Critical Care最新文献

{"title":"Advanced serial analysis of the diaphragm surface EMG: insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay","authors":"R. S. P. Warnaar, A. D. Cornet, A. Beishuizen, D. W. Donker, E. Oppersma","doi":"10.1186/s13054-025-05424-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05424-5","url":null,"abstract":"Ventilatory support levels in ICU patients should be tailored to both optimal gas exchange and respiratory muscle loading, as over- and underassistance may cause diaphragm dysfunction. The diaphragm’s capacity to overcome mechanical load and deliver ventilatory output is reflected by the patient’s neural respiratory drive (NRD), tidal volume (TV) and respiratory rate (RR). Surface electromyography of the diaphragm (sEMGdi) offers a continuous, non-invasive measure of NRD. We investigated the effect of pressure support (PS) level on the coupling of diaphragm electrical activity (sEAdi) and ventilatory output during the ICU stay. In clinically stable ICU patients (N = 17), four PS-levels were applied on alternate days, based on the clinical value (− 3, + 0, + 3, and + 6 cmH2O). sEAdi time-product (ETPdi) was calculated from high-quality sEAdi waveforms, using a novel, advanced signal analysis approach. The breath-by-breath correlation between ETPdi and TV was defined as neuro-ventilatory coupling (NVC), enabling quantification of the neuro-ventilatory response. On group level (13 patients, 26 PS-trials), ETPdi and RR increased with decreasing PS-levels (2.4 and 1.6 percentage point (pp)/cmH2O), whereas TV decreased (2.5 pp/cmH2O). Longitudinal analysis (4 patients, 14 PS-trials) showed strengthened coupling between ETPdi and TV during weaning, reflected by an increase in median NVC from 3.4% (IQR 2.9) to 26.3% (IQR 21.7) between the first and last PS-trial. Advanced sEMGdi analysis allows for non-invasive quantification of NVC, reflecting the diaphragm’s capacity to overcome mechanical load. In patients approaching liberation from MV, increasing NVC indicates the shift from near-passive to active breathing. This study demonstrates the potential of NVC to inform tailoring of ventilatory support levels. Trial registration number: Dutch Trial Register NL9654. Registered August 05, 2021.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"159 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144341231","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":"Preoxygenation strategies for endotracheal intubation in resource-limited settings: reframing the basics","authors":"Dai Quang Huynh, Ngan Hoang Kim Trieu, Thao Thi Ngoc Pham","doi":"10.1186/s13054-025-05508-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05508-2","url":null,"abstract":"<p>Endotracheal Intubation (ETI) is a common procedure in the emergency department and intensive care units (ICUs). In contrast to elective surgical patients, critically ill patients often face acute hypoxemic events related to underlying pulmonary pathology, elevated metabolic demands, impaired respiratory drive, obesity, or an inability to protect the airway from aspiration. Nearly half of emergency intubations were complicated by major adverse events, most commonly cardiovascular collapse, severe hypoxemia, and even cardiac arrest [1]. Critically ill patients with acute hypoxemic respiratory failure (AHRF) are particularly vulnerable to rapid oxygen desaturation during ETI due to intrapulmonary shunting and restrained functional residual capacity (FRC), which limit the effectiveness of conventional preoxygenation. These patients cannot tolerate prolonged apnea, resulting in frequent oxygen desaturation during laryngoscopy, immediately after intubation, or even following ventilator connection. Preoxygenation strategies incorporating positive end-expiratory pressure (PEEP), such as noninvasive positive pressure ventilation (NIPPV), can enhance alveolar recruitment, preserve FRC, and optimize oxygen storage. In resource-limited settings (LRS), where advanced backup equipment and staffing may be unavailable, ETI remains one of the major challenges for physicians in Emergency Departments and ICUs.</p><p>Preoxygenation is essential to increasing oxygen reserves, prolonging the safe apnea time during ETI, and reducing hypoxemia-related complications. However, traditional preoxygenation using a non-rebreather mask or bag-mask ventilation (BVM) with 100% oxygen is often inadequate in critically ill patients due to low flow rates and lack of PEEP.