Critical Care最新文献

{"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":"<p>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.</p><p>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.</p><p>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 <i>how the trial reported norepinephrine doses</i> to be ambiguous. The manner in which norepinephrine <i>doses</i> are reported is what contributes to heterogeneity between studies and obscures evidence interpretation, not the description of the <i>formulation</i> 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].</p><p>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 <i>how norepinephrine doses are reported</i>. 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.</p><p>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}

{"title":"Therapeutic target of high fresh frozen plasma to red blood cell ratio in severe blunt trauma","authors":"Gaku Fujiwara, Kosuke Inoue, Wataru Ishii, Tadashi Echigo, Shoji Yokobori, Naoto Shiomi, Naoya Hashimoto, Shigeru Ohtsuru, Yohei Okada","doi":"10.1186/s13054-025-05678-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05678-z","url":null,"abstract":"To assess heterogeneous treatment effects of high fresh frozen plasma (FFP) to red blood cell (RBC) transfusion ratios in patients with severe blunt trauma and to identify subgroups that derive the greatest survival benefit. This multicenter retrospective cohort study used data from the Japan Trauma Data Bank (2019–2023). Adults with severe blunt trauma (Injury Severity Score ≥ 16) who received transfusions were included. Patients were categorized into high-FFP (FFP:RBC > 1) and low-FFP (FFP:RBC ≤ 1) groups. A causal forest machine learning model was applied to a derivation cohort (2019–2021) to estimate conditional average treatment effects (CATEs) and identify subgroups with the highest predicted benefit. Findings were validated in a separate cohort (2022–2023). Among 6,679 patients, in-hospital mortality was 23.3% in the derivation and 23.2% in the validation cohort. Causal forest analysis revealed lactate level and Glasgow Coma Scale (GCS) score as key effect modifiers. A therapeutic target subgroup—defined as lactate ≥ 4.5 mmol/L and GCS ≤ 12—comprised 20.7% of the validation cohort. This subgroup showed a substantially greater mortality reduction with high-FFP transfusion (risk difference –13.3%, 95% CI –22.4 to –4.2%; number needed to treat [NNT] 7.5), compared with the overall cohort (risk difference –3.3%, 95% CI –6.7 to 0.5%; NNT 32.1). Results were consistent across sensitivity analyses. High FFP-to-RBC transfusion ratios may confer the greatest benefit in patients with impaired consciousness and metabolic acidosis. Identifying high-benefit subgroups using machine learning could support more individualized transfusion strategies in trauma care.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295809","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":"Correction: D-PRISM: a global survey-based study to assess diagnostic and treatment approaches in pneumonia managed in intensive care","authors":"Luis Felipe Reyes, Cristian C. Serrano‑Mayorga, Zhongheng Zhang, Isabela Tsuji, Gennaro De Pascale, Valeria Enciso Prieto, Mervyn Mer, Elyce Sheehan, Prashant Nasa, Goran Zangana, Kostoula Arvaniti, Alexis Tabah, Gentle Sunder Shrestha, Hendrik Bracht, Arie Zainul Fatoni, Khalid Abidi, Helmi bin Sulaiman, Vandana Kalwaje Eshwara, Liesbet De Bus, Yoshiro Hayashi, Pervin Korkmaz, Ali Ait Hssain, Niccolo Buetti, Qing Yuan Goh, Arthur Kwizera, Despoina Koulenti, Nathan D. Nielsen, Pedro Povoa, Otavio Ranzani, Jordi Rello, Andrew Conway Morris","doi":"10.1186/s13054-025-05610-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05610-5","url":null,"abstract":"<p><b>Correction: Critical Care (2024) 28:381</b></p><p><b>https://doi.org/10.1186/s13054-024-05180-y</b></p><p>Following the publication of the original article [1], the authors identified an error in the author name of Kostoula Arvaniti and that the equal contribution was missing for Luis Felipe Reyes and Cristian C. Serrano‑Mayorga.</p><p>The incorrect author name is:</p><p>Kostoula Avanti.</p><p>The correct author name is:</p><p>Kostoula Arvaniti.</p><p>The author group has been updated in this correction article and the original article [1] has been corrected.