Critical Care最新文献

{"title":"Mortality in septic patients treated with short-acting betablockers: a comprehensive meta-analysis of randomized controlled trials","authors":"Mihai-Gabriel Alexandru, Patrick Niewald, Stefan Krüger, Rainer Borgstedt, Tony Whitehouse, Mervyn Singer, Sebastian Rehberg, Sean S. Scholz","doi":"10.1186/s13054-024-05174-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05174-w","url":null,"abstract":"Treatment with short-acting betablockers in septic patients remains controversial. Two recent large multicenter trials have provided additional evidence on this therapeutic approach. We thus performed a meta-analysis, including the most recent data, to evaluate the potential impacts of treatment with short-acting betablockers on mortality in adult septic patients. The data search included PubMed, Web of Science, ClinicalTrials.gov and the Cochrane Library. A meta-analysis of all eligible peer-reviewed studies was performed in accordance with the PRISMA statement. Only randomized, controlled studies with valid classifications of sepsis and intravenous treatment with short-acting betablockers (landiolol or esmolol) were included. Short-term mortality served as the primary endpoint. Secondary endpoints included effects on short-term mortality regarding patient age and cardiac rhythm. A total of seven studies summarizing 854 patients fulfilled the predefined criteria and were included. Short-term mortality as well as pooled mortality (longest period of data on mortality) was not significantly impacted by treatment with short-acting betablockers when compared to the reference treatment (Risk difference, − 0.10 [95% CI, − 0.22 to 0.02]; p = 0.11; p for Cochran’s Q test = 0.001; I2 = 73%). No difference was seen when comparing patients aged < 65 versus ≥ 65 years (p = 0.11) or sinus tachycardia with atrial fibrillation (p = 0.27). Despite statistical heterogeneity, no significant publication bias was observed. Administration of short-acting betablockers did not reduce short-term mortality in septic patients with persistent tachycardia. Future studies should also provide extensive hemodynamic data to enable characterization of cardiac function before and during treatment.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"257 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142718296","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":"Weaning of non COPD patients at high-risk of extubation failure assessed by lung ultrasound: the WIN IN WEAN multicentre randomised controlled trial","authors":"Jean-Jacques Rouby, Sébastien Perbet, Jean-Pierre Quenot, Mao Zhang, Pascal Andreu, Mona Assefi, Yuzhi Gao, Romain Deransy, Jie Lyu, Charlotte Arbelot, Youzhong An, Antoine Monsel, Xia Jing, Philippe Guerci, Chuanyun Qian, Luiz Malbouisson, Dominique Morand, Louis Puybasset, Emmanuel Futier, Jean-Michel Constantin, Bruno Pereira","doi":"10.1186/s13054-024-05166-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05166-w","url":null,"abstract":"Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF. Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90. Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome. Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142713197","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 renin–angiotensin–aldosterone-system in sepsis and its clinical modulation with exogenous angiotensin II","authors":"Matthieu Legrand, Ashish K. Khanna, Marlies Ostermann, Yuki Kotani, Ricard Ferrer, Massimo Girardis, Marc Leone, Gennaro DePascale, Peter Pickkers, Pierre Tissieres, Filippo Annoni, Katarzyna Kotfis, Giovanni Landoni, Alexander Zarbock, Patrick M. Wieruszewski, Daniel De Backer, Jean-Louis Vincent, Rinaldo Bellomo","doi":"10.1186/s13054-024-05123-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05123-7","url":null,"abstract":"Dysregulation of the renin–angiotensin–aldosterone-system (RAAS) in sepsis is a complex and early phenomenon with a likely significant contribution to organ failure and patient outcomes. A better understanding of the pathophysiology and intricacies of the RAAS in septic shock has led to the use of exogenous angiotensin II as a new therapeutic agent. In this review, we report a multinational and multi-disciplinary expert panel discussion on the role and implications of RAAS modulation in sepsis and the use of exogenous angiotensin II. The panel proposed guidance regarding patient selection and treatment options with exogenous angiotensin II which should trigger further research.