</p><p>Recent evidence supports that both HFNC and NIPPV are effective preoxygenation strategies in patients with AHRF. A recent network meta-analysis by Pitre et al. [2], which included 15 randomized trials and over 3400 patients, found that HFNC and NIPPV were superior to facemask oxygenation in reducing the incidence of peri-intubation hypoxemia. Importantly, NIPPV reduced the risk of hypoxemia compared with HFNC (relative risk [RR] 0.73, 95% CI 0.55–0.98) and facemask oxygen (RR 0.51, 95% CI 0.39–0.65). HFNC also demonstrated superiority over the facemask (RR 0.69, 95% CI 0.54–0.88), likely due to its ability to deliver high and stable oxygen flow during apnoeic oxygenation, wash out pharyngeal dead space, and improve FRC. Additionally, NIPPV might reduce the risk of serious adverse events compared with HFNC (RR 0.32, 95% CI 0.11–0.91) and probably does so compared to facemasks (RR 0.30, 95% CI 0.12–0.77). These findings reinforce prior individual trial results, highlighting the efficacy and safety of NIPPV, especially in patients with moderate-to-severe AHRF. Furthermore, the strategy combined NIPPV and HFNC effectively maintained oxygen saturation during laryngoscopy in severe AHRF patients. Similarly, in","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"45 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144341203","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 effects of extracorporeal blood purification (oXiris®) in patients with cardiogenic shock who require VA-ECMO (CLEAN ECMO): a prospective, open-label, randomized controlled pilot study","authors":"Ryoung-Eun Ko, Ki Hong Choi, Kyungho Lee, Junseok Jeon, Hye Ryoun Jang, Chi Ryang Chung, Yang Hyun Cho, Taek Kyu Park, Joo Myung Lee, Young Bin Song, Joo-Yong Hahn, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Jeong Hoon Yang","doi":"10.1186/s13054-025-05495-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05495-4","url":null,"abstract":"A systemic inflammatory response can contribute to poor outcomes in an advanced stage of cardiogenic shock (CS). We investigated the efficacy of extracorporeal endotoxin and cytokine adsorption using oXiris in patients with CS undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). In this prospective, single-center, randomized, open-label pilot trial, 40 patients with CS who were undergoing VA-ECMO were randomly assigned to receive either oXiris for 24 h (n = 20) or usual care (n = 20). The primary endpoint was endotoxin levels at 48 h. Secondary endpoints included changes in inflammatory cytokines, vasoactive-inotropic score (VIS), ECMO weaning success, and in-hospital and 30-day mortality. The median endotoxin levels at 48 h were 0.5 (IQR 0.4–1.0) in the oXiris group and 0.4 (IQR 0.2–0.5) in the control group, with no significant difference between them (P = 0.097). The oXiris group showed significant temporal reductions in GDF-15 and IL-6 levels, with IL-6 revealing significant reductions from baseline to 24 h (P = 0.020) and from baseline to 7 days (P = 0.003). VIS decreased significantly from baseline to 48 h (-13.63, 95% CI: -20.90 – -6.34, P < 0.001) and 7 days (-12.19, 95% CI: -21.0 – -3.31, P = 0.007) in the oXiris group, but intergroup differences were insignificant. ECMO weaning success, duration of ECMO support, and mortality rates were similar between the groups. In this pilot study conducted on CS patients requiring VA-ECMO, oXiris treatment did not significantly reduce endotoxin levels or improve patient centered clinical outcomes. NCT05642273, registered 8 December 2022.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144329157","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":"Tocilizumab in improving the hemodynamics of septic children with vasoplegia shock","authors":"En‑Pei Lee, Jainn-Jim Lin, Shih‑Hsiang Chen, Han‑Ping Wu","doi":"10.1186/s13054-025-05512-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05512-6","url":null,"abstract":"&lt;p&gt;Sepsis remains a leading cause of pediatric morbidity and mortality worldwide. Septic shock, a progression of sepsis characterized by profound cardiovascular dysfunction, carries mortality rates as high as 40–80% and often results in long-term neurocognitive deficits. In patients with septic shock, vasoplegia is the worse presentation of hemodynamics which related higher mortality. Vasoplegia is an abnormally low systemic vascular resistance (SVR) that is manifest as profound hypotension or the requirement for therapies to avoid this, in the presence of a normal or increased cardiac output [1].