Critical Care最新文献

{"title":"Based -evidence, an intervention study to improve sleep quality in awake adult ICU patients: a prospective, single-blind, clustered controlled trial","authors":"Yanting Zhang, Yihua Yang, Chong Cheng, Gui Hou, Xinbo Ding, Jing Ma","doi":"10.1186/s13054-024-05161-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05161-1","url":null,"abstract":"Evidence-based guidelines advocate promoting sleep in intensive care unit (ICU) patients, yet many patients experience poor sleep quality. We sought to develop a collaborative evidence-based intervention with healthcare providers and assess whether evidence-based sleep interventions could improve sleep quality in awake adult ICU patients. We conducted a prospective, nonrandomized cluster control trial in two intensive care units (ICUs) at a tertiary general teaching hospital in China. Patients aged 18 years or older who stayed in the ICU for one night or more and were conscious were eligible for enrollment. We only blinded the patients, not the outcome assessors. On the basis of evidence-based practice and clinical reality, we developed intervention measures for the intervention group, which mainly included four aspects: reducing environmental noise in the ICU, adjusting nursing actions, modifying nighttime lighting, and other measures. The assessment tools used were wearable actigraphy sleep monitoring devices and the Richards-Campbell Sleep Questionnaire (RCSQ). The primary outcomes were patient sleep quality, including total sleep time, deep sleep time, light sleep time, rapid eye movement (REM) time, number of awakenings, overall sleep score, and patients' self-assessment of their sleep quality that night. The data collected were analyzed via SPSS and Mplus statistical software for between-group analysis, pre-post comparison, profile analysis, and calculation of the intervention effect size. From September 1, 2023, to January 31, 2024, 713 patients underwent eligibility assessment, and ultimately 246 patients were included in the analysis, with 125 in the intervention group and 121 in the control group. Comparative analysis revealed no statistically significant differences in sleep quality between the two groups when the duration in the ICU = 1 night (P > 0.05), with a small intervention effect size. However, the intervention group had higher sleep quality scores (sleep monitoring wristband: 57.74 ± 22.55 > 57.72 ± 19.39; RCSQ questionnaire: 60.58 ± 22.14 > 57.61 ± 24.4) and total sleep time (440.42 ± 262.11 > 420.31 ± 236.89), a lower awakening frequency (3.98 ± 2.69 < 6.09 ± 4.66) and a lower awakening frequency (3.976 ± 2.693 < 6.09 ± 4.664) than did the control group. The sleep quality of patients who stayed in the ICU for > 1 night significantly improved in all the parameters except rapid eye movement time (min) according to the pre-post-test analyses (P < 0.05), with a medium to large intervention effect size and favorable intervention effects. Evidence-based interventions significantly improve sleep quality in ICU patients hospitalized for more than one day. However, our results do not support the improvement of sleep quality in patients admitted to the ICU for one day. Clinical trial registration: ChiCTR2300075763, Registered 14 September 2023—Retrospectively registered, https://www.chictr.org.cn/bin/userProject ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142599740","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":"Predictors of weaning failure in ventilated intensive care patients: a systematic evidence map","authors":"Fritz Sterr, Michael Reintke, Lydia Bauernfeind, Volkan Senyol, Christian Rester, Sabine Metzing, Rebecca Palm","doi":"10.1186/s13054-024-05135-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05135-3","url":null,"abstract":"Ventilator weaning is of great importance for intensive care patients in order to avoid complications caused by prolonged ventilation. However, not all patients succeed in weaning immediately. Their spontaneous breathing may be insufficient, resulting in extubation failure and the subsequent need for reintubation. To identify patients at high risk for weaning failure, a variety of potential predictors has already been examined in individual studies and meta-analyses over the last decades. However, an overview of all the predictors investigated is missing. To provide an overview of empirically investigated predictors for weaning failure. A systematic evidence map was developed. To this end, we conducted a systematic search in the Medline, Cochrane, and CINAHL databases in December 2023 and added a citation search and a manual search in June 2024. Studies on predictors for weaning failure in adults ventilated in the intensive care unit were included. Studies on