Critical Care最新文献

{"title":"Association between neurofilament light chain concentrations and outcomes in patients with moderate to severe traumatic brain injury: a systematic review and meta-analysis.","authors":"Marwan Bouras, Mathieu Pageau, Marc-Aurèle Gagnon, Olivier Costerousse, Karolane Demers, Anouk Grenier-Gagnon, Chartelin Jean Isaac, Tomas Hayg Torkomyan, François Lauzier, Ryan Zarychanski, Charles L Francoeur, Peter Gerges, Godwill Abiala, Lynne Moore, Shane W Englis, Alexis F Turgeon","doi":"10.1186/s13054-026-06036-3","DOIUrl":"https://doi.org/10.1186/s13054-026-06036-3","url":null,"abstract":"<p><strong>Background: </strong>Moderate to severe traumatic brain injury (TBI) is associated with high rates of mortality and long-term disability. Accurate biomarkers are needed to predict longterm neurological outcomes and guide decision-making early after TBI. Neurofilament light chain (NfL), a structural protein of neurons, has emerged as a promising candidate, but its association with outcomes in this population remains uncertain.</p><p><strong>Methods: </strong>We conducted a systematic review and meta-analysis to assess the association between blood or cerebrospinal fluid NfL concentrations and outcomes in adults with moderate to severe TBI. We searched MEDLINE, Embase, Cochrane CENTRAL and Web of Science from inception to October 2025. Eligible studies included cohort studies or randomized controlled trials reporting NfL levels measured during the acute phase and reporting at least one outcome of interest. Our primary outcome was long-term neurological function, defined as the latest available Glasgow Outcome Scale (GOS) or Glasgow Outcome Scale-Extended (GOS-E) score, dichotomized into unfavorable (GOS ≤ 3 or GOS-E ≤ 4) and favorable (GOS > 3 or GOS-E > 4). Mortality, at any time point, was a secondary outcome. Risk of bias was assessed using an adapted scale from the QUADAS-2 tool, and certainty of evidence was evaluated using GRADE criteria.</p><p><strong>Results: </strong>Fourteen studies (2,905 participants) were included, with ten (n = 1,648) contributing to the meta-analysis for our primary outcome. Higher NfL concentrations were associated with unfavorable neurological outcomes, with moderately higher levels in patients with poor outcomes compared with those with favorable outcomes (SMD 0.45, 95% CI 0.33-0.56; I² = 12%). Six studies (n = 483) assessed mortality; higher NfL concentrations were associated with increased mortality (SMD 0.71, 95% CI 0.04-1.39; I² = 82%), with a more consistent association when NfL was measured within 24 h after injury (I² = 0%). The certainty of evidence was graded as very low for both outcomes, reflecting risk of bias and, for mortality, additional inconsistency and imprecision.</p><p><strong>Conclusions: </strong>Higher NfL concentrations were associated with unfavorable neurological outcomes after moderate-to-severe TBI. The association with mortality was more uncertain and should be interpreted with caution given the substantial heterogeneity across studies. Its incremental prognostic value beyond known predictors remains uncertain.</p><p><strong>Trial registration: </strong>PROSPERO CRD42022332110, 22 May 2022.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13147746/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147834656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Methodological considerations in meta-analytic evaluation of cangrelor in critically ill patients: a response to Bottussi et al.","authors":"Hendrianus Hendrianus, Sang Yeub Lee, Jun Hwan Cho, Jinhwan Jo, Sang-Wook Kim, Young-Hoon Jeong","doi":"10.1186/s13054-026-06051-4","DOIUrl":"https://doi.org/10.1186/s13054-026-06051-4","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13141614/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147834687","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Renal replacement therapy in patients under extracorporeal membrane oxygenation: a narrative review.","authors":"Filip Tomovic, Arnaud Thibault-Baum, Nikola Glogonjac, Caroline P Martens, Slobodan Sajinovic, Vedran Premuzic, Max Bell, Lui Forni, Antoine Schneider, Thomas Rimmelé, Frank Bidar","doi":"10.1186/s13054-026-06033-6","DOIUrl":"https://doi.org/10.1186/s13054-026-06033-6","url":null,"abstract":"<p><strong>Background: </strong>The use of extracorporeal membrane oxygenation (ECMO) has expanded for severe respiratory and circulatory failure. Acute kidney injury (AKI) is one of the most frequent complications. Up to 85% of ECMO patients develop AKI and approximately half of them require renal replacement therapy (RRT) making a comprehensive understanding of both therapies and their interaction essential for patient management. However, evidence to guide ECMO-specific RRT strategies remains limited.