&lt;/p&gt;&lt;p&gt;IL-6 plays a pivotal role in sepsis-induced endothelial injury, promoting vascular permeability, myocardial dysfunction, and ultimately vasoplegia. Tocilizumab, an IL-6 receptor blocker, has shown promise in modulating inflammatory cascades in various hyperinflammatory states. This study investigates whether tocilizumab improves hemodynamics and outcomes in pediatric patients with septic shock and vasoplegia.&lt;/p&gt;&lt;p&gt;We retrospectively analyzed pediatric patients with septic shock admitted to the PICU of Chang Gung Children’s Hospital from January 2018 to February 2025. Inclusion criteria were a diagnosis of septic shock requiring vasoactive support.&lt;/p&gt;&lt;p&gt;Pediatric septic shock was defined as cardiovascular dysfunction (hypotension, need for vasoactive agents) or impaired organ perfusion and therapeutic strategies were based on the 2017 American College of Critical Care Medicine [2]. From 2022 onward, patients with elevated IL-6 levels received a single dose of tocilizumab early during shock. Patients from 2018 to 2021 served as historical controls without tocilizumab therapy.&lt;/p&gt;&lt;p&gt;Hemodynamic monitoring was performed using a pulse index continuous cardiac output (PiCCO) system (Pulsion Medical Systems, Munich, Germany) or electrical cardiometry (ICON, Osypka Medical GmbH, Berlin, Germany), depending on the study period. We collected serial cardia index (CI), systemic vascular resistance index (SVRI) and vasoactive-inotropic score (VIS) during the first 72 h of PICU admission. Serum IL-6 levels were measured serially at days 0, 3, 5, and 7 using the Elecsys immunoassay. Vasoplegia was defined as the SVRI lower than normal range without the support of vasopressor [3]. To quantify the severity of vasoplegia and monitor its clinical progression, we developed the Vascular Reactivity Index (VRI), defined as SVRI/VIS (Systemic Vascular Resistance Index divided by Vasoactive-Inotropic Score). A lower VRI reflects greater vasoplegia severity and signals the need for more intensive hemodynamic support. In our cohort, VRI demonstrated favorable prognostic accuracy, with an average area under the receiver operating characteristic curve (AUC) exceeding 0.80 for predicting mortality in pediatric septic shock with vasoplegia [4].&lt;/p&gt;&lt;p&gt;The baseline characteristics had no significantly difference between the tocilizumab (&lt;i&gt;n&lt;/i&gt; = 31) and control (&lt;i&gt;n&lt;/i&gt; = 33","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"236 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144329156","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":"Critical care illness in allogeneic hematopoietic stem-cell transplantation recipients with chronic graft versus host disease","authors":"Dara Chean, Romy Younan, Thibault Dupont, Emmanuel Canet, Anne-Sophie Moreau, Muriel Picard, Djamel Mokart, Laura Platon, Julien Mayaux, Florent Wallet, Nahema Issa, Jean-Herlé Raphalen, Frédéric Pène, Anne Renault, Régis Peffault de Latour, Naike Bigé, Elie Azoulay, Antoine Lafarge","doi":"10.1186/s13054-025-05486-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05486-5","url":null,"abstract":"Chronic graft-versus-host disease (cGVHD) is a leading long-term complication following allogeneic hematopoietic stem-cell transplantation (Allo-HSCT). However, its impact on outcomes in critically ill Allo-HSCT recipients has little been evaluated. We conducted a post hoc analysis of a multicenter cohort study involving Allo-HSCT recipients admitted to 14 French intensive care units (ICUs) between January 1, 2015, and December 31, 2020. The primary endpoint was 90-day mortality after admission. The prevalence of cGVHD was 10% (114/1164), with a severe form of the disease in half the patients. The most common manifestation was skin involvement (94%), followed by gastrointestinal tract (56%), liver (28%), and lungs (19%). The primary reason for ICU admission was acute respiratory failure (43%), with 65% of patients presenting with multi-organ dysfunction. Overall survival was 61% at 90 days and 40% at 3 years. The Sequential Organ Failure Assessment score at ICU admission was the only independent predictor of 90-day mortality (HR/point 1.32 [95% CI 1.21–1.46]; p < 0.01). cGVHD severity did not significantly influence survival. Patients with cGVHD had comparable survival rates to those with controlled acute GVHD or without GVHD (90-day: 61% vs. 55% and 66%; 3-year: 40% vs. 32% and 47%). In critically ill Allo-HSCT recipients, the presence or severity of cGVHD is not associated with survival and should not influence the decision to admit or not the patient to the ICU. However, careful discussions about the goals of care should be undertaken in patients with severe hepatic or pulmonary involvement. Retrospectively registered.