Critical Care最新文献

{"title":"Length of hospital and intensive care unit stay in patients with invasive candidiasis and/or candidemia treated with rezafungin: a pooled analysis of two randomised controlled trials","authors":"Patrick M. Honoré, Matteo Bassetti, Oliver A. Cornely, Herve Dupont, Jesús Fortún, Marin H. Kollef, Peter Pappas, John Pullman, Jose Vazquez, Inga Bielicka, Sara Dickerson, Nick Manamley, Taylor Sandison, George R. Thompson","doi":"10.1186/s13054-024-05152-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05152-2","url":null,"abstract":"Invasive candidiasis/candidemia (IC/C) is associated with a substantial health economic burden driven primarily by prolonged hospital stay. The once-weekly IV echinocandin, rezafungin acetate, has demonstrated non-inferiority to caspofungin in the treatment of IC/C. This paper reports a post hoc pooled exploratory analysis of length of stay (LoS) for hospital and intensive care unit (ICU) stays in two previously published clinical trials (ReSTORE [NCT03667690] and STRIVE [NCT02734862], that compared rezafungin with daily IV caspofungin (stable patients in the caspofungin group who met relevant criteria could step down to fluconazole after 3 days or more). LoS outcomes were analysed descriptively in the pooled modified intention to treat (mITT) population (all patients who had a documented Candida infection in line with trial requirements and received at least one dose of study drug). In addition, to adjust for an imbalance between treatment groups in the proportion receiving mechanical ventilation at baseline, a generalised linear model with mechanical ventilation as a binary covariate was applied. Responses to an exploratory question in the phase 3 trial on possible earlier discharge with weekly rezafungin are also reported. 294 patients were included (rezafungin 139, caspofungin 155), of whom 126 (43%) had ICU admission. Patients treated with rezafungin had a numerically shorter LoS than with caspofungin in all analyses. Mean total LoS was 25.2 days, vs 28.3 days with caspofungin, and mean ICU LoS was 16.1 vs 21.6 days for rezafungin and caspofungin, respectively. After adjustment for mechanical ventilation status the difference in ICU LoS was 4.1 days, a relative difference of 24% (95% CI -11%, 72%). Physicians would have considered earlier discharge for 16% of patients (30/187) with weekly rezafungin, an average of 5–6 days earlier. Rezafungin may enable shorter hospital and ICU LoS in IC/C compared with daily IV caspofungin, with accompanying savings in resource use. Further research is needed to confirm this in the real-world setting. Trial registration. NCT03667690 (ReSTORE; September 12, 2018); NCT02734862 (STRIVE; April 12, 2016).","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"10 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598471","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":"Epidemiology of β-blocker use among critically iII patients during and after septic shock","authors":"Stuthi Iyer, Jason N. Kennedy, Peter C. Nauka, Mourad H. Senussi, Christopher W. Seymour","doi":"10.1186/s13054-024-05145-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05145-1","url":null,"abstract":"<p>β-Blockers are used widely in the outpatient care of chronic disease, but less is known about how to restart chronic therapy during and after hospitalization for septic shock [1, 2]. We sought to characterize the epidemiology of β-blocker treatment during and after septic shock among patients administered chronic β-blocker therapy in the year prior to hospitalization [3].</p><p>We studied patients who received outpatient β-blocker therapy in the 12 months prior to hospitalization at 12 UPMC hospitals from 2010 to 2014 with follow up through 2019. Eligible patients were adults (age ≥ 18 years) with septic shock, defined as suspected infection and sequential organ failure assessment (SOFA) score ≥ 2 within 24 h of admission and receiving vasopressor therapy [4]. Demographics, biomarkers, outpatient and inpatient β-blocker and vasopressor administration were abstracted from outpatient records (EPIC Inc.) for each admission day up to 14 days (CERNER Inc.). Patients were stratified as: (i) those who were administered β-blockers each hospital day (“continued”), (ii) those with cessation of chronic therapy for more than 24 h with or without restart during the hospital stay (“held”), and (iii) those who never received β-blockers (“discontinued”). Descriptive data were compared across groups using the Kruskal–Wallis test and χ<sup>2</sup> test with a Bonferroni adjusted (2-sided) significance level of <i>P</i> < 0.05, as appropriate. All analyses used Stata, version 18.0 (StataCorp).</p><p>Of 22,208 patients, 3748 were hospitalized with septic shock and received chronic β-blockers (mean age 67 ± 14 years, 56% male, 87% White, median SOFA score 9.0 (IQR: 6.0–11.0) (Fig. 1A). Of those who received chronic therapy, 405 (11%) continued, 2,025 (54%) held, and 1,317 (35%) discontinued chronic β-blocker therapy during intensive care. Patients in whom β-blockers were discontinued presented with greater SOFA score (“continued,” median SOFA 8.0 (IQR: 6.0–11.0); “held,” 8.0 (IQR: 6.0–11.0; “discontinued,” 10.0 (IQR: 7.0–12.0); <i>p</i> < 0.001), while first-measured biomarkers, such as serum lactate, troponin, and platelets, were similar across groups.