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"80 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142713201","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Time-dependent intervention in the database study examining the efficacy of whole blood transfusion in traumatic patients","authors":"Taisuke Shibata, Saburo Minami, Atsushi Shiraishi","doi":"10.1186/s13054-024-05115-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05115-7","url":null,"abstract":"&lt;p&gt;We read with great interest the database study by Aoki et al. [1], published in Critical Care. As highlighted in this article, whole blood (WB) transfusion for patients with trauma or severe hemorrhage has recently attracted worldwide attention for its promising potential in reducing mortality [2,3,4]. This study examines the association between the whole blood rate (WBR), defined as the number of WB units divided by the sum of WB units and packed red blood cells (PRBCs), and 24-h mortality in trauma patients requiring massive transfusion. The results suggest that a higher WBR is associated with improved survival and a lower risk of acute kidney injury (AKI) in patients who received whole blood transfusion within 4 h of hospital arrival. The study utilized generalized estimating equations to adjust for covariates, including clustering, and conducted sensitivity analyses that accounted for the heterogeneity of the lowest WBR group, further enhancing the robustness of the results. Therefore, this study has significant implications for current trauma resuscitation strategies. However, we believe there are some untreated biases, particularly time-dependent intervention bias, which warrant careful consideration.&lt;/p&gt;&lt;p&gt;Firstly, the intervention in this study design is time-dependent; that is, the risk of mortality could continuously influence the physician's decision to administer WB transfusion, and WB transfusion, in turn, could influence the risk of mortality. The risk of mortality and transfusion decisions interact dynamically over time during early trauma care. Component transfusion is routinely administered and readily available at many trauma centers, whereas WB transfusion often depends on the institution's system or regional blood bank, typically making it available later. In many cases, component transfusion is administered first, followed by WB transfusion. Under this assumption, WBR would be zero in the early phase when only component transfusion is being used, and would gradually increase once WB transfusion begins, ranging from zero to one. If, as the authors assume, the intervention, expressed as a continuous variable, affects outcomes, then the time-dependent WBR would impact outcomes differently over time. Thus, evaluating the relationship between a time-dependent intervention like WBR and outcomes at a specific point in time may not fully capture the true relationship.&lt;/p&gt;&lt;p&gt;Additionally, the relationship between WBR and outcomes may introduce immortal time bias. This bias occurs in epidemiological and clinical studies when there is a period during which participants cannot experience the outcome of interest, such as death [5]. Patients with severe trauma are at high risk of early death. Assuming that WBR increases over time, patients with a lower WBR may be those who died early due to severity, while patients with a higher WBR may have survived longer.&lt;/p&gt;&lt;p&gt;Statistical models that account for time-dependent interventions and immo","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"189 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142713238","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":"Inhaled nitric oxide clinical confusions: population types, duration, and responsiveness","authors":"Kai Liu, Shi-Min Zhang, Jing-chao Luo, Min-jie Ju","doi":"10.1186/s13054-024-05181-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05181-x","url":null,"abstract":"&lt;p&gt;To the Editor,&lt;/p&gt;&lt;p&gt;Inhaled nitric oxide (iNO) is widely used to treat hypoxic patients, especially those with acute respiratory distress syndrome (ARDS) [1]. We read with great interest the study by Isha et al. investigating the therapeutic efficacy of low-dose iNO in patients with COVID-19 [2]. Although this study provides valuable insights into this therapeutic approach, several considerations merit detailed discussion.