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Reyes LF, Serrano-Mayorga CC, Zhang Z, et al. D-PRISM: a global survey-based study to assess diagnostic and treatment approaches in pneumonia managed in intensive care. Crit Care. 2024;28:381. https://doi.org/10.1186/s13054-024-05180-y.</p><p>Article PubMed PubMed Central Google Scholar </p></li></ol><p>Download references<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><span>Author notes</span><ol><li><p>Luis Felipe Reyes and Cristian C. Serrano‑Mayorga have contributed equally to this manuscript.</p><p> The original article can be found online athttps://doi.org/10.1186/s13054-024-05180-y.</p></li></ol><h3>Authors and Affiliations</h3><ol><li><p>Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia</p><p>Luis Felipe Reyes & Cristian C. Serrano‑Mayorga</p></li><li><p>Clinica Universidad de La Sabana, Chia, Colombia</p><p>Luis Felipe Reyes, Cristian C. Serrano‑Mayorga & Valeria Enciso Prieto</p></li><li><p>PhD Biosciences Program, Engineering School, Universidad de La Sabana, Chia, Colombia</p><p>Cristian C. Serrano‑Mayorga</p></li><li><p>Pandemic Sciences Institute, University of Oxford, Oxford, UK</p><p>Luis Felipe Reyes</p></li><li><p>Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China</p><p>Zhongheng Zhang</p></li><li><p>Hospital Israelita Albert Einstein, Sao Paulo, Brazil</p><p>Isabela Tsuji</p></li><li><p>Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Universita Cattolica del Sacro Cuore, Rome, Italy</p><p>Gennaro De Pascale</p></li><li><p>Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy</p><p>Gennaro De Pascale</p></li><li><p>Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa</p><p>Mervyn Mer</p></li><li><p>Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, U","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"126 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295780","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":"Is volatile sedation truly associated with increased mortality in mechanically ventilated critically ill adults compared to intravenous sedation? Moving beyond pairwise meta-analysis to individual agent assessment via bayesian network meta-analysis","authors":"Po-An Su, Pei‑Chun Lai, Yen-Ta Huang","doi":"10.1186/s13054-025-05681-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05681-4","url":null,"abstract":"<p><b>Dear editor,</b></p><p>ICU sedation represents a cornerstone of critical care management, balancing patient comfort and safety against the risks of oversedation, prolonged mechanical ventilation, and drug-related adverse effects. We read with great interest the recent meta-analysis by Yamamoto et al. examining volatile sedation in critically ill adults receiving mechanical ventilation [1]. Surprisingly, their findings demonstrated that volatile sedation was associated with increased mortality compared with intravenous sedation (relative risk [RR]: 1.17; 95% confidence interval: 1.02–1.35).</p><p>The authors conducted rigorous analyses to explore whether this result, which contradicted their original hypothesis, might reflect methodological limitations. Trial sequential analysis suggested possible false-positive findings, as the Z-curve crossed conventional but not α-spending boundaries, with the sample size well below the required information size. Bayesian analysis yielded more conservative estimates (RR: 1.16; 95% credible interval [CrI]: 0.94–1.42) but indicated a 92.8% probability of increased mortality. They also performed numerous sensitivity analyses to explore potential explanations for their findings. GRADE assessment rated evidence certainty as low, precluding definitive conclusions. This systematic review exemplifies methodological rigor, achieving high quality on AMSTAR2 (A MeaSurement Tool to Assess systematic Reviews, version 2) [2]. We particularly commend their comprehensive statistical approach, which prompts deeper consideration of whether volatile sedation truly increases mortality in this population.