</p><p><strong>Main body: </strong>ECMO-related AKI arises from a complex interplay between patient and circuit factors that promote inflammation, endothelial injury, and tubular damage. Timing of RRT initiation in ECMO patients often relies on criteria used in the general critically ill population. Fluid overload is consistently associated with worse outcomes, and observational data suggest that earlier RRT, primarily to control fluid balance, may improve survival although randomized trials in ECMO patients are lacking. All RRT modalities can theoretically be used, but continuous techniques are preferred. RRT can be delivered via a parallel circuit using a dedicated venous catheter or integrated into the ECMO circuit. Integrated configurations reduce the need for additional vascular access and may prolong filter lifespan but require careful pressure management and team expertise to avoid alarms, hemolysis, and air embolism. Anticoagulation strategies must balance bleeding and thrombosis risk across both circuits; unfractionated heparin remains standard, while regional citrate anticoagulation can safely extend filter lifespan in selected patients although data is lacking in patients under veno-arterial ECMO. RRT during ECMO is associated with higher short-term mortality and an increased burden of chronic kidney disease among survivors.</p><p><strong>Conclusions: </strong>The management of AKI in ECMO patients remains a major clinical challenge. While RRT is often required in this population, optimal strategies for its initiation, modality selection, and integration with ECMO circuits are still evolving. Current evidence underscores the need for individualized approaches based on patient characteristics. Future research should focus on defining standardized protocols for RRT implementation in ECMO, use of regional citrate anticoagulation, optimizing patient selection, and evaluating long-term renal and survival outcomes.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":" ","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147811905","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":"Association of mortality and neurological outcomes with hypocapnia in adult patients with acute brain injury: an updated meta-analysis.","authors":"Nekane Romero-García, Chiara Robba, Alberto Ruiz-Pacheco, María Pascual-González, Carmen Beltran-Piles, Arnau Devís-Peiró, Jorge F Martí-Cervera, Lavienraj Premraj, Raphaël Cinotti, Fabio Silvio Taccone, Rafael Badenes","doi":"10.1186/s13054-026-06058-x","DOIUrl":"https://doi.org/10.1186/s13054-026-06058-x","url":null,"abstract":"<p><strong>Background: </strong>Carbon dioxide is a key determinant of cerebral blood flow and is needed to prevent secondary damage in neurocritical care; however, optimal targets across the heterogeneous spectrum of acute brain injury (ABI) remain to be elucidated. The aim of this study was to evaluate the association between arterial hypocapnia and mortality and neurological outcomes in adult patients with ABI.</p><p><strong>Methods: </strong>Six electronic databases were systematically searched from inception to January 2025. Observational and randomized controlled trials comparing exposure to hypocapnia, defined as an arterial partial pressure of carbon dioxide (PaCO₂) lower than 35 mmHg, and no-hypocapnia in adult patients with ABI-related conditions (including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, central nervous system infections, brain tumors, and post-cardiac arrest encephalopathy) were included. Random-effects meta-analyses were conducted using the restricted maximum likelihood (REML) method to pool unadjusted odds ratios (ORs). The primary outcome was all-cause mortality, and the secondary outcome was the occurrence of poor neurological outcomes defined using validated scales. Prespecified subgroup analyses and meta-regression were conducted to explore sources of heterogeneity.</p><p><strong>Results: </strong>A total of 8,637 records were identified after duplicate removal, of which 37 studies met inclusion criteria for the systematic review. Twenty-seven studies (51,373 patients) were included for mortality outcomes, and thirteen studies (3,814 patients) were included for neurological outcomes. Hypocapnia was associated with higher odds of mortality in adult patients with ABI (OR 1.29, 95% CI 1.05-1.59). Subgroup analyses demonstrated variability across ABI types, with stronger associations observed in subarachnoid hemorrhage and ischemic stroke populations. Hypocapnia was also associated with increased odds of poor neurological outcomes (OR 2.09, 95% CI 1.24-3.54), particularly in the traumatic brain injury population. Subgroup analyses suggested that the association with neurological outcomes was more consistent in studies defining exposure as severe hypocapnia (PaCO₂<32 mmHg).