&lt;/p&gt;&lt;p&gt;The factors that influence the effectiveness of iNO include patient population heterogeneity, and previous multicenter studies have reported response rates ranging from 20 to 60% [3]. Similar differences are observed in COVID-19 patients, possibly due to biological factors, such as such as the suppressed endogenous nitric oxide, across various populations [4]. In Isha’s study, the authors used multiple levels of categorization. This included initial grouping based on breathing status (spontaneous vs. intubated), followed by subdivisions considering factors such as progression to intubation, iNO usage, the timing of iNO initiation (pre- or post-intubation), early intubation (&lt; 5 days), and iNO use for more than 48 h before intubation. However, the absence of patient-self stratification, along with a complex system that focused on the type of respiratory support, posed significant challenges to interpreting the results. Additionally, this extensive stratification likely resulted in small subgroup sizes, which may have compromised statistical power. Future trials should focus on well-defined patient subgroups, rather than on broad, heterogeneous populations.&lt;/p&gt;&lt;p&gt;The effect of iNO on oxygenation varies over time, making the duration of iNO treatment an important factor. Long-term iNO inhalation can lead to time-dependent changes in drug effects, with patients gradually developing stronger responses to lower doses of NO [5]. In Isha’s study, the duration of iNO administration was not specified, especially for those in the spontaneously breathing group who received iNO before intubation. It is unclear whether these patients continued iNO treatment after intubation, which could affect the results.&lt;/p&gt;&lt;p&gt;The response criteria for iNO in hypoxic patients are crucial. The widely accepted criterion for iNO effectiveness is a 20% increase in PaO&lt;sub&gt;2&lt;/sub&gt;, PaO&lt;sub&gt;2&lt;/sub&gt;/FiO&lt;sub&gt;2&lt;/sub&gt;, or the oxygenation index (within 30 min to 1 h after iNO initiation), which serves as a reliable indicator for evaluating the immediate treatment effect [5, 6]. In contrast, the authors defined a response as an increase in PaO2/FiO2 or a decrease in FiO2 within 48 h. This 48-h extended assessment and the uncertainty in the range of oxygenation enhancement may have influenced the estimation of immediate physiological responses to iNO, potentially affecting the interpretation of outcomes, particularly in the absence of iNO duration data.&lt;/p&gt;&lt;p&gt;Finally, we appreciate the authors' efforts in conducting this research. While iNO showed a positi","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"67 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142697098","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":"Cost-effectiveness of high flow nasal cannula therapy versus continuous positive airway pressure for non-invasive respiratory support in paediatric critical care","authors":"Zia Sadique, Silvia Moler Zapata, Richard Grieve, Alvin Richards-Belle, Izabella Lawson, Robert Darnell, Julie Lester, Kevin P. Morris, Lyvonne N. Tume, Peter J. Davis, Mark J. Peters, Richard G. Feltbower, Paul R. Mouncey, David A. Harrison, Kathryn M. Rowan, Padmanabhan Ramnarayan","doi":"10.1186/s13054-024-05148-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05148-y","url":null,"abstract":"High flow nasal cannula therapy (HFNC) and continuous positive airway pressure (CPAP) are two widely used modes of non-invasive respiratory support in paediatric critical care units. The FIRST-ABC randomised controlled trials (RCTs) evaluated the clinical and cost-effectiveness of HFNC compared with CPAP in two distinct critical care populations: acutely ill children (‘step-up’ RCT) and extubated children (‘step-down’ RCT). Clinical effectiveness findings (time to liberation from all forms of respiratory support) showed that HFNC was non-inferior to CPAP in the step-up RCT, but failed to meet non-inferiority criteria in the step-down RCT. This study evaluates the cost-effectiveness of HFNC versus CPAP. All-cause mortality, health-related Quality of Life (HrQoL), and costs up to six months were reported using FIRST-ABC RCTs data. HrQoL was measured with the age-appropriate Paediatric Quality of Life Generic Core Scales questionnaire and mapped onto