Critical Care最新文献

{"title":"Intraosseous access in resuscitation.","authors":"Renxian Xie, Lifeng Xiao","doi":"10.1186/s13054-025-05651-w","DOIUrl":"https://doi.org/10.1186/s13054-025-05651-w","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"29 1","pages":"445"},"PeriodicalIF":9.3,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145344044","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":"Adjunctive terlipressin versus placebo in the treatment of refractory septic shock: a randomized, placebo-controlled trial.","authors":"Surat Tongyoo, Chawanee Chayakul, Thipdhorn Aritajati, Tanya Tanyalakmara","doi":"10.1186/s13054-025-05669-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05669-0","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"29 1","pages":"443"},"PeriodicalIF":9.3,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145344041","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":"Lung-protective ventilation strategy in acute respiratory distress syndrome: a critical reappraisal of current practice.","authors":"Kwang Joo Park","doi":"10.1186/s13054-025-05675-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05675-2","url":null,"abstract":"<p><p>Recognition of ventilator-induced lung injury has led to the development of lung-protective ventilation strategies, significantly influencing the management of acute respiratory distress syndrome (ARDS). By the end of the 20th century, five randomized controlled trials had compared the survival benefits of low tidal volume (VT) ventilation with those of traditional high VT ventilation. Two studies demonstrated favourable outcomes, most notably the landmark ARDS Network trial, which established the widely recommended VT of 6 mL/kg predicted body weight. However, the universal application of a fixed VT has been controversial, with poor adherence in clinical practice. The two trials used a greater contrast in VTs (6 vs. 12 mL/kg) than did the others (7-11 mL/kg) and incorporated methodological extremes, including toleration of elevated airway pressures or encouragement of unnecessary increases. In addition, disparities in underlying aetiologies and ventilatory parameters, such as unbalanced positive end-expiratory pressure and respiratory rates, may have influenced the results. There is no conclusive evidence to support the superiority of 6 mL/kg over intermediate VTs (7-10 mL/kg). Many subsequent studies have suggested that VT requirements should be individualized on the basis of lung mechanics and physiological status. The benefits of the current recommendations may be limited by factors such as the severity of hypoxemia, lung compliance, dead-space fraction, and inaccuracies in formula-based lung volume estimation. The goal of mechanical ventilation in ARDS patients is supportive rather than curative; therefore, a moderate approach is recommended in clinical practice. Further studies are needed to establish an individualized, patient-centred approach that allows more flexible and moderate settings.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"29 1","pages":"444"},"PeriodicalIF":9.3,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145343976","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":"Diagnostic performance of a 250-ml net ultrafiltration challenge to identify risk of preload-dependence in critically ill patients undergoing continuous renal replacement therapy: a randomized, cross-over trial.","authors":"Charlotte Biscarrat, Guillaume Deniel, Matthieu Chivot, Hodane Yonis, Louis Chauvelot, Mehdi Mezidi, Jean-Christophe Richard, Laurent Bitker","doi":"10.1186/s13054-025-05674-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05674-3","url":null,"abstract":"<p><strong>Introduction: </strong>During continuous renal replacement therapy (CRRT), preload-independent patients risk of becoming preload-dependent in case of excessive net ultrafiltration (UF_NET). We aimed to evaluate the ability of a UF_NET challenge to identify de novo preload-dependence in preload-independent patients undergoing CRRT.</p><p><strong>Materials and methods: </strong>We conducted a single-center, randomized, cross-over trial, enrolling adult patients with CRRT, calibrated continuous cardiac index (CCI) monitoring, and preload-independent at time of enrolment. The diagnostic test consisted of 250-ml UF_NET removal over 15 (fast challenge) or 30 min (slow challenge), preceded and followed by a postural maneuver (PM) evaluating preload-dependence using CCI relative variations. Patients underwent both types of challenges, starting with either fast or slow challenges as determined by randomization, separated by a wash-out period of 24 h. We evaluated the performance of UF_NET challenges to diagnose de novo preload-dependence using the area under the receiver operating curve (AUROC) of the relative change in calibrated cardiac index between before and after the challenge (∆CI_UFC), based on the result of the PM performed after the challenge (responder if positive, non-responder if negative). NCT05214729.