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"45 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144329158","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 Landscape of lower respiratory tract herpesviruses in severe pneumonia patients: a multicenter, retrospective study with prospective validation","authors":"Fengqi Liu, Yiqi Zhuang, Xiaohan Huang, Laurent Papazian, Hongliu Cai, Huanzhang Shao, Qiong Chen, Chao Xie, Kankai Tang, KangChen Li, Mingqiang Wang, Yinghe Xu, Peng Shen, Qianqian Wang, Xuwei He, Nan Wang, Hongyu Wang, Muhua Dai, Yonghui Xiong, Lin Zhong, Yujie Pan, Lihong Chu, Bin Yang, Gensheng Zhang, Hua Zhou, Jinfu Xu, Chao Jiang, Lingtong Huang","doi":"10.1186/s13054-025-05496-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05496-3","url":null,"abstract":"Herpesviruses are widely distributed in the lower respiratory tract, yet no study has comprehensively characterized their clinical features and prognostic impact in severe pneumonia. In this multicenter, retrospective study, we included severe pneumonia patients who underwent bronchoalveolar lavage fluid (BALF) metagenomic testing in intensive care units across 17 medical centers from January 2019 to June 2023. Based on metagenomic results, patients were categorized into herpesvirus-negative, HSV-1, EBV, CMV, HHV-6B, and HHV-7 groups. Propensity score matching and multivariable Cox regression were used to compare mortality between herpesvirus-positive and -negative patients. Interaction analyses were conducted to assess the impact of co-detection of different herpesviruses. Besides, main findings were validated using data from a prospective multicenter cohort. Among 1,737 enrolled patients, the 28-day mortality rate was 41.3% (718/1,737). Herpesviruses were detected in 828 patients. Detection frequencies were: HSV-1 (26.8%), CMV (17.8%), EBV (16.6%), HHV-7 (5.3%), HHV-6B (2.2%), and VZV (0.5%). Clinical characteristics varied across herpesvirus groups. No single herpesvirus was independently associated with increased mortality compared to the negative group. However, co-detection of HSV-1 and CMV was significantly associated with higher 28-day mortality (vs. both negative: adj-HR = 1.439, 95% CI: 1.093–1.894, P = 0.009). This finding was validated in a prospective cohort (adj-HR = 1.656, 95% CI: 1.061–2.585, P = 0.026). Herpesviruses are frequently detected in the lower respiratory tract of patients with severe pneumonia, with distinct clinical features across virus types. Co-detection of HSV-1 and CMV was associated with increased 28-day mortality. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"16 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144329161","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":"Bayesian reanalysis reinforces the potential mortality benefit of TNF-α inhibitors in COVID-19: a methodological perspective","authors":"Jia-Jin Chen, Pei‑Chun Lai, Yen-Ta Huang","doi":"10.1186/s13054-025-05506-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05506-4","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;Five and a half years since its emergence, despite widespread vaccination efforts, COVID-19 has not disappeared due to viral evolution similar to influenza virus variants, with recurrent sporadic outbreaks occurring in many regions, cities, and countries. Consequently, intensivists worldwide continue to face severe cases, making it crucial to synthesize evidence for managing critically ill COVID-19 patients from both randomized controlled trials (RCTs) and non-RCTs accumulated over recent years. Systematic reviews with meta-analysis of similar outcomes, when pooling is feasible, represent highly valued evidence in clinical medicine, including critical care [1]. This approach is particularly valuable given the high heterogeneity among critically ill patients and recruitment challenges that often result in individual studies being underpowered to achieve statistical significance in frequentist analyses, necessitating appropriate statistical weighting through meta-analysis to achieve adequate results [2].