Critical Care最新文献

{"title":"Sex differences in sepsis outcomes across the lifespan: a population-based cohort study in Germany","authors":"Norman Rose, Islam Agrama, Irit Nachtigall, Mathias W. Pletz, Jenny Rosendahl, Ha-Yeun Chung, Christina E. Zielinski, Diana Dudziak, Melissa Spoden, Patrik Dröge, Stefan Hagel, Carolin Fleischmann-Struzek","doi":"10.1186/s13054-025-05657-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05657-4","url":null,"abstract":"Sepsis is a major global health concern influenced by both biological sex and socially constructed gender roles, which can affect disease susceptibility, progression, treatment and outcomes. Evidence on sex-specific differences in sepsis often lacks age-specific analysis, despite known interactions between sex, age, and immune function. We aimed to investigate age-dependent associations between sex and mortality as well as long-term outcomes among sepsis survivors after hospitalization. This retrospective, population-based cohort study based on nationwide health claims data from 2009 to 2017 of 23.0 million beneficiaries of a large German health insurance provider. Patients aged 15 years and older with incident hospital-treated sepsis identified by ICD-10-GM codes in 2013 to 2014 were included. Female and male sex. Differences in 12-months mortality, medical, psychological and cognitive diagnoses, as well as dependency on nursing care by sex and age were analyzed using generalized additive models including sex*age interaction effects. We report average marginal effects (AME) for sex and age as estimates of the adjusted marginal increase or decrease of the event rate of outcomes. We included 159,684 sepsis patients in 2013/2014, of which 75,809 (47.5%) were female and 83,875 (52.5%) were male. The average marginal hospital and 12-months mortality over the observed age distribution was AME = − 2.8% (95% CI, − 3.2%, − 2.3%, P < .001) and AME = − 5.4% (95% CI, − 5.9%, − 4.9%, P < .001) lower in females, respectively. Significant female survival benefits were predominantly found beyond age 44 (hospital mortality) and age 47 (12-months mortality). Females were also less often affected by cognitive impairments, but more often experienced psychological and physical impairments as well as nursing care dependency with differential associations observable across the lifespan. Sepsis long-term outcomes appear to be influenced by a complex interaction between age and sex. While our study focuses on these factors, it is important to acknowledge that observed associations cannot be attributed to biological sex alone, as numerous additional factors - directly or indirectly related to sex- may also contribute. These findings underscore the importance of incorporating sex-specific considerations into sepsis care and post-acute support strategies to improve long-term outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"21 1","pages":"408"},"PeriodicalIF":15.1,"publicationDate":"2025-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145154106","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":"Clinical and biological profiles associated with the time of occurrence of citrate accumulation in patients receiving continuous renal replacement therapy","authors":"Frank Bidar, Nicolas Chardon, Quentin Darnajoux, Matthieu Petit, Jean-Luc Fellahi, Frederic Aubrun, Laurent Argaud, Jean-Christophe Richard, Frederic Dailler, Florent Wallet, Thomas Rimmelé","doi":"10.1186/s13054-025-05648-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05648-5","url":null,"abstract":"Citrate accumulation (CA) is a feared complication in critically ill patients undergoing regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT). This study aimed to describe the characteristics of patients presenting CA within a large cohort of unselected critically ill patients receiving RCA-CRRT depending on the time of occurrence of CA after CRRT initiation. This retrospective, multicenter observational study performed in nine intensive care units (ICU) in Lyon, France, included patients treated with RCA-CRRT between January 2020 and January 2022. CA was defined by a total to ionized calcium ratio (tCa/iCa) ≥ 2.3 associated with hypocalcemia and metabolic acidosis. Among 2080 patients, 76 (3.7%) developed CA: 69 (91%) experienced CA within 24 h after CRRT initiation (initial CA) and 7 (9%) after 24 h (late-onset CA). Only lactate levels at CRRT initiation differed between patients with initial CA and those with late-onset CA (10 mmol/l [4.6–16] vs 1.4 mmol/l [1–3.8], p = 0.006 respectively). In the initial CA group, 39 (57%) exhibited signs of CA within 6 h or less (immediate CA) and 30 (43%) showed signs of CA between 6 and 24 h. Over the first 24 h, patients with initial CA presented a marked increase in lactate levels, worsening norepinephrine requirements, persistent elevation of the tCa/iCa