</p><p><strong>Results: </strong>We included 20 patients, comprising 36 UF_NET challenges (19 fast and 17 slow challenges). In intention-to-treat (ITT), the rate of preload-dependence after the challenge was 33% (12/36, 95% confidence interval: 19% to 51%). In ITT, the AUROC of ∆CI_UFC to identify de novo preload-dependence was 0.74 (95% confidence interval: 0.58-0.88), with the respective AUROCs of fast and slow challenges not reaching statistical significance. After exclusion of 5 challenges a posteriori identified as being preload-dependent before challenge start (modified intention-to-treat [mITT], N = 31), the AUROC of ∆CI_UFC was 0.83 (0.66-0.99), with ∆CI_UFC not significantly differing between fast and slow challenges. In mITT, CCI variation during the PM preceding the challenge predicted de novo preload-dependence with an AUROC of 0.82 (0.65-0.98), at an optimal threshold of + 5%.</p><p><strong>Conclusions: </strong>A 250-ml UF_NET challenge had acceptable diagnostic performance to identify preload-independent patients becoming preload-dependent during CRRT, with no detectable difference between fast and slow challenges. A CCI variation ≥ 5% during a PM in preload-independent patients may help identify those at risk of becoming preload-dependent.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"29 1","pages":"446"},"PeriodicalIF":9.3,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145344043","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":"Cardiovascular effects of hypertonic lactate solutions: acid-base or metabolic cause, or both? Authors' reply.","authors":"Kristoffer Berg-Hansen, Mette Glavind Bülow Pedersen, Nigopan Gopalasingam, Oskar Kjærgaard Hørsdal, Niels Møller, Henrik Wiggers, Roni Nielsen","doi":"10.1186/s13054-025-05728-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05728-6","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"29 1","pages":"447"},"PeriodicalIF":9.3,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145344042","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":"Challenging ageism in eCPR: the quiet discrimination","authors":"Sasa Rajsic, Robert Breitkopf","doi":"10.1186/s13054-025-05715-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05715-x","url":null,"abstract":"&lt;p&gt;&lt;b&gt;To the editor, &lt;/b&gt;&lt;/p&gt;&lt;p&gt;We read with great interest the report on left-digit bias (LDB)&lt;sup&gt;&lt;span&gt;Footnote &lt;/span&gt;1&lt;/sup&gt;and invasive treatments among out-of-hospital cardiac arrest patients with shockable rhythm [1]. This prospective, multicenter observational study included data from approximately 140 hospitals and a total of 5,943 patients across Japan. The authors identified a significant LDB affecting ECMO implementation at age 70, with rates declining from 34.2% to 24.5%. Despite this steep decline, the analysis revealed no significant discontinuities in neurological recovery or one-month survival across age thresholds, challenging the rationale behind rigid age-based treatment cutoffs.&lt;/p&gt;&lt;p&gt;Evidence supporting the efficacy of extracorporeal cardiopulmonary resuscitation (eCPR) continues to expand, and the study by Miyamoto et al. represents an important contribution to this growing body of high-quality data. While definitive inclusion criteria for eCPR must ultimately be guided by future studies, we emphasize the critical importance of avoiding age discrimination.&lt;/p&gt;&lt;p&gt;Placing disproportionate weight on age as a categorical variable, while overlooking clinical dimensions of comorbidities and frailty, risks reducing complex critical care decisions to crude arithmetic. Although this approach simplifies patient selection, it fails to capture the heterogeneity of aging and the wide variability in physiological resilience among older adults. Consequently, rigid adherence to these cutoffs risks excluding patients who, despite their chronological age, may possess sufficient physiological reserve and rehabilitation potential to benefit from advanced therapies.&lt;/p&gt;&lt;p&gt;Negative societal and clinical perceptions of aging often shape treatment decisions. Older adults may be denied indicated therapies due to assumptions about reduced adaptability, diminished benefit, or the false belief that their conditions are merely the natural consequence of aging [2]. Such attitudes foster systematic undertreatment and are reflected in evidence of covert age-based rationing, especially in cardiac care, palliative medicine, and access to high-risk but potentially life-saving interventions.&lt;/p&gt;&lt;p&gt;These tensions were thrown into stark relief during the COVID-19 pandemic [3]. Triage proposals, rushed into place under the urgency of crisis, drew criticism for undermining the constitutional principle of the equal worth of life and for eroding human dignity [4]. In response, alternative allocation strategies, such as randomized allocation or “first-come, first-served” principles were proposed to safeguard fairness and mitigate discriminatory practices.