</p><p><strong>Conclusions: </strong>Arterial hypocapnia was associated with increased mortality and poor neurological outcomes in adults with acute brain injury, although the evidence is predominantly observational and limited randomized data are available. These findings underscore the need for cautious, individualized PaCO₂ management and further high-quality prospective research.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":" ","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147811823","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":"Ultrasound-derived muscle metrics in critical illness: from measurement to clinical meaning.","authors":"Alejandro Chapa-Rodriguez, Sarvesh Sharma, Satyanarayana Vaidya","doi":"10.1186/s13054-026-06068-9","DOIUrl":"https://doi.org/10.1186/s13054-026-06068-9","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13134186/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147811871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The six phases of prolonged veno-venous extracorporeal membrane oxygenator support: a conceptual framework.","authors":"Kenneth R Hoffman, Arne Diehl, Paul Nixon, Sarah A Yong, Eddy Fan, Carol Hodgson, Aidan J C Burrell","doi":"10.1186/s13054-026-06065-y","DOIUrl":"https://doi.org/10.1186/s13054-026-06065-y","url":null,"abstract":"<p><p>Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a complex and invasive intervention used increasingly in the management of severe respiratory failure. Once established, the management of prolonged V-V ECMO support involves balancing priorities of lung protection, prevention of pulmonary complications, sedation weaning and safe reduction in ECMO support. These occur variably as the pulmonary pathology resolves and ECMO support is reduced. Evidence based strategies to assist clinicians during prolonged V-V ECMO support are lacking, with the majority of literature focussing on ventilation strategies following ECMO initiation and the criteria for separation from V-V ECMO once liberation is considered safe. Practice is largely clinician and institution dependent with significant heterogeneity. There are numerous questions which remain unanswered regarding the prioritisation and strategies for safe V-V ECMO weaning. This review aimed to provide a novel conceptual framework to assist clinicians by dividing prolonged V-V ECMO support into six phases: ultra-lung-protective, lung protective, transition to spontaneous breathing, liberation trial, decannulation and post decannulation support. We reviewed existing literature and identified knowledge gaps for future research.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":" ","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147811892","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":"Minimally invasive extracorporeal CO₂ removal in hypercapnic respiratory failure: a prospective observational study.","authors":"Vitalii Kryvenko, Faeq Husain-Syed, Elisa Schnell, Gani Oruqaj, Rory E Morty, Susanne Herold, Matthias Hecker, Khodr Tello, Werner Seeger, István Vadász","doi":"10.1186/s13054-026-06062-1","DOIUrl":"10.1186/s13054-026-06062-1","url":null,"abstract":"<p><strong>Background: </strong>Lung-protective ventilation in acute respiratory distress syndrome (ARDS) can lead to hypercapnia, an independent risk factor for increased mortality. Extracorporeal CO₂ removal (ECCO₂R) enables further reduction of ventilator intensity, but its routine use is limited due to safety concerns. In the current study, we evaluated the feasibility, efficacy, and safety of minimally invasive ECCO₂R (miECCO₂R) implemented via a renal replacement therapy (RRT) platform in patients with mild-to-moderate ARDS and refractory hypercapnia.</p><p><strong>Methods: </strong>In this prospective single-center observational study, 20 ICU patients with persistent hypercapnia despite escalated ventilation received either standalone miECCO₂R (n = 11) or miECCO₂R combined with continuous RRT (n = 9). As a primary outcome, efficacy of miECCO₂R was assessed. Moreover, ventilator parameters, disease severity, renal function, and adverse events were evaluated as secondary outcome parameters over a time-course of five days upon initiation of miECCO₂R.</p><p><strong>Results: </strong>miECCO₂R led to a rapid and sustained reduction in PaCO₂ levels from 71.4 mm Hg to 51.6 mm Hg within 24 h. This was accompanied by normalization of pH, and the median CO₂ clearance rate was 64.5 mL/min. Driving pressure decreased significantly from 22 cm H₂O to 15 cm H₂O by day 5, while oxygenation remained stable. The standalone miECCO₂R treatment group demonstrated faster CO₂ reduction, probably due to higher blood flow rates. There were no severe adverse events related to either the device or the therapy. Circuit clotting was managed by system exchange, without clinical consequences for the patients. Platelet counts declined moderately, but no major bleeding complications occurred.