children, outpatients, non-invasive ventilation, or explanatory factors of weaning failure were excluded. Two reviewers performed the screening and data extraction independently. Data synthesis followed an inductive approach in which the predictors were thematically analyzed, sorted, and clustered. Of the 1388 records obtained, 140 studies were included in the analysis. The 112 prospective and 28 retrospective studies investigated a total of 145 predictors. These were assigned to the four central clusters ‘Imaging procedures’ (n = 22), ‘Physiological parameters’ (n = 61), ‘Scores and indices’ (n = 53), and ‘Machine learning models’ (n = 9). The most frequently investigated predictors are the rapid shallow breathing index, the diaphragm thickening fraction, the respiratory rate, the P/F ratio, and the diaphragm excursion. Predictors for weaning failure are widely researched. To date, 145 predictors have been investigated with varying intensity in 140 studies that are in line with the current weaning definition. It is no longer just individual predictors that are investigated, but more comprehensive assessments, indices and machine learning models in the last decade. Future research should be conducted in line with international weaning definitions and further investigate poorly researched predictors. Registration, Protocol: https://doi.org/10.17605/OSF.IO/2KDYU ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142599739","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":"Length of hospital and intensive care unit stay in patients with invasive candidiasis and/or candidemia treated with rezafungin: a pooled analysis of two randomised controlled trials","authors":"Patrick M. Honoré, Matteo Bassetti, Oliver A. Cornely, Herve Dupont, Jesús Fortún, Marin H. Kollef, Peter Pappas, John Pullman, Jose Vazquez, Inga Bielicka, Sara Dickerson, Nick Manamley, Taylor Sandison, George R. Thompson","doi":"10.1186/s13054-024-05152-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05152-2","url":null,"abstract":"Invasive candidiasis/candidemia (IC/C) is associated with a substantial health economic burden driven primarily by prolonged hospital stay. The once-weekly IV echinocandin, rezafungin acetate, has demonstrated non-inferiority to caspofungin in the treatment of IC/C. This paper reports a post hoc pooled exploratory analysis of length of stay (LoS) for hospital and intensive care unit (ICU) stays in two previously published clinical trials (ReSTORE [NCT03667690] and STRIVE [NCT02734862], that compared rezafungin with daily IV caspofungin (stable patients in the caspofungin group who met relevant criteria could step down to fluconazole after 3 days or more). LoS outcomes were analysed descriptively in the pooled modified intention to treat (mITT) population (all patients who had a documented Candida infection in line with trial requirements and received at least one dose of study drug). In addition, to adjust for an imbalance between treatment groups in the proportion receiving mechanical ventilation at baseline, a generalised linear model with mechanical ventilation as a binary covariate was applied. Responses to an exploratory question in the phase 3 trial on possible earlier discharge with weekly rezafungin are also reported. 294 patients were included (rezafungin 139, caspofungin 155), of whom 126 (43%) had ICU admission. Patients treated with rezafungin had a numerically shorter LoS than with caspofungin in all analyses. Mean total LoS was 25.2 days, vs 28.3 days with caspofungin, and mean ICU LoS was 16.1 vs 21.6 days for rezafungin and caspofungin, respectively. After adjustment for mechanical ventilation status the difference in ICU LoS was 4.1 days, a relative difference of 24% (95% CI -11%, 72%). Physicians would have considered earlier discharge for 16% of patients (30/187) with weekly rezafungin, an average of 5–6 days earlier. Rezafungin may enable shorter hospital and ICU LoS in IC/C compared with daily IV caspofungin, with accompanying savings in resource use. Further research is needed to confirm this in the real-world setting. Trial registration. NCT03667690 (ReSTORE; September 12, 2018); NCT02734862 (STRIVE; April 12, 2016).","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598471","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":"Representation of intensivists’ race/ethnicity, sex, and age by artificial intelligence: a cross-sectional study of two text-to-image models","authors":"Mia Gisselbaek, Mélanie Suppan, Laurens Minsart, Ekin Köselerli, Sheila Nainan Myatra, Idit Matot, Odmara L. Barreto Chang, Sarah Saxena, Joana Berger-Estilita","doi":"10.1186/s13054-024-05134-4","DOIUrl":"https://doi.org/10.1186/s13054-024-05134-4","url":null,"abstract":"Integrating artificial intelligence (AI) into intensive care practices can enhance patient care by providing real-time predictions and aiding clinical decisions. However, biases in AI models can undermine diversity, equity, and inclusion (DEI) efforts, particularly in visual representations of healthcare professionals. This work aims to examine the demographic representation of two AI text-to-image models, Midjourney and ChatGPT DALL-E 2, and assess their accuracy in depicting the demographic characteristics of intensivists. This cross-sectional study, conducted from May to July 2024, used demographic data from the USA workforce report (2022) and intensive care trainees (2021) to compare real-world intensivist demographics with images generated by two AI models, Midjourney v6.0 and ChatGPT 4.0 DALL-E 2. A total of 1,400 images were generated across ICU subspecialties, with outcomes being the comparison of sex, race/ethnicity, and age representation in AI-generated images to the actual workforce demographics. The AI models demonstrated noticeable biases when compared to the actual U.S. intensive care workforce data, notably overrepresenting White and young doctors. ChatGPT-DALL-E2 produced less female (17.3% vs 32.2%, p < 0.0001), more White (61% vs 55.1%, p = 0.002) and younger (53.3% vs 23.9%, p < 0.001) individuals. While Midjourney depicted more female (47.6% vs 32.2%, p < 0.001), more White (60.9% vs 55.1%, p = 0.003) and younger intensivist (49.3% vs 23.9%, p < 0.001). Substantial differences between the specialties within both models were observed. Finally when compared together, both models showed significant differences in the Portrayal of intensivists. Significant biases in AI images of intensivists generated by ChatGPT DALL-E 2 and Midjourney reflect broader cultural issues, potentially perpetuating stereotypes of healthcare worker within the society. This study highlights the need for an approach that ensures fairness, accountability, transparency, and ethics in AI applications for healthcare.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598287","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 β-blocker use among critically iII patients during and after septic shock","authors":"Stuthi Iyer, Jason N. Kennedy, Peter C. Nauka, Mourad H. Senussi, Christopher W. Seymour","doi":"10.1186/s13054-024-05145-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05145-1","url":null,"abstract":"&lt;p&gt;β-Blockers are used widely in the outpatient care of chronic disease, but less is known about how to restart chronic therapy during and after hospitalization for septic shock [1, 2]. We sought to characterize the epidemiology of β-blocker treatment during and after septic shock among patients administered chronic β-blocker therapy in the year prior to hospitalization [3].&lt;/p&gt;&lt;p&gt;We studied patients who received outpatient β-blocker therapy in the 12 months prior to hospitalization at 12 UPMC hospitals from 2010 to 2014 with follow up through 2019. Eligible patients were adults (age ≥ 18 years) with septic shock, defined as suspected infection and sequential organ failure assessment (SOFA) score ≥ 2 within 24 h of admission and receiving vasopressor therapy [4]. Demographics, biomarkers, outpatient and inpatient β-blocker and vasopressor administration were abstracted from outpatient records (EPIC Inc.) for each admission day up to 14 days (CERNER Inc.). Patients were stratified as: (i) those who were administered β-blockers each hospital day (“continued”), (ii) those with cessation of chronic therapy for more than 24 h with or without restart during the hospital stay (“held”), and (iii) those who never received β-blockers (“discontinued”). Descriptive data were compared across groups using the Kruskal–Wallis test and χ&lt;sup&gt;2&lt;/sup&gt; test with a Bonferroni adjusted (2-sided) significance level of &lt;i&gt;P&lt;/i&gt; &lt; 0.05, as appropriate. All analyses used Stata, version 18.0 (StataCorp).&lt;/p&gt;&lt;p&gt;Of 22,208 patients, 3748 were hospitalized with septic shock and received chronic β-blockers (mean age 67 ± 14 years, 56% male, 87% White, median SOFA score 9.0 (IQR: 6.0–11.0) (Fig. 1A). Of those who received chronic therapy, 405 (11%) continued, 2,025 (54%) held, and 1,317 (35%) discontinued chronic β-blocker therapy during intensive care. Patients in whom β-blockers were discontinued presented with greater SOFA score (“continued,” median SOFA 8.0 (IQR: 6.0–11.0); “held,” 8.0 (IQR: 6.0–11.0; “discontinued,” 10.0 (IQR: 7.0–12.0); &lt;i&gt;p&lt;/i&gt; &lt; 0.001), while first-measured biomarkers, such as serum lactate, troponin, and platelets, were similar across groups.