ratio, decrease in prothrombin time, and increase in transaminases. Patients with immediate CA showed higher lactate concentration and more severe metabolic acidosis at CRRT initiation compared to patients with early CA whereas other markers did not differ significantly between the two groups. The area under the Receiver Operating Characteristic curve of lactate and pH for predicting immediate citrate accumulation were 0.75 [0.62 – 0.87] and 0.74 [0.62 – 0.85] respectively, with optimal cutoff values of 10.6 mmol/L and 7.14 respectively. The ICU mortality rate among patients with CA was 97% compared to 55% in the whole cohort. CA is a rare phenomenon in patients under RCA-CRRT. Severe metabolic acidosis with hyperlactatemia at CRRT initiation is the most relevant marker to identify patients at risk of immediate CA and should encourage close monitoring of tCa/iCa ratio.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"21 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145141548","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":"Oropharyngeal ultrafast ultrasound measurements in mechanically ventilated critically ill patients do not identify post-extubation stridor","authors":"Margaux Machefert, Guillaume Prieur, Carlos Díaz López, Claire Dubois, Guillaume Schnell, Elise Artaud-Macari, Bouchra Lamia, Yann Combret, Clément Medrinal","doi":"10.1186/s13054-025-05659-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05659-2","url":null,"abstract":"Post-extubation stridor is a common complication of endotracheal intubation in ICU. This study aimed to assess whether a series of pre-extubation upper airway ultrasound measurements using shear wave elastography (SWE) could help in detecting post-extubation stridor. A prospective observational study (NCT05611437) was conducted between 2022 and 2024, which consecutively included 150 adults ICU patients intubated for more than 24 h, without prior surgical or neurological upper airway disease nor swallowing disorders. SWE measurements were performed in the 24 h before extubation. The occurrence of post-extubation stridor, dysphonia and swallowing disorders were assessed within 72 h. 125 participants were included in the final analysis. A total of 2,625 ultrasound images were obtained, with 81% deemed interpretable. Post-extubation stridor occurred in 9% of patients and was independently associated with sepsis at admission (OR 8.98; 95%CI 1.3–62.1). No differences were observed between upper airway ultrasound in patients with or without stridor. Stridor was associated with higher rates of dysphonia (82% vs. 23%), swallowing disorders (36% vs. 11%), and extubation failure (46% vs. 10%). Swallowing disorders were independently associated with the duration of mechanical ventilation (OR 1.10; 95% CI 1.04–1.17). Dysphonia was associated with female sex (OR 3.23; 95%CI 1.24–8.37), sternothyroid muscle stiffness (OR 1.11; 95%CI 1.04–1.18), and days of mechanical ventilation (OR 1.09; 95%CI 1.02–1.15). Oropharyngeal SWE is feasible in critically ill patients before extubation, but was not predictive of post-extubation stridor. Further studies are needed to explore its role in predicting post-extubation upper airway complications.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"57 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133639","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":"Use of a molecular syndromic panel for the etiological diagnosis of ventilator-associated bacterial pneumonia: impact on clinical outcomes and antibiotic use from a multicenter, prospective study","authors":"Daniele Roberto Giacobbe, Greta Cattardico, Claudia Bartalucci, Vincenzo Di Pilato, Marco Muccio, Alessandro Limongelli, Alessio Signori, Alessandra Bandera, Bruno Cacopardo, Edoardo Campanella, Alessandro Caroli, Annamaria Cattelan, Marta Colaneri, Andrea Cortegiani, Laura Curci, Gennaro De Pascale, Giuseppe Vittorio De Socio, Filippo Del Puente, Antonino Di Fede, Chiara Fanelli, Nicholas Geremia, Maddalena Giannella, Giacomo Grasselli, Chiara Maci, Ivana Maida, Davide Mangioni, Andrea Marino, Maria Mazzitelli, Maria Chiara Meloni, Marco Merli, Elena Momesso, Chiara Oltolini, Carlo Pallotto, Sandro Panese, Matteo Passerini, Emanuele Pontali, Daniele Riccucci, Matteo Rinaldi, Marco Ripa, Vincenzo Scaglione, Francesco Saverio Serino, Vincenzo Spagnuolo, Giulia Spurio, Stefania Tigano, Carlo Torti, Giovanna Travi, Laura Magnasco, Federica Portunato, Federica Briano, Malgorzata Mikulska, Lorenzo Ball, Chiara Robba, Nicolò Patroniti, Denise Battaglini, Mauro Giacomini, Gian Maria..","doi":"10.1186/s13054-025-05632-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05632-z","url":null,"abstract":"Ventilator-associated bacterial pneumonia (VABP) is a common infection in critically ill patients in intensive care units (ICU), with attributable mortality of up to 13%, and