&lt;/p&gt;&lt;p&gt;We read with great interest the systematic review and meta-analysis by Jánosi et al. examining TNF-α inhibitors for COVID-19 treatment [3]. The authors conducted a rigorous analysis addressing an important clinical question, demonstrating potential reduced mortality with TNF-α inhibitor treatment (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.44–1.00, &lt;i&gt;P&lt;/i&gt; = 0.052). Their comprehensive search strategy, careful study selection, and transparent reporting strengthen the validity of their findings. We commend the authors’ thorough methodology and agree with their conclusions. However, we noticed that one included study Farokhnia et al., reported zero events in both arms [4]. While this study’s weight was minimal (0.7%) in the random-effects model, the 95% confidence interval touching 1.00 creates an interpretive challenge regarding statistical significance—a limitation inherent to frequentist hypothesis testing. This borderline p-value exemplifies a common dilemma in critical care research: how to interpret and communicate findings that suggest clinical benefit but narrowly miss conventional significance thresholds.&lt;/p&gt;&lt;p&gt;While frequentist meta-analysis yields binary significant/non-significant decisions based on arbitrary thresholds, Bayesian approaches provide posterior distributions that directly quantify the probability of different effect sizes. This probabilistic framework is particularly advantageous with sparse data, where frequentist methods require continuity corrections that may bias results [5]. Bayesian analysis enables direct probability statements that align with clinical reasoning, avoiding the interpretive challenges of borderline p-values and providing more nuanced information for clinical decision-making [6]. Increasingly, meta-analyses in critical care medicine are adopting Bayesian approaches to address these limitations [7]. For example, Cheng et al.‘s recent publication in Critical Care on h","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"24 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144320302","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":"Can we predict the future of respiratory failure prediction?","authors":"Alex K. Pearce, Shamim Nemati, Ewan C. Goligher, Catherine L. Hough, Andre L. Holder, Gabriel Wardi, Philip Yang, Aaron Boussina, Patrick G. Lyons, Sarina Sahetya, Atul Malhotra, Angela Rogers","doi":"10.1186/s13054-025-05484-7","DOIUrl":"https://doi.org/10.1186/s13054-025-05484-7","url":null,"abstract":"Mortality in patients with acute respiratory failure remains high. Predicting progression of acute respiratory failure may be critical to improving patient outcomes. Machine learning, a subset of artificial intelligence is a rapidly expanding area, which is being integrated into several areas of clinical medicine. This manuscript will address the knowledge gap in predicting the onset and progression of respiratory failure, provide a review of existing prognostic strategies, and provide a clinical perspective on the implementation and future integration of machine learning into clinical care. Existing strategies for predicting respiratory failure, such as prediction scores and biomarkers, offer both strengths and limitations. While these tools provide some prognostic value, machine learning presents a promising, data-driven approach to prognostication in the intensive care unit. Machine learning has already shown success in various areas of clinical medicine, although relatively few algorithms target respiratory failure prediction specifically. As machine learning grows in the context of respiratory failure, outcomes such as the need for invasive mechanical ventilation and escalation of respiratory support (e.g. non-invasive ventilation) have been identified as key targets. However, the development and implementation of machine learning models in clinical care involves complex challenges. Future success will depend on rigorous model validation, clinician collaboration, thoughtful trial design, and the application of implementation science to ensure integration into clinical care. Machine learning holds promise for optimizing treatment strategies and potentially improving outcomes in respiratory failure. However, further research and development are necessary to fully realize its potential in clinical practice.