</p><p>Here, we present an alternative analytical approach—Bayesian network meta-analysis (NMA)—to examine the four sedatives individually: two volatile agents (isoflurane, sevoflurane) and two intravenous agents (propofol, midazolam). Our rationale stems from the distinct pharmacological profiles of these agents. Notable differences exist between volatile agents: isoflurane primarily reduces systemic vascular resistance while maintaining cardiac output, whereas sevoflurane causes more pronounced myocardial depression with less vasodilation [3]. Such differences could impact hemodynamics and potentially influence mortality. Similarly, propofol’s hemodynamic effects [4] and midazolam’s association with increased delirium risk [5] may differentially affect outcomes. Therefore, pooling agents by class in pairwise meta-analysis may introduce substantial heterogeneity. While Yamamoto et al. addressed this through sensitivity analyses, we propose that NMA comparing all four agents individually provides a more granular assessment.</p><p>Mesnil et al. (2011) was the sole three-arm study in their review, comparing sevoflurane, propofol, and midazolam [6]. Conducting NMA using only the originally included studies might produce biased results because the network connection between propofol and midazolam relies on a single direct compari","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"62 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145289196","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":"Circulating endothelial signatures correlate with worse outcomes in COVID-19, respiratory failure and ARDS","authors":"Ana C. Costa Monteiro, Harry Pickering, Aartik Sarma, Clove S. Taylor, Meagan M. Jenkins, Fei-Man Hsu, Brian Nadel, Ofer Levy, Lindsey R. Baden, Esther Melamed, Lauren I. R. Ehrlich, Grace A. McComsey, Rafick P. Sekaly, Charles B. Cairns, Elias K. Haddad, Albert C. Shaw, David A. Hafler, Ruth R. Montgomery, David B. Corry, Farrah Kheradmand, Mark A. Atkinson, Scott C. Brakenridge, Nelson I. Agudelo Higuita, Jordan P. Metcalf, Catherine L. Hough, William B. Messer, Bali Pulendran, Kari C. Nadeau, Mark M. Davis, Linda N. Geng, Ana Fernandez-Sesma, Viviana Simon, Florian Krammer, Monica Kraft, Chris Bime, Carolyn S. Calfee, David J. Erle, Steve Bosinger, Walter Eckalbar, Holden Maecker, Adeeb Rahman, Leying Guan, Bjoern Peters, Steven H. Kleinstein, Alison D. Augustine, Joann Diray-Arce, Patrice M. Becker, Nadine Rouphael, Michael Agus, Hrishikesh Kulkarni, Joanna M. Schaenmann, Ramin Salehi-Rad, Michael A. Matthay, Elaine F. Reed, Anil Sapru","doi":"10.1186/s13054-025-05596-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05596-0","url":null,"abstract":"Elevated circulating endothelial cells (CECs), released from monolayers after insult, have been implicated in worse outcomes in ARDS and COVID-19, however there is no consensus proteomic phenotype that define CECs. We queried whether a transcriptomic approach would alternatively support the presence of endothelial cells in circulation and correlate with worsening respiratory failure. To test whether elevated endothelial cell signatures (ECS) in circulation plays a role in worse respiratory outcomes, we used unsupervised bulk-transcriptome deconvolution to quantify ECS% in two cohorts. Our pilot analysis included pediatric patients requiring invasive mechanical ventilation (CAF-PINT, NCT01892969). Our validation cohort included adult hospitalized patients with COVID-19 (IMPACC, NCT04378777), testing the association of ECS% to outcomes in patients at risk of acute respiratory failure/ARDS. Primary outcome was 28-day mortality. In CAF-PINT, day 0 ECS% was higher in non-survivors compared to survivors of respiratory failure (2.8%, IQR 2.4–3.4% versus 2.6%, IQR 2.2–3.0% n = 244, p < 0.05, Wilcoxon rank-sum). In IMPACC, baseline ECS% (< 72 h of hospitalization) was higher in COVID-19 non-survivors versus survivors (2.9%, IQR 2.6–3.4%, versus 2.7%, IQR 2.3–3.1%, n = 932, p < 0.001, Wilcoxon rank-sum). Each 1% increase in baseline ECS% was significantly associated with mortality (adjusted OR 1.36, CI 1.03–1.79) by multivariable logistic regression. Increased baseline ECS% was associated with worse respiratory trajectories (2.5%, IQR 2.2–2.8% for trajectory with no oxygen requirements, 2.9%, IQR 2.6–3.4% for the trajectory with fatal outcome by day 28, n = 932, p < 0.001, one-way ANOVA). Quantifying ECS by deconvolution supports a transcriptomics-driven approach towards the non-invasive evaluation of endothelial damage in respiratory outcomes. This is a first step towards elucidating mechanistic components linking endothelial damage to ARDS utilizing non-invasive, circulating transcriptomic data by leveraging a novel deconvolution approach.