its etiological diagnosis remains challenging. We conducted a multicenter, prospective, observational study within the MULTI-SITA platform to assess the impact on relevant clinical and antimicrobial stewardship outcomes of the use of a molecular syndromic panel (BIOFIRE® FILMARRAY® Pneumonia plus), in addition to a standard approach based on culture. The primary outcome measure was 30-day mortality from VABP onset. Overall, 237 patients with VABP were included in the study. In multivariable analysis, SOFA score (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.04–1.22, p = 0.003), previous isolation of carbapenem-resistant Pseudomonas aeruginosa (HR 3.02, 95% CI 1.25–7.32, p = 0.015), and solid neoplasm (HR 2.15, 95% CI 1.12–4.14, p = 0.022) were associated with increased mortality, while no association was registered for the molecular syndromic panel performed (HR 1.07, 95% CI 0.59–1.93, p = 0.825). In secondary analyses, use of the molecular syndromic panel resulted in more events of either de-escalation or initiation of appropriate antibiotic therapy at day 1 from VABP onset in comparison with a standard approach based on culture only (41.3% vs. 27.8%, p = 0.041). The use of a molecular syndromic panel in patients with VABP was able to impact antibiotic decisions, without an unfavorable effect on mortality. Further study is necessary to assess the long-term effects in terms of antimicrobial stewardship of molecular syndromic panels-based antibiotic treatment decisions.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"59 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133650","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":"Reply to: “eCPR challenge: navigating the fine line between life and burden”","authors":"Masahiro Kashiura, Yuki Kishihara, Hiroyuki Tamura, Shunsuke Amagasa, Hideto Yasuda, Takashi Moriya","doi":"10.1186/s13054-025-05658-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05658-3","url":null,"abstract":"&lt;p&gt;To the editor,&lt;/p&gt;&lt;p&gt;We appreciate Rajsic and Breitkopf [1] for their thoughtful commentary on our recent article describing sub-phenotypes in patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR) [2]. We fully agree with their central point that neurologically favorable survival must be the primary outcome of interest when evaluating ECPR. Indeed, as we reported, one-month neurological outcome, defined by the cerebral performance category (CPC), was included as a secondary endpoint in our analysis. Our findings showed that only a minority of patients achieved favorable neurological recovery, underscoring the importance of refining patient selection.&lt;/p&gt;&lt;p&gt;Several recent studies provide additional perspective on the long-term outcomes of ECPR. In the INCEPTION randomized trial, favorable neurological survival at 30 days was 20% in the ECPR group compared with 16% in the conventional CPR group, with no significant difference between arms. Six-month outcomes were similar, with 20% maintaining good neurological function [3]. A large meta-analysis reported overall survival of 29% and favorable neurological outcomes in 24% of ECPR patients [4]. More encouragingly, long-term follow-up data indicate that approximately one in five patients achieve one-year survival with preserved cardiac function and independence, with many returning to meaningful daily life [5, 6]. These results suggest that, while early mortality is common, carefully selected patients can achieve durable neurological and functional recovery.&lt;/p&gt;&lt;p&gt;Our study differs from prior investigations by focusing on latent sub-phenotypes. We demonstrated that ECPR outcomes are not uniform: the “standard eCPR” group achieved a survival of nearly 27%, while other subgroups had far lower rates [2]. This heterogeneity may partly explain discrepancies between registries and trials. In Japan, there is concern that ECPR may be applied too liberally, potentially exposing patients with limited potential for recovery to invasive interventions and prolonged intensive care. Identifying favorable sub-phenotypes therefore represents an important step toward defining which patients are most likely to benefit.&lt;/p&gt;&lt;p&gt;Nonetheless, we acknowledge that the concerns highlighted in the commentary—ethical dilemmas, socioeconomic burden, and the emotional toll on families—cannot be dismissed. Initiation of ECPR is usually undertaken without explicit patient consent, and the resulting outcomes may not align with individual values. Families are often left to face not only the decision of life-sustaining treatment withdrawal but also long-term caregiving responsibilities, which may impose profound psychological and financial strain. These realities remind us that survival alone is insufficient as a benchmark for success.