</p><p><strong>Conclusions: </strong>miECCO₂R delivered via an RRT platform appears to be a safe and effective method of controlling hypercapnia and facilitating lung-protective ventilation in patients with ARDS. These findings need to be supported by further randomized controlled trials that can more definitely demonstrate the impact of miECCO₂R on clinical outcomes.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13130721/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147765003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Tracheobronchial exposure should not be equated with parenchymal target attainment for nebulized amikacin.","authors":"Guofu Mao, Haizhen Lan","doi":"10.1186/s13054-026-06064-z","DOIUrl":"10.1186/s13054-026-06064-z","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-04-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13126840/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147765043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Blood pressure response index trajectories identify distinct hemodynamic phenotypes and predict mortality in septic shock: a two-database retrospective cohort study.","authors":"Yongshi Shen, Wei Zhang, Kangni Lin, Peng Zheng, Xinwei Liu, Jinsen Weng, Yong Ye","doi":"10.1186/s13054-026-06059-w","DOIUrl":"10.1186/s13054-026-06059-w","url":null,"abstract":"<p><strong>Background: </strong>Vasopressor responsiveness in septic shock is typically assessed using static metrics that cannot capture temporal hemodynamic evolution. The Blood Pressure Response Index (BPRI = mean arterial pressure / Vasoactive-Inotropic Score) integrates hemodynamic response and treatment intensity into a single metric, but its longitudinal trajectory patterns remain unexplored.</p><p><strong>Methods: </strong>We applied latent class mixed models to BPRI trajectories during the first 48 h of vasopressor therapy in 4,389 septic shock patients from MIMIC-IV (development cohort). External validation was performed via parameter transport to 1,240 eICU-CRD patients. The prognostic significance of trajectory phenotypes was assessed using multivariable logistic and Cox regression with a three-level adjustment framework, restricted mean survival time analysis, and incremental predictive value assessment beyond conventional severity scores.</p><p><strong>Results: </strong>Six distinct hemodynamic phenotypes were identified with ICU mortality ranging from 21.9% (C3 Responders) to 54.5% (C2 Non-Responders). Parameter transport validation showed preserved class separation and prognostic gradient (average posterior probability 0.960) in eICU-CRD. After full multivariable adjustment, C2 (OR 3.67, 95% CI 2.76-4.86) and C1 (OR 2.68, 95% CI 2.08-3.46) remained independently associated with ICU mortality. Restricted mean survival time analysis showed the largest adjusted losses for C2 (- 2.56 days at τ = 14 days) with minimal attenuation from unadjusted estimates, suggesting an association that persisted after comprehensive adjustment. Adding trajectory classification to severity scores yielded statistically significant incremental discrimination (ΔAUC + 0.020, P < 0.001), while static BPRI added no further information.</p><p><strong>Conclusions: </strong>BPRI trajectory analysis identifies six hemodynamic phenotypes in septic shock that are validated in an independent external database, are independently associated with mortality, and capture temporal hemodynamic response patterns missed by static assessments. These phenotypes may facilitate risk stratification and enrichment strategies for clinical trials targeting vasopressor-dependent patients.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":" ","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-04-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147765045","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":"Better teaching in the ICU: from educational principles to case-based, visualization-guided, and AI-enhanced training infrastructure.","authors":"Tongjuan Zou, Wanhong Yin","doi":"10.1186/s13054-026-06056-z","DOIUrl":"10.1186/s13054-026-06056-z","url":null,"abstract":"","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"30 1","pages":""},"PeriodicalIF":9.3,"publicationDate":"2026-04-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13126764/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147764963","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}