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"40 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145283524","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":"Computed tomography image quality with high-flow contrast via high-pressure central venous catheter in critically ill patients","authors":"Emmanuelle Gentil, Quentin de Roux, Solène Ribot, Lucien Lapeyre, Victor PalombI, Alain Luciani, Christophe Quesnel, Vania Tacher, Nicolas Mongardon","doi":"10.1186/s13054-025-05673-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05673-4","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;Contrast-enhanced computed tomography (CECT) is a key diagnostic procedure in critically ill patients, in whom contrast media (CM) is injected most of the time through central venous catheter (CVC). The quality of contrast enhancement relies on patient-dependent (cardiac output, weight and size) or patient-independent (technology of CT-scan, type of catheter, site of injection, CM volume, and injection rate) factors [1]. Injection rate is a crucial parameter of contrast enhancement, but is limited by the intrinsic quality of the venous access, with risks of displacement, ballooning, rupture and contrast extravasation in case of high-pressure (HP) or high-flow rate [2]. While standard CVC allow injection rate up to 5 mL/sec, manufacturers do not recommend to use them for pressure injection [3]. Thus, CVCs allowing higher pressures and flow rates have been recently designed [4]. This could improve the image quality of CECT, or reduce CM volume for similar quality, thereby reducing the risk of contrast-induced acute kidney injury and minimizing environmental impact. However, the interest of CM injection at high-flow through HP CVC has never been investigated. Here we report on the objective image quality of CECT images obtained with CM injected at high-flow rate through HP CVC versus standard flow rates through standard CVC. All critically ill adult patients with superior vena cava CVC requiring thoracic and/or abdominal CECT were analyzed. Before September 2023 (retrospective/before period), standard CVC were used (references: CV-12703, CV-15703, CV-12854, CV-15854, Arrow&lt;sup&gt;®&lt;/sup&gt;/Teleflex&lt;sup&gt;®&lt;/sup&gt;). After September 2023 (prospective/after period), HP CVC were used (references: EU-42854-HPS, EU-45854-HPS, Arrow&lt;sup&gt;®&lt;/sup&gt;/Teleflex&lt;sup&gt;®&lt;/sup&gt;). Patients on ECMO or requiring isolated head CT-scan were excluded. Except flow rate, all CT-scans with CM injection were performed according to the same protocol. CM injection was performed with the device Bracco Injeneering SA&lt;sup&gt;®&lt;/sup&gt; (650197 CT Expres™ - Control Panel). Monoergenetic CT acquisitions were performed with CT device (Revolution CT Apex Elite, General Electric Medical Systems&lt;sup&gt;®&lt;/sup&gt;). The injection sequence was 10 mL of isotonic saline, CM injection with volume set at 1 mL/kg, and purge of 20 mL of isotonic saline at the same flow rate. In the standard CVC group, the flow rate was set of 3.5 mL/s, with injection through the 16-gauge distal lumen; in the HP CVC group, the flow rate was set at 10 mL/s, with injection through the dedicated 14-gauge medial lumen. Image quality was assessed based on combination of aortic and liver Signal-to-Noise Ratio (SNR) and Contrast-to-Noise Ratio (CNR) at arterial and portal time at the level of coeliac trunk in aorta and in liver, with blind analysis by a senior radiologist. Briefly, the SNR quantifies the strength of a signal relative to the background noise. It is calculated by dividing the mean signal intensity by the ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"37 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145283526","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":"Optimal antibiotic use in the intensive care unit","authors":"Scott T. Micek, M. Cristina Vazquez Guillamet, Daniel Reynolds, Sarah Matuszak, Lauren Kolodziej, Marin H. Kollef","doi":"10.1186/s13054-025-05653-8","DOIUrl":"https://doi.org/10.1186/s13054-025-05653-8","url":null,"abstract":"Antibiotic