&lt;/p&gt;&lt;p&gt;In conclusion, we appreciate the opportunity to respond to these important reflections. We agree that future research must extend be","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"35 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133652","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":"Temporal dimensions of oxygen saturation exposure and clinical outcomes in critically ill patients: a retrospective multi-database cohort study","authors":"Xiao-Yan Ding, Hai-Ping Xu, Jing-Ru Zhang, Han Chen","doi":"10.1186/s13054-025-05652-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05652-9","url":null,"abstract":"Most studies on SpO2 exposure patterns focus solely on SpO2 intensity and neglect exposure duration. We systematically investigated the associations between SpO2 exposure patterns and clinical outcomes from both intensity and temporal dimensions in critically ill patients. In this retrospective cohort study, 121,758 critically ill patients were analyzed. The patient data were obtained from three databases: SICdb (n = 11,324) for continuous exposure analysis using heatmaps, MIMIC-IV (n = 50,110) for cumulative exposure analysis, and eICU (n = 60,324) for validation. We examined the relationships between SpO2 exposure and 28-day mortality using Cox regression and logistic regression models. Restricted cubic spline analysis was performed using time-weighted SpO2 as a continuous variable to examine the continuous association between SpO2 values and mortality risk. Both analytical approaches revealed a U-shaped relationship between SpO2 and mortality. Heatmap analysis revealed a SpO2 of 93.5–97% as optimal, whereas Cox regression showed that a SpO2 of 96–97% conferred the strongest protection (HR 0.714, 95% CI 0.694–0.733; P < 0.001). Prolonged exposure to SpO2 > 98% had a diminishing effect, whereas SpO2 < 93.5% increased mortality risk (HR 1.236, P < 0.001). External validation confirmed these findings (AUC 0.813). Our study confirms a U-shaped relationship between SpO2 and outcomes, emphasizing that oxygenation assessments should consider both intensity and duration. A prolonged SpO2 above 98% or below 94% should be avoided in critically ill patients.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133651","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":"A soleful insight: shoe dislocation as a marker for severe injuries in car accident victims","authors":"Shaoyang Zhang, Jueyue Yan, Zhipeng Xu","doi":"10.1186/s13054-025-05650-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05650-x","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;In trauma care practice, we have observed that patients whose shoes are detached at the scene of a car accident often suffer severe injuries and have poorer prognoses. This suggests that shoe dislocation at the accident site may serve as a simple, rapid indicator for assessing injury severity. The underlying mechanism may involve force transmission through the feet and ankles during impact, causing shoes to be ejected while significant stress is applied to deeper tissues, resulting in serious internal injuries.&lt;/p&gt;&lt;p&gt;Typically, car accident injuries are initially assessed based on vital signs, visible wounds, and consciousness levels. However, patients with minor surface injuries may later present with hidden severe conditions such as intracranial bleeding, organ rupture, or spinal fractures (Fig. 1 A). Shoe dislodgment could act as a critical visual clue indicating a higher injury magnitude, suggesting deeper anatomical involvement, including damage to vital organs and the central nervous system.&lt;/p&gt;&lt;p&gt;As illustrated in Fig. 1B, we retrospectively analyzed 326 consecutive trauma patients—specifically pedestrians, cyclists, or scooter riders who were struck by motor vehicles and admitted to our trauma center between 2022 and 2024. Only patients with clearly documented shoe status in prehospital or emergency records were included to ensure data reliability. Among them, 61 patients (18.7%) had at least one shoe dislodged at the scene.Compared with those whose shoes remained intact, the shoe-dislocation group had significantly higher Injury Severity Scores (mean ± SD: 26.9 ± 9.8 vs. 14.2 ± 7.5, &lt;i&gt;p&lt;/i&gt; &lt; 0.001). They also had higher incidences of severe traumatic brain injury (GCS ≤ 8: 29.5% vs. 10.3%, &lt;i&gt;p&lt;/i&gt; &lt; 0.001), pelvic/lower extremity fractures (52.5% vs. 21.6%, &lt;i&gt;p&lt;/i&gt; &lt; 0.001), and multisystem involvement (72.1% vs. 31.8%, &lt;i&gt;p&lt;/i&gt; &lt; 0.001). These associations support the hypothesis that shoe dislocation correlates with severe trauma and can help prioritize patients for advanced care.