&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"493\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;Patient characteristics and prescribing patterns. &lt;b&gt;A&lt;/b&gt; Patient characteristics of adults with septic shock who received chronic β-blocker therapy prior to hospitalization. Abbreviations include: d, days; ICU, intensive care unit; INR, international normalized ratio; IQR, interquartile range; no, number; SD, sta","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142599741","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":"Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates","authors":"Fur-Hsing Wen, Holly G. Prigerson, Li-Pang Chuang, Tsung-Hui Hu, Chung-Chi Huang, Wen-Chi Chou, Siew Tzuh Tang","doi":"10.1186/s13054-024-05160-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05160-2","url":null,"abstract":"Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates’ PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care. Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors. Most surrogates were female (59.1%), the patient’s adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult–child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class. Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598288","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":"Changes in central venous-to-arterial PCO2 difference and central venous oxygen saturation as markers to define fluid responsiveness in critically ill patients: a pot-hoc analysis of a multi-center prospective study","authors":"Jihad Mallat, Osama Abou-Arab, Malcolm Lemyze, Dahlia Saleh, Pierre-Grégoire Guinot, Marc-Olivier Fischer","doi":"10.1186/s13054-024-05156-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05156-y","url":null,"abstract":"The main aim of the study whether changes in central venous-to-arterial CO2 difference (ΔP(v–a)CO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness (FR) in sedated and mechanically ventilated septic patients. We also sought to determine whether the degree of FR was related to baseline ScvO2 and P(v–a)CO2 levels. This was a post-hoc analysis of a multicenter prospective study. We included 205 mechanically ventilated patients with acute circulatory failure. Cardiac index (CI), P(v–a)CO2, ScvO2, and other hemodynamic variables were measured before and after VE. A VE-induced increase in CI > 15% defined fluid responders. Areas under the receiver operating characteristic curves (AUCs) and the gray zones were determined for ΔP(v–a)CO2 and ΔScvO2. One hundred fifteen patients (56.1%) were classified as fluid responders. The AUCs for ΔP(v–a)CO2 and ΔScvO2 to define FR were 0.831 (95% CI 0.772–0.880) (p < 0.001) and 0.801 (95% CI 0.739–0.853) (p < 0.001), respectively. ΔP(v–a)CO2 ≤ 2.1 mmHg and ΔScvO2 ≥ 3.4% after VE allowed the categorization between responders and non-responders with positive predictive values of 90% and 86% and negative predictive values of 58% and 64%, respectively. The gray zones for ΔP(v–a)CO2 (− 2 to 0 mmHg) and ΔScvO2 (− 1 to 5%) included 22% and 40.5% of patients, respectively. ΔP(v–a)CO2 and ΔScvO2 were independently associated with FR in multivariable analysis. No significant relationships were found between pre-infusion ScvO2 and P(v–a)CO2 levels and FR. In mechanically critically ill patients, ΔP(v–a)CO2 and ΔScvO2 are reliable parameters to define FR and can be used in the absence of CI measurement. The response to VE was independent of baseline ScvO2 and P(v–a)CO2 levels. Clinical trial registration The study was registered in the ClinicalTrials.gov registry: NCT03225378, date: July 20, 2017.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142597295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The efficacy of fiber-supplemented enteral nutrition in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis","authors":"Jana Larissa Koch, Charles Chin Han Lew, Felix Kork, Alexander Koch, Christian Stoppe, Daren K. Heyland, Ellen Dresen, Zheng-Yii Lee, Aileen Hill","doi":"10.1186/s13054-024-05128-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05128-2","url":null,"abstract":"Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic. For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes. Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I2 = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I2 = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome. Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142596905","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":"Pressure support, patient effort and tidal volume: a conceptual model for a non linear interaction","authors":"Mattia Docci, Giuseppe Foti, Laurent Brochard, Giacomo Bellani","doi":"10.1186/s13054-024-05144-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05144-2","url":null,"abstract":"Pressure support ventilation (PSV) is a form of assisted ventilation which has become frequently used, with the aim of partially unloading the patient’s inspiratory muscles. Both under- and over-assistance should be avoided to target a lung- and diaphragm- protective ventilation. Herein, we propose a conceptual model, supported by actual data, to describe how patient and ventilator share the generation of tidal volume (Vt) in PSV and how respiratory system compliance (Crs) affects this interaction. We describe the presence of a patient-specific range of PSV levels, within which the inspiratory effort (Pmus) is modulated, keeping Vt relatively steady on a desired value (Vttarget). This range of assistance may be considered the “adequate PSV assistance” required by the patient, while higher and lower levels may result in over- and under-assistance respectively. As we also show, the determinants of over- and under- assistance borders depend on the combination of Crs and the inspiratory effort which the patient is able to sustain over a period of time. These concepts can be applied at the bedside to understand if the level of assistance is adequate to patient’s demand, focusing on the variation of relevant parameters (Vt, Pmus and pressure-muscle-index) as patient reaction to a change in the level of assistance.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142588766","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":"Commenting on baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study","authors":"James Cheng Chung Wei, Poi Kuo, Po-Cheng Shih","doi":"10.1186/s13054-024-05116-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05116-6","url":null,"abstract":"&lt;p&gt;We read with great interest the article by You et al., which provides valuable insights into the comparative efficacy of baricitinib and tocilizumab in mechanically ventilated COVID-19 patients [1]. While the study’s findings are important, especially regarding the lower 30-day mortality in the baricitinib group, we believe that the issue of confounding by indication was not sufficiently addressed and may have significantly influenced the results.&lt;/p&gt;&lt;p&gt;Confounding by indication occurs when treatment assignment is influenced by disease severity, leading to a bias in outcome comparison between treatment groups. In this study, patients in the tocilizumab group appeared to be more severely ill at baseline compared to those in the baricitinib group. Although the authors employed propensity score matching (PSM) to balance baseline characteristics, the data suggest that the tocilizumab group had a higher severity of illness, which could explain some of the observed differences in mortality. Notably, patients in the tocilizumab group had longer durations of mechanical ventilation prior to drug administration, higher use of extracorporeal membrane oxygenation (ECMO), and more severe comorbidities, as detailed in the supplementary tables. These factors strongly suggest that tocilizumab was more likely administered to patients in critical condition, potentially skewing the mortality comparison in favor of baricitinib.&lt;/p&gt;&lt;p&gt;Furthermore, while PSM is effective at balancing observable variables, it may not fully account for unmeasured or residual confounders, such as the timing of drug administration relative to disease progression or the specific clinical criteria that influenced treatment choices. Baricitinib was administered for a median of 8 days, while tocilizumab was often given as a single dose. This difference in treatment duration and pharmacodynamics could have further impacted the results. Baricitinib, with its broader anti-inflammatory effects and prolonged administration, may have provided a more sustained reduction in inflammation, whereas the single-dose nature of tocilizumab could have limited its efficacy in severely ill patients.&lt;/p&gt;&lt;p&gt;Additionally, the study does not provide sufficient detail regarding the criteria used to determine whether a patient received baricitinib or tocilizumab beyond the similar indications in general consideration [2]. Without understanding the clinical decision-making process, it is difficult to evaluate the extent to which confounding by indication may have influenced the results. If tocilizumab was preferentially administered to patients with more rapidly progressing or refractory disease, the higher mortality rate in this group might reflect underlying disease severity rather than a difference in drug efficacy [3]. &lt;/p&gt;&lt;p&gt;It may be beneficial to consider a subgroup analysis excluding patients requiring total parenteral nutrition (TPN), as those unable to tolerate enteral nutrition typically represent a mor","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142580091","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}