the Child Health Utility 9D index score at six months. Quality-Adjusted Life Years (QALYs) were estimated by combining HrQoL with mortality. Costs at six months were calculated by measuring and valuing healthcare resources used in paediatric critical care units, general medical wards and wider health service. The cost-effectiveness analysis used regression methods to report the cost-effectiveness of HFNC versus CPAP at six months and summarised the uncertainties around the incremental cost-effectiveness results. In both RCTs, the incremental QALYs at six months were similar between the randomised groups. The estimated incremental cost at six months was − £4565 (95% CI − £11,499 to £2368) and − £5702 (95% CI − £11,328 to − £75) for step-down and step-up RCT, respectively. The incremental net benefits of HFNC versus CPAP in step-down RCT and step-up RCT were £4388 (95% CI − £2551 to £11,327) and £5628 (95% CI − £8 to £11,264) respectively. The cost-effectiveness results were surrounded by considerable uncertainties. The results were similar across most pre-specified subgroups, and the base case results were robust to alternative assumptions. HFNC compared to CPAP as non-invasive respiratory support for critically-ill children in paediatric critical care units reduces mean costs and is relatively cost-effective overall and for key subgroups, although there is considerable statistical uncertainty surrounding this result.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"189 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142697039","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":"Passive leg raising uncovers venous congestion: dynamic fluid intolerance and the Doppler Starling curve","authors":"Jon-Emile S. Kenny","doi":"10.1186/s13054-024-05171-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05171-z","url":null,"abstract":"&lt;p&gt;Morosanu and colleagues have recently published a fascinating pilot study in &lt;i&gt;Critical Care&lt;/i&gt; [1]. Following elective coronary artery bypass grafting (CABG), patients were enrolled who were mechanically-ventilated within 6 h of admission to the intensive care unit (ICU) and who had acute circulatory failure. In these patients, the authors measured the change in portal vein pulsatility index (PVPI, i.e., as a surrogate of venous filling/congestion) and the left ventricular outflow tract velocity time integral (LVOT VTI, i.e., as a surrogate of stroke volume) at 5 time points: at baseline (T&lt;sub&gt;1&lt;/sub&gt;), one minute (T&lt;sub&gt;2&lt;/sub&gt;) into a passive leg raise (PLR), and two minutes after returning to the semi-recumbent position (T&lt;sub&gt;3&lt;/sub&gt;). Then, if the patient had both low PVPI and an LVOT VTI change of at least 12% during the PLR (i.e., the patient was considered &lt;i&gt;both&lt;/i&gt; fluid tolerant and responsive, respectively), the patient received 7 mL/kg of Lactated Ringer’s solution (LR) over 10 min. Two additional measures were then taken: 2 min (T&lt;sub&gt;4&lt;/sub&gt;) and 20 min (T&lt;sub&gt;5&lt;/sub&gt;) following completion of the LR infusion. The authors examined the incidence of venous congestion (VC, i.e., defined as a PVPI ≥ 50%) following the LR and whether the antecedent PLR could predict VC. As well, they reported adverse clinical outcomes (e.g., ICU length of stay and acute kidney injury) and other echocardiographic measures as a pilot investigation.&lt;/p&gt;&lt;p&gt;The authors included 40 patients in their analysis with measures at T&lt;sub&gt;1&lt;/sub&gt;-T&lt;sub&gt;5&lt;/sub&gt;; in nearly one-half of patients, VC (i.e., PVPI of at least 50%) was observed at T&lt;sub&gt;4&lt;/sub&gt; (i.e., early VC), though this fell to only 5% at T&lt;sub&gt;5&lt;/sub&gt;. Patients with early VC had significantly higher central venous pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. Finally, the PVPI at T&lt;sub&gt;2&lt;/sub&gt; (i.e., during the PLR) predicted early VC with an area under the curve of 0.998, using a threshold of 44.3%.&lt;/p&gt;&lt;p&gt;When giving IV fluids, 3 basic questions should be answered: 1.) is there an indication for IV fluids? 2.) are IV fluids safe? and 3.) are IV fluids effective [2]? By enrolling only patients with signs of peripheral hypo-perfusion, the answer to the first question for the patients enrolled by Morosanu and colleagues was ‘yes.’ Safety of IV fluid can be considered within the framework of ‘tolerance’ versus ‘intolerance’ [3, 4]. By including only patients with a low PVPI as a sign of low venous pressure, we presume that the post-CABG patients in the investigation of Morosanu et al. are ‘tolerant’; so, the answer to question 2 is also ‘yes’ (barring any other signals of harm such as elevated lung water, etc.). Finally, the ‘efficacy’ of IV fluid hinges upon increased venous return (and, therefore, preload) engaging the Starling mechanism and augmenting stroke volume (SV) (i.e., there is a state of ‘fluid responsiveness’). Yet, to be truly ‘effective,’ t","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142713205","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":"Culture-negative sepsis may be a different entity from culture-positive sepsis: a prospective nationwide multicenter cohort study","authors":"Youjin Chang, Ju Hyun Oh, Dong Kyu Oh, Su Yeon Lee, Dong-gon Hyun, Mi Hyeon Park, Chae-Man Lim","doi":"10.1186/s13054-024-05151-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05151-3","url":null,"abstract":"The distinction between culture-positive sepsis and culture-negative sepsis regarding clinical characteristics and outcomes remains contentious. We aimed to elucidate these differences using large-scale nationwide data. This prospective cohort study analyzed data from the Korean Sepsis Alliance registry, comprising 21 intensive care units (ICUs) across 20 hospitals from September 2019 to December 2021. Patients meeting the Sepsis-3 criteria were included. Among 11,981 sepsis patients, 3501 were analyzed, all of whom were referred to the ICU through the emergency department (mean age: 72 ± 13 years; 1976 [56%] males). Of these, 2213 (63%) were culture-positive sepsis and 1288 (37%) were culture-negative sepsis. Compared to the culture-positive sepsis group, the culture-negative sepsis group exhibited less severe illness, with lower Sequential Organ Failure Assessment scores and less deteriorated vital signs. While pulmonary-origin sepsis was common in both groups, culture-negative patients primarily presented with pulmonary infections and had a higher incidence of respiratory failure. In comparison to the culture-positive sepsis group, blood cultures and the administration of empirical antibiotics were performed less promptly in the culture-negative sepsis group. Patients with culture-negative sepsis also showed lower compliance with fluid resuscitation (98.4% vs. 96.9%, p = 0.038; culture-positive sepsis vs. culture-negative sepsis) and received vasopressors earlier (31.1% vs. 35.9%, p = 0.012). In-hospital mortality did not differ significantly between the two groups (31.6% vs. 34.9%, p = 0.073); however, in patients with septic shock, culture-negative sepsis had higher mortality rates (37.6% vs. 45.1%, p = 0.029). The apparent appropriateness of empirical antibiotics in the culture-negative septic shock was higher than that of the culture-positive septic shock (85.2% vs. 96.8%, p < 0.001). Culture-negativity independently predicted poor prognosis in septic shock patients (OR: 1.462, 95% CI [1.060–2.017], p = 0.021). In patients with septic shock, culture-negativity was associated with increased mortality, despite the paradoxically higher appropriateness of empirical antibiotics than culture-positive patients. These contradictory findings suggest that the current criteria for determining the appropriateness of empirical antibiotic therapy may not be valid for culture-negative sepsis.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"256 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142697142","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":"Inhaled antibiotics for treating pneumonia in invasively ventilated patients in intensive care unit: a meta-analysis of randomized clinical trials with trial sequential analysis","authors":"Nicolò Sella, Tommaso Pettenuzzo, Alessandro De Cassai, Francesco Zarantonello, Sabrina Congedi, Andrea Bruni, Eugenio Garofalo, Honoria Ocagli, Dario Gregori, Federico Longhini, Paolo Navalesi, Annalisa Boscolo","doi":"10.1186/s13054-024-05159-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05159-9","url":null,"abstract":"The use of inhaled antibiotics for treating pneumonia in invasively ventilated patients offers a direct approach, allowing for high local concentrations of the drug in the lower respiratory tract while simultaneously reducing systemic toxicity. However, the real