbonate, and heart rate. In multivariate analysis, PCI was independently associated with reduction in-hospital mortality. CTP demonstrated exceptionally high specificity (100%; 95% CI 92–100%) and positive predictive value (100%; 95%CI 6.3–100%) for the prediction of NSBI. For CTP, Bennet’s S-score showed excellent agreement between the two readers (s = 0.82–0.95). CTP was safe and demonstrated very high specificity and positive predictive value and may be used as an additional diagnostic tool for identifying patients at high risk of in-hospital mortality.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"33 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144130358","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":"First dose target attainment with extended infusion regimens of piperacillin and meropenem","authors":"Gustaf Beijer, Maria Swartling, Elisabet I. Nielsen, Olof Breuer, Christian G. Giske, Erik Eliasson, Johan Petersson","doi":"10.1186/s13054-025-05445-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05445-0","url":null,"abstract":"Standard dosing regimens of meropenem and piperacillin-tazobactam frequently fail to achieve targeted plasma concentrations in critically ill patients. Extended or continuous regimens are often used to improve target attainment. Although prompt antibiotic initiation is a major determinant of survival, few studies have reported systemic concentrations early after treatment initiation. No prior study has reported concentrations immediately after the loading dose and first extended infusion. This study aimed to evaluate plasma target attainment during the first dosing interval with an extended infusion regimen in a general intensive care unit (ICU). Adult ICU patients were prospectively included in conjunction with the first administration of meropenem or piperacillin-tazobactam. Treatment was initiated with a 0.5 h loading dose immediately followed by a 3 h extended infusion; typically 4 + 4 g piperacillin or 1(− 2)g + 1(− 2)g meropenem, in line with the local ICU protocol. Patients requiring renal replacement therapy were excluded. Plasma concentrations were measured post-loading dose (Cmax), near the end of the first extended infusion, and at the end of the first dosing interval (Cmin). Samples were analyzed using validated tandem mass spectrometry (UHPLC-MS/MS) methods. The primary endpoint was the proportion of patients achieving 100% time above minimum inhibitory concentrations (fT > MIC) during the first dosing interval. This was evaluated using observed Cmin above 2 mg/L (meropenem) and 20 mg/L (piperacillin). Additionally, published pharmacokinetic models were applied to the observed data for %fT > MIC estimation, using an a posteriori Bayesian approach. We included 65 meropenem and 142 piperacillin measurements from 22 and 48 patients, respectively. Many patients (45% meropenem, 38% piperacillin) failed to reach 100% fT > MIC with the standard regimens used. Target non-attainment was associated with high estimated glomerular filtration rates (eGFR) and suspected augmented renal clearance (ARC). All meropenem patients that failed to reach target had eGFR > 90 mL/min/1.73 m2, as did 76% of corresponding piperacillin patients. Patients with suspected ARC frequently exhibited a tenfold or greater peak-to-trough decline (Cmin/Cmax < 0.1). Despite aggressive dosing, plasma concentrations often fail to reach 100% fT > MIC during the first dosing interval. Alternative regimens and early plasma concentration measurements followed by adaptive dose adjustments should be considered to improve target attainment.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144113955","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}