resistance has emerged as one of the most important factors influencing the outcomes of patients with life-threatening infections in the ICU. The increasing prevalence of antibiotic-resistant infections globally highlights the importance of this issue for all intensivists. Antibiotic utilization in the ICU should be optimized to ensure that timely appropriate treatment is administered in a way that minimizes the subsequent emergence of antibiotic resistance. Antibiotic strategies have been developed to assist clinicians in achieving this important balance. Familiarity with local ICU pathogens and their antibiotic susceptibilities is at the forefront of optimizing ICU antibiotic practices. Moreover, timely antibiotic administration along with pharmacokinetic/pharmacodynamic (PK/PD) optimization, including ideal dosing and infusion duration, should be key components of all ICU antibiotic strategies. Microbiologic testing to include conventional pathogen identification and susceptibility testing as well as use of microbiologic rapid diagnostic tests can confirm the antibiotic regimen that is required to treat the causative pathogens while allowing de-escalation to occur if possible. Similarly, biomarkers such as procalcitonin can aid with avoiding unnecessary antibiotic use in the ICU and shortening their overall duration. ICUs should routinely employ formal programs for reviewing and optimizing antibiotic practices. These programs can include directed input from pharmacists and microbiologists during ICU rounds, the use of specialized order sets focusing on duration of treatment with stop as well as dosing optimization guidance, use of computerized decision support tools, incorporated protocols for the prevention of nosocomial infections, and the appropriate use of antibiotic prophylaxis regimens to include selective digestive decontamination (SDD). Tracking antibiotic practices in the ICU, as well as changing patterns of pathogens and antibiotic susceptibilities, mandate regular modification and updating of these practices over time. Antibiotic combination regimens can also be employed in some circumstances to increase the likelihood of treatment success with an appropriate initial regimen while also reducing the propensity for resistance emergence. Additionally artificial intelligence/machine learning (AI/ML) methods will increasingly serve to enhance antibiotic decision making in the future. Antibiotic optimization strategies in the ICU should routinely be employed by a multi-specialty group including intensivists, microbiologists, pharmacists, infectious disease specialists, and infection control practitioners. Regular review and updating of ICU antibiotic practices will help to safeguard their long-term use to optimize patient outcomes while minimizing resistance emergence.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145283520","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":"Antibiotic therapy in necrotizing soft tissue infections: a narrative review of the greater Paris SURFAST consortium","authors":"Caroline Charlier, Bérénice Souhail, Stéphane Dauger, Paul-Louis Woerther, Alexandre Bleibtreu, Marion Caseris, Olivier Chosidow, Chloé Bertolus, Camille Hua, Gentiane Monsel, Asmaa Tazi, Tomas Urbina, Benjamin Vérillaud, Philippe Montravers, Raphaël Lepeule, Nicolas de Prost","doi":"10.1186/s13054-025-05664-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05664-5","url":null,"abstract":"Necrotizing soft tissue infections (NSTIs) are uncommon, yet rapidly progressive and potentially fatal conditions. However, evidence-based guidance on antibiotic therapy remains limited. Current recommendations emphasize the need for broad-spectrum empirical coverage, including gram-positive, gram-negative, anaerobes, and Streptococcus pyogenes when clinically indicated. We aimed at developing a practical, evidence-based framework for empirical antibiotic therapy in NSTIs. This narrative review is informed by a comprehensive literature search of PubMed, without date restrictions. We propose a structured decision-making algorithm for empirical antibiotic selection in NSTIs, integrating key clinical parameters: infection site, healthcare-associated versus community-acquired origin, risk factors for extended-spectrum β-lactamase-producing Enterobacterales and methicillin-resistant Staphylococcus aureus, and signs of sepsis or septic shock. Alternative regimens are provided for patients with severe β-lactam allergies. Special considerations for immunocompromised and other vulnerable host populations are also addressed. This review offers clinicians a pragmatic, stepwise approach to antibiotic therapy in NSTIs, while identifying critical knowledge gaps and priorities for future research. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"9 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145255594","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":"Tailored strategy for managing post-cardiac-arrest patients using an early stratification tool: a French university hospital experience","authors":"Clotilde Bachollet, Alain Cariou, Hélène Caillon, Emmanuel Canet, Jean-Baptiste Lascarrou","doi":"10.1186/s13054-025-05667-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05667-2","url":null,"abstract":"&lt;p&gt;To the Editor,&lt;/p&gt;&lt;p&gt;For patients who remain comatose after cardiac arrest and return of spontaneous circulation (ROSC), the benefits and indications of sedatives and hypothermia remain unclear. The latest guidelines recommend continuous core-temperature monitoring and active fever (&gt;37.7 °C) prevention for at least 72 h [1], with no adjustments according to the severity of hypoxic-ischemic brain injury (HIBI) at ICU admission. Short-acting sedatives and opioids are also recommended, but the optimal depth and duration of sedation is unknown. Conceivably, patients with limited HIBI may be unlikely to require hypothermia or prolonged sedation [2], two treatments that prolong the ICU stay. Tools designed for early HIBI assessment are available but rarely used [3]. One such tool is the modified Cardiac Arrest Hospital Prognosis (mCAHP) score [4, 5], whose accuracy has been validated in an external study [3].&lt;/p&gt;&lt;p&gt;Since January 2024, we routinely determine the mCAHP score immediately at ICU admission. Among patients admitted after cardiac arrest in a shockable rhythm, we compared those admitted during the 14 months before vs. the 14 months after this protocol change. All patients received controlled normothermia using the Medi-Therm III device (Gaymarc, NYC, NY). During the before period, all patients were given continuous sedation targeting a Richmond Agitation Sedation Scale (RASS) score of −4. During the after period, this sedation strategy was applied only in those patients whose mCAHP score was ≥ 80, indicating moderate-to-severe HIBI. The other patients had their sedation stopped early (Figure 1). Data collection was prospective, as part of a different study (NCT05606809).&lt;/p&gt;&lt;p&gt;Continuous data were described as mean ± SD or median [inter-quartile range], depending on distribution, and categorical data as number (percentage). Continuous variables were compared by applying Student’s &lt;i&gt;t&lt;/i&gt; test, the Mann–Whitney U test, or the Kruskal-Wallis test, as appropriate, and categorical variables using the Chi2 test or Fisher’s test, as appropriate. &lt;i&gt;P&lt;/i&gt; values &lt; 0.05 were considered significant. Given the exploratory nature of the study, no adjustment for multiple testing was performed.&lt;/p&gt;&lt;p&gt;We included 36 patients during the before period and 34 during the after period (eFigure 1). Three patients in the after period were managed with hypothermia at 33° due to suspected severe HIBI (mCAHP = 81, 102 and 116). We found no significant differences between the two groups regarding patient and cardiac-arrest characteristics, resuscitation modalities, proportion of patients with a presumed cardiac cause, mechanical ventilation duration, ICU length of stay, ICU survival, or favorable outcome on day 90 defined as a modified Rankin scale score of 0 to 3 (eTable 1).&lt;/p&gt;&lt;p&gt;When we compared the patients in the after period whose mCAHP score was &lt; 80 vs. ≥80, we found that the latter were older (&lt;i&gt;P&lt;/i&gt; = 0.03), had a longer low-flow duration (&lt;i","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"84 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145246569","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}