efficacy and safety of nebulized antibiotics remain unclear. The aim of the present is to assess among critically adult patients with pneumonia and invasive ventilation, whether receiving adjuvant inhaled antibiotics improves the rate of microbiological eradication. A comprehensive literature search of randomized clinical trials (RCTs) was conducted (from inception until September 20, 2024, PROSPERO-CRD592906) across Medline, Embase, and Scopus. Randomized controlled trials, enrolling intensive care units (ICU) patients with pneumonia and comparing nebulized antimicrobial therapy (inhaled group) with intravenous antimicrobial treatment or intravenous antimicrobial therapy plus inhaled placebo (control group), were included. The primary outcome was the rate of microbiological eradication after treatment. Secondary outcomes were the rate of clinical recovery, the incidence of drug-related adverse events, ICU and hospital mortality. A qualitative analysis was conducted according to the GRADE framework. Data were pooled using an odds-ratio analysis. The heterogeneity and reliability of our results were evaluated using the I2-statistic and trial sequential analysis (TSA), respectively. A total of 11 RCTs (1472 patients) met the inclusion criteria. Compared to controls, the use of adjuvant inhaled antibiotics determined a greater rate of microbiological eradication (OR 2.63, 95% CI 1.36–5.09; low certainty of evidence). The TSA confirmed the reliability of our primary outcome. Moreover, nebulized antibiotics increased the risk of bronchospasm (OR 3.15, 95% CI 1.33–7.47; high evidence), while nephrotoxicity, clinical recovery, ICU and hospital survival (either in the case of pneumonia caused by MDR bacteria or not) were not different between groups. In conclusion, compared to the sole intravenous therapy, the use of adjuvant inhaled antibiotics for treatment of pneumonia in invasively ventilated critically ill patients was associated with a greater incidence of microbiological eradication (low GRADE and high risk of publication bias), but not with clinical recovery and survival.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142697137","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 sepsis-associated acute kidney injury in critically ill patients: a multicenter, prospective, observational cohort study in South Korea","authors":"Myung Jin Song, Yeonhoon Jang, Matthieu Legrand, Sunghoon Park, RyoungEun Ko, Gee Young Suh, Dong Kyu Oh, Su Yeon Lee, Mi Hyeon Park, Chae-Man Lim, Se Young Jung, Sung Yoon Lim","doi":"10.1186/s13054-024-05167-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05167-9","url":null,"abstract":"Despite the clinical importance of sepsis-associated acute kidney injury (SA-AKI), little is known about its epidemiology. We aimed to investigate the incidence and outcomes of SA-AKI, as well as the risk factors for mortality among patients with severe SA-AKI in critically ill patients. This secondary multicenter, observational, prospective cohort analysis of sepsis in South Korea evaluated patients aged ≥ 19 years admitted to intensive care units with a diagnosis of sepsis. The primary outcome was the incidence of SA-AKI, defined using the new consensus definition of the Acute Disease Quality Initiative 28 Workgroup. Secondary outcomes were in-hospital mortality and risk factors for in-hospital mortality. Between September 2019 and December 2022, 5100 patients were admitted to intensive care units with a diagnosis of sepsis, and 3177 (62.3%) developed SA-AKI. A total of 613 (19.3%), 721 (22.7%), and 1843 (58.0%) patients had stage 1, 2, and 3 SA-AKI, respectively. Severe SA-AKI (stages 2 and 3 combined) was associated with an increased risk of in-hospital mortality. Adherence to the fluid resuscitation component of the one-hour sepsis bundle was associated with a decreased risk of in-hospital mortality in severe SA-AKI (adjusted odds ratio, 0.62; 95% confidence interval, 0.48–0.79; P < 0.001). Of the patients admitted to the intensive care unit for sepsis, 62.3% developed SA-AKI. Severe SA-AKI was associated with an increased risk of mortality. Adherence to the fluid resuscitation component of the one-hour sepsis bundle can potentially improve outcomes in these patients.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"35 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142694108","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}