&lt;/p&gt;&lt;p&gt;Against this backdrop, two ethical frameworks contend for primacy. Utilitarian approaches seek to maximize benefit, often by prioritizing patients expected to gain the greatest number of “life-years”. Yet this arithmetic, efficient as it may seem, risks quiet age discrimination and conflicts with the princip","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"48 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145311261","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":"Deep learning models for ICU readmission prediction: a systematic review and meta-analysis","authors":"Emanuele Koumantakis, Konstantina Remoundou, Nicoletta Colombi, Carmen Fava, Ioanna Roussaki, Alessia Visconti, Paola Berchialla","doi":"10.1186/s13054-025-05642-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05642-x","url":null,"abstract":"Intensive Care Unit (ICU) readmissions are associated with increased morbidity, mortality, and healthcare costs. Therefore, determining an appropriate timing of ICU discharge is critical. In this context, deep learning (DL) approaches have attracted significant attention. We conducted a systematic review of studies developing or validating DL models for ICU readmission prediction, published up to March 4th, 2025, and indexed in PubMed, Embase, Scopus, and Web of Science. We summarised them along multiple dimensions, including outcome and population definition, DL architecture, reproducibility, generalizability, and explainability, and provided a meta-analytic estimate of model performance. We included 24 studies encompassing 49 DL models, predominantly trained on US-based datasets, and rarely subjected to external validation. There was considerable variability across study settings, including the definition and timeframe of the ICU readmission outcome, as well as DL architecture used, alongside a substantial risk of bias. Technical reproducibility and model interpretation were rare. A meta-analysis of AUROC values from 11 studies yielded a mean of 0.78 (95% CI = 0.72–0.84), with very high heterogeneity (I2 = 99.9%). Models targeting disease-specific ICU subpopulations achieved significantly higher performance (mean AUROC = 0.92, 95% CI = 0.89–0.95, p = 0.002), and substantially lower heterogeneity (I2 = 17.1%). DL models showed promising performances in predicting ICU readmissions, but exhibited several shortcomings, including low reproducibility, over-reliance on a few US-based datasets, and limited explainability. Additionally, the high heterogeneity and risk of bias limited our ability to assess their pooled performance through meta-analysis. Taken together, our observations suggest that the quality of the evidence regarding the application of DL approaches to ICU readmission prediction is poor, thus hindering their clinical applicability.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"34 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145311551","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":"Resistance training and β-hydroxy-β-methylbutyrate for functional recovery in critical illness: a multicenter 2 × 2 factorial randomized trial","authors":"Tingting Wu, Yueqing Wei, Jing Xiong, Jingbing Wu, Xiuxia Lin, Yaoning Zhuang, Chenjuan Luo, Meilian Xu, Xuexian Chen, Zhizhong Lin, Hong Li","doi":"10.1186/s13054-025-05660-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05660-9","url":null,"abstract":"Combined nutrition and rehabilitation is a top research priority for ICU-acquired weakness, yet the optimal strategy and clinical benefits remain unclear. This study aimed to evaluate the independent and combined effects of resistance training (RT) and β-hydroxy-β-methylbutyrate (HMB) in critically ill adults. We conducted a multicenter, open-label, 2 × 2 factorial randomized controlled trial with blinded outcome assessment in 266 adult ICU patients. Participants were randomized to receive RT, HMB supplementation, combined interventions, or standard care. Treatments began in the ICU and continued until discharge. Primary outcomes at discharge included six-minute walk distance (6MWD) and the Short Physical Performance Battery (SPPB). Secondary outcomes included muscle strength and mass, patient-reported outcomes, and mortality at 1, 6, and 12 months. Analyses followed the intention-to-treat principle, using linear mixed-effects models to estimate the independent and interactive effects of RT and HMB. RT significantly improved physical function at discharge, with higher SPPB scores (mean difference:1.32 points; P = 0.003) and longer 6MWD (56.20 m; P < 0.001), compared with patients who did not receive RT. It was associated with lower 6-month (OR, 0.51; P = 0.011) and 12-month mortality (OR, 0.55; P = 0.014), and increased grip strength (3.19 kg; P = 0.008), appendicular skeletal muscle mass (0.997 kg; P = 0.005), and skeletal muscle index (0.428 kg/m²; P = 0.025). RT reduced fatigue and improved sleep quality and psychological symptoms (P < 0.05), but had no effect on cognition or overall quality of life. HMB modestly increased phase angle (0.367; P = 0.020) and reduced fatigue (–1.069 points, P = 0.005), but had no effect on other outcomes; hyperglycemia occurred in 3 of 134 patients receiving HMB. No interaction between RT and HMB was detected. This expanded trial provides novel evidence that RT not only improves physical function but also increases muscle mass, enhances patient-reported outcomes, and lowers 6- and 12-month mortality in critically ill patients. HMB supplementation offered only modest effects on phase angle and fatigue, with no synergistic benefit when combined with RT. ChiCTR2200057685 ( https://www.chictr.org.cn/ ) was registered on March 15th, 2022.