&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05650-x/MediaObjects/13054_2025_5650_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"363\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05650-x/MediaObjects/13054_2025_5650_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;Shoe dislocation as an indicator of injury severity in motor vehicle collisions. (&lt;b&gt;A&lt;/b&gt;) Trauma patient with shoe dislocation indicating severe internal injuries. (&lt;b&gt;B&lt;/b&gt;) Comparison of outcomes in shoe dislocation (&lt;i&gt;n&lt;/i&gt; = 61) vs. no dislocation (&lt;i&gt;n&lt;/i&gt; = 265) groups post-MVC. Shoe dislocation group had higher ISS, traumatic brain injury, fractures, multi-system involvement, longer ICU stays, higher ventilation rates,","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"2 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133654","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":"Assessing risk of respiratory depression following initial phenobarbital loading for severe alcohol withdrawal syndrome","authors":"Amy Suhotliv, Alexander Miller, Jovanpreet Singh, Kristine Torres-Lockhart, Maria Sanchez Carriel, Amira Mohamed, Daniel G. Fein, Ari Moskowitz, Veronika Blinder","doi":"10.1186/s13054-025-05661-8","DOIUrl":"https://doi.org/10.1186/s13054-025-05661-8","url":null,"abstract":"&lt;p&gt;Severe alcohol withdrawal syndrome is a common cause of intensive care unit admission [1]. First-line treatment usually involves benzodiazepines [2], but phenobarbital has resurfaced as an alternative, with its use increasing across hospitals [3]. Prior evidence suggests phenobarbital may reduce the likelihood of mechanical ventilation and possibly shorten hospital length of stay [3]. Despite this, concerns about respiratory depression have limited its administration to emergency departments and ICUs [4]. Patients are often initially managed on hospital wards with benzodiazepines or transferred to an ICU for phenobarbital loading, even though the actual risk of acute respiratory compromise in this setting has not been well described. We sought to share our experience with phenobarbital loading and to examine how often respiratory deterioration occurred in the 24 h that followed, the period of highest exposure and therefore greatest potential risk.&lt;/p&gt;&lt;p&gt;Beginning in mid-2021, our center in the Bronx implemented a protocol that included phenobarbital for selected cases of alcohol withdrawal. Over the following two and a half years, 82 patients received a phenobarbital load, defined as a dose of at least 7 mg/kg. Twenty-five were already receiving invasive mechanical ventilation at the time of administration, leaving 57 who were not ventilated and who form the basis of this report. Of these, 50 patients (87.7%) required no respiratory support at baseline, 4 (7.0%) were receiving oxygen via nasal cannula or facemask, and 3 (5.3%) were on non-invasive support. The subsequent 24 h were examined for any increase in respiratory support, ranging from new oxygen supplementation to intubation.&lt;/p&gt;&lt;p&gt;Six patients (10.5%) experienced an escalation of respiratory support within 24 h of phenobarbital loading [Fig. 1]. Five were intubated within the first six hours and one at nine hours. Three of the intubations were due to persistent withdrawal symptoms that remained uncontrolled, one was for seizures, and one was for gastrointestinal bleeding requiring endoscopy. Only a single patient appeared to experience a respiratory event plausibly related to phenobarbital. This individual had already aspirated during a seizure and required high oxygen support before receiving the medication. They had also received levetiracetam and benzodiazepines in the hours prior. After the load, worsening hypoxia and hypercapnia necessitated intubation. Another patient required 2 L nasal cannula after the load, but this was attributed to pleural effusion rather than sedative effect. Notably, all patients who required increased support had received phenobarbital doses between 9.5 and 14.2 mg/kg, whereas those who remained stable received doses spanning 7.1 to 28.6 mg/kg, with an average of 14.7 mg/kg.&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs1305","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"83 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133658","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":"Restrictive fluid management with early de-escalation versus usual care in critically ill patients (reduce trial): a feasibility randomized controlled trial","authors":"Thummaporn Naorungroj, Ukrit Prajantasen, Tewa Sanla-ead, Tanuwong Viarasilpa, Surat Tongyoo","doi":"10.1186/s13054-025-05624-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05624-z","url":null,"abstract":"Optimal fluid management in critically ill patients varies across different phases of care. This study examined the feasibility of adding a restrictive fluid strategy with early de-escalation to standard care for patients with circulatory shock. We performed a