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"11 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144319925","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":"Can we reliably use pulse pressure as a surrogate for stroke volume? Physiological background and potential clinical implications for shock resuscitation","authors":"Zbigniew Putowski, Jean-Louis Teboul, Ricardo Castro, Denis Chemla, Jonatan Oras, Sebastian Morales, Eduardo Kattan, Glenn Hernandez","doi":"10.1186/s13054-025-05490-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05490-9","url":null,"abstract":"In critically ill patients, early hemodynamic assessment is essential for guiding shock resuscitation. While cardiac output (CO) is a key indicator of circulatory status, its measurement is often limited by technical and practical constraints. This perspective explores the physiological and clinical relevance of pulse pressure (PP) as a potential surrogate for stroke volume (SV), emphasizing its accessibility at the bedside. The paper discusses how factors such as arterial compliance, vascular tone, and pulse wave amplification influence the PP-SV relationship, often complicating interpretation in acute and complex hemodynamic states. It also examines the effects of vasopressors, vascular decoupling, and catheter site on PP measurements, particularly in septic shock. Despite its limitations, the review highlights how peripheral PP, when carefully interpreted, may aid in identifying low SV and guiding early resuscitation strategies.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"45 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144319873","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":"What is the optimal approach to analyse ventilator-free days? A simulation study","authors":"Laurent Renard Triché, Matthieu Jabaudon, Nicolas Molinari, Jean-Marie Forel, Jean-Michel Constantin, Bruno Pereira, Sylvie Chevret","doi":"10.1186/s13054-025-05474-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05474-9","url":null,"abstract":"Ventilator-free days (VFDs) are a composite outcome in critical care research, reflecting both survival and mechanical ventilation duration. However, analysis methods for VFDs are inconsistent, with some focusing on counts and others on time-to-event outcomes, while other approaches such as the multistate model and the win ratio have emerged. We aimed to evaluate various statistical models through simulations to identify the optimal approach for analysing VFDs. First, 16 datasets of 300 individuals were simulated, comparing a control group to an intervention with varying survival rates and ventilation durations. Various statistical models were evaluated for statistical power and Type I error rate. Four clinical trial datasets (LIVE study, NCT02149589; ARMA study, NCT00000579; ACURASYS study, NCT00299650; COVIDICUS study, NCT04344730) were then used to apply the same statistical models to analyse VFDs. Twelve statistical methods were evaluated, including count-based, time-to-event approaches, and the win-ratio. Additionally, sensitivity analyses were conducted. Most statistical methods effectively controlled Type I error rate, except for the zero-inflated and hurdle Poisson/negative binomial count submodels, as well as the cause-specific Cox regression model for death. The power to detect survival benefit and ventilation duration effects varied, with time-to-event approaches, the Mann–Whitney test, the proportional odds model and the win ratio generally performing best. Similar results were observed in sensitivity analyses. In the real datasets, the multistate model, the Mann–Whitney test, the proportional odds model and the win ratio generally showed a significant association between VFDs and randomisation groups. The multistate model could be recommended as the optimal approach for analysing VFDs, as it outperformed the other methods and offers a more interpretable effect size than the proportional odds model and the win ratio.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"16 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144320301","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}