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"21 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295807","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":"Patient preference predictors revisited: technically feasible, ethically desirable, yet must be clinically relevant","authors":"Andrea Ferrario, Beatrix Göcking, Giovanna Brandi, Emanuela Keller, Nikola Biller-Andorno","doi":"10.1186/s13054-025-05637-8","DOIUrl":"https://doi.org/10.1186/s13054-025-05637-8","url":null,"abstract":"Although goal-concordant care is central to patient-centered medicine, determining treatment preferences for incapacitated patients remains a challenge. Nearly two decades ago, algorithms were proposed to estimate the most likely treatment preferences in the absence of advance directives, aiming to support surrogate decision-making. This idea has evolved into a race toward increasingly complex models, driven by the assumption that expanding data collection and refining predictive methods will yield more accurate approximations of patients’ unknown treatment preferences. Despite extensive debate on the epistemic, ethical, and clinical challenges of these algorithms, none have been successfully implemented in clinical practice. We contend that this failure does not stem from any of these challenges but, rather, from conceptualizing these models simply as technically sophisticated replicas of advance directives, abstracting a few high-level treatment preferences across all clinical contexts while ignoring setting-specific, temporal, and relational factors. The barrier to the implementation of these models is fundamentally a technology design problem that requires a novel design perspective to ensure their clinical relevance. We discuss this perspective using neuro-intensive care as a case study and examine how algorithmic models could support time-sensitive decision-making for patients with severe acute brain injury. The success of patient preference predictions depends not only on their being technically feasible and ethically promising but on ensuring clinical relevance.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"94 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295808","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":"Norepinephrine formulation itself does not constitute heterogeneity in shock trials","authors":"Patrick M. Wieruszewski, Seth R. Bauer","doi":"10.1186/s13054-025-05720-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05720-0","url":null,"abstract":"&lt;p&gt;We read with great interest the recent systematic review by McDonald et al. in which they evaluate the available clinical trial evidence regarding the impact of vasopressor selection on renal outcomes in septic shock and provide guidance for the future of trial design in this arena [1]. We agree with the authors that norepinephrine salt formulations are an important issue in shock research, but for different reasons. Specifically, we would like to comment on their statements that “the type of formulation can impact the actual effect of norepinephrine” and that this “represents an important cause of heterogeneity” to bring clarity to the issue.&lt;/p&gt;&lt;p&gt;The issue surrounding norepinephrine salt formulations has garnered significant interest over the last four years [2]. Central to this issue is the physiochemical necessity for norepinephrine to be processed into a conjugated salt preparation, without which, intravenous administration to humans would be physically impossible [3]. Hence, several different preparations of norepinephrine (including tartrate, bitartrate, and hydrochloride salts) are available for clinical use worldwide [4]. Importantly, the salt components of these products are biologically inactive ingredients, thus regardless of which formulation is used, the pharmacological activity of molecular norepinephrine (and by extension, its vasoconstrictive potency) is the exact same across all products [5]. Simply put, the formulation of norepinephrine used has no impact on its clinical effect.&lt;/p&gt;&lt;p&gt;Of the 17 randomized trials McDonald et al. identified, they found just one reported which formulation of norepinephrine was used in the trial [6]. However, that report simply stated the product used in the trial was norepinephrine bitartrate. This leaves the very important detail of &lt;i&gt;how the trial reported norepinephrine doses&lt;/i&gt; to be ambiguous. The manner in which norepinephrine &lt;i&gt;doses&lt;/i&gt; are reported is what contributes to heterogeneity between studies and obscures evidence interpretation, not the description of the &lt;i&gt;formulation&lt;/i&gt; utilized [7]. Indeed, an official statement from the European Society of Intensive Care Medicine and Society of Critical Care Medicine recommended reporting all norepinephrine doses in research publications in its base form (molecular norepinephrine), regardless of which salt formulation is used [8].&lt;/p&gt;&lt;p&gt;Taken altogether, while many different norepinephrine formulations are available for use across the world, they all contain the same pharmaceutically active norepinephrine molecule and thus exert the same clinical effect. The specific formulation that is used is less important, and rather, emphasis must be placed on &lt;i&gt;how norepinephrine doses are reported&lt;/i&gt;. Clarity surrounding how issues related to norepinephrine salt formulations are discussed is critical for the future of trial design, evidence interpretation and synthesis, and application of research findings to patient care.&lt;/p&gt;&lt;p&gt;No datasets ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"123 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295806","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}