single-center, feasibility, randomized controlled trial, involving patients with shock who required fluid resuscitation and were admitted in the medical intensive care unit. After initial fluid resuscitation, patients were randomly assigned (1:1) to either a restrictive fluid strategy or usual care. The restrictive group targeted a near-zero fluid balance over 3 days by limiting fluid intake and using diuretics or mechanical fluid removal when needed. The primary outcome was cumulative fluid balance at day 3. The secondary outcomes were the lengths of stay in the intensive care unit and the hospital, the mechanical ventilation duration, acute kidney injury, renal replacement therapy, and mortality. We enrolled 100 patients, assigning 50 to the restrictive strategy and 50 to usual care. By day 3, the restrictive group showed a lower cumulative fluid balance than usual care (‒2353 mL vs. 793 mL, p < 0.001). This trend continued to day 7 (‒3032 mL vs. 1125 mL, p < 0.001). The restrictive group also had shorter stays in the intensive care unit and the hospital (7 vs. 10 days, p = 0.006; 16 vs. 22 days, p = 0.02). There were no statistically significant differences in hospital or 30-day mortality rates between the groups (18% vs. 38%, p = 0.05; 12% vs. 30%, p = 0.05, respectively). Similarly, no significant differences were observed in the incidence of acute kidney injury or the use of renal replacement therapy. A restrictive fluid strategy with early de-escalation and de-resuscitation is feasible and may reduce fluid accumulation and showed a signal for reduced hospital stay without increasing adverse events in critically ill patients following acute fluid resuscitation. TCTR20220719002 (The trial has been reviewed and approved by TCTR committee on July 16th, 2022). A restrictive fluid strategy that employs a protocol-based intervention to achieve a target fluid balance after initial resuscitation in patients with sepsis appears feasible, does not increase harm, and may improve outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"12 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133606","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":"Outcomes of transplant recipients on ECMO for COVID-19 respiratory failure: an ELSO registry study","authors":"Marijke Peetermans, Alexandre Bohyn, Philippe Meersseman, Alexander Wilmer, Joost Wauters, Bart Meyns, Matthias Lubnow, Ann Belmans, Thomas Müller, Alexander P.J. Vlaar, Alain Combes, Greet Hermans","doi":"10.1186/s13054-025-05636-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05636-9","url":null,"abstract":"ECMO outcomes in COVID-19-related respiratory failure among solid organ transplant (SOT) and hematopoietic stem-cell transplant recipients (HSCT) are poorly described. We investigated: (1) whether transplant patients (SOT/HSCT) with COVID-19 have worse outcomes than non-immunocompromised (IC) COVID-19 patients, and (2) whether among transplant recipients (SOT/HSCT), those with COVID-19 have worse outcomes than those with non-COVID-19-related respiratory failure. Additionally, we aimed to identify factors independently associated with mortality among COVID-19 transplants. Retrospective analyses of the Extracorporeal Life Support Organization Registry from 1/1/2017 to 31/07/2023. Two comparisons were made: (1) transplant COVID-19 versus non-IC COVID-19, and (2) transplant COVID-19 versus transplant non-COVID-19 patients. Outcomes were analyzed using propensity score (PS)-adjusted, multivariable, and PS-matched analyses, adjusting for a priori identified confounders. Primary outcome was in-hospital mortality. Among 38,270 runs, 146 transplant COVID-19, 12,552 non-IC-COVID-19 and 886 transplant non-COVID-19 runs were identified. In-hospital mortality in transplant COVID-19 patients was 75.3% and the risk was invariably increased compared to non-IC-COVID-19 (PS-adjusted OR: 2.36 [95%CI:1.61–3.46], p < 0.001, multivariable OR:2.35 [95%CI:1.59–3.49], p < 0.001, and PS-matched analysis OR: 1.89 [95%CI:1.21–2.95], p < 0.005) and transplant non-COVID-19 patients (PS-adjusted OR: 4.20 [95%CI:2.74–6.44], p < 0.001, multivariable OR: 3.79 [95%CI:2.51–5.74], p < 0.001, and PS-matched analyses OR: 3.17 [95%CI:1.90–5.28], p < 0.001). Mortality difference remained stable over time. Older age independently associated with higher mortality. This was accompanied by higher need for renal replacement therapy compared to non-IC-COVID-19 patients. Compared to transplant non-COVID-19 patients, ECMO runs and time-to-live discharge were invariably prolonged. Hemorrhagic, metabolic, pulmonary and infectious complications consistently occurred more frequently. Mortality was high in COVID-19 transplant ECMO patients, warranting cautious use of ECMO in this population.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145133653","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}