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"493\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png\" width=\"685\"/></picture><p>Patient characteristics and prescribing patterns. <b>A</b> Patient characteristics of adults with septic shock who received chronic β-blocker therapy prior to hospitalization. Abbreviations include: d, days; ICU, intensive care unit; INR, international normalized ratio; IQR, interquartile range; no, number; SD, sta","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"37 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142599741","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":"Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates","authors":"Fur-Hsing Wen, Holly G. Prigerson, Li-Pang Chuang, Tsung-Hui Hu, Chung-Chi Huang, Wen-Chi Chou, Siew Tzuh Tang","doi":"10.1186/s13054-024-05160-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05160-2","url":null,"abstract":"Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates’ PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care. Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors. Most surrogates were female (59.1%), the patient’s adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult–child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class. Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"19 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598288","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":"Changes in central venous-to-arterial PCO2 difference and central venous oxygen saturation as markers to define fluid responsiveness in critically ill patients: a pot-hoc analysis of a multi-center prospective study","authors":"Jihad Mallat, Osama Abou-Arab, Malcolm Lemyze, Dahlia Saleh, Pierre-Grégoire Guinot, Marc-Olivier Fischer","doi":"10.1186/s13054-024-05156-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05156-y","url":null,"abstract":"The main aim of the study whether changes in central venous-to-arterial CO2 difference (ΔP(v–a)CO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness (FR) in sedated and mechanically ventilated septic patients. We also sought to determine whether the degree of FR was related to baseline ScvO2 and P(v–a)CO2 levels. This was a post-hoc analysis of a multicenter prospective study. We included 205 mechanically ventilated patients with acute circulatory failure. Cardiac index (CI), P(v–a)CO2, ScvO2, and other hemodynamic variables were measured before and after VE. A VE-induced increase in CI > 15% defined fluid responders. Areas under the receiver operating characteristic curves (AUCs) and the gray zones were determined for ΔP(v–a)CO2 and ΔScvO2. One hundred fifteen patients (56.1%) were classified as fluid responders. The AUCs for ΔP(v–a)CO2 and ΔScvO2 to define FR were 0.831 (95% CI 0.772–0.880) (p < 0.001) and 0.801 (95% CI 0.739–0.853) (p < 0.001), respectively. ΔP(v–a)CO2 ≤ 2.1 mmHg and ΔScvO2 ≥ 3.4% after VE allowed the categorization between responders and non-responders with positive predictive values of 90% and 86% and negative predictive values of 58% and 64%, respectively. The gray zones for ΔP(v–a)CO2 (− 2 to 0 mmHg) and ΔScvO2 (− 1 to 5%) included 22% and 40.5% of patients, respectively. ΔP(v–a)CO2 and ΔScvO2 were independently associated with FR in multivariable analysis. No significant relationships were found between pre-infusion ScvO2 and P(v–a)CO2 levels and FR. In mechanically critically ill patients, ΔP(v–a)CO2 and ΔScvO2 are reliable parameters to define FR and can be used in the absence of CI measurement. The response to VE was independent of baseline ScvO2 and P(v–a)CO2 levels. Clinical trial registration The study was registered in the ClinicalTrials.gov registry: NCT03225378, date: July 20, 2017.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"62 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142597295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The efficacy of fiber-supplemented enteral nutrition in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis","authors":"Jana Larissa Koch, Charles Chin Han Lew, Felix Kork, Alexander Koch, Christian Stoppe, Daren K. Heyland, Ellen Dresen, Zheng-Yii Lee, Aileen Hill","doi":"10.1186/s13054-024-05128-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05128-2","url":null,"abstract":"Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic. For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes. Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I2 = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I2 = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome. Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"70 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142596905","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":"Pressure support, patient effort and tidal volume: a conceptual model for a non linear interaction","authors":"Mattia Docci, Giuseppe Foti, Laurent Brochard, Giacomo Bellani","doi":"10.1186/s13054-024-05144-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05144-2","url":null,"abstract":"Pressure support ventilation (PSV) is a form of assisted ventilation which has become frequently used, with the aim of partially unloading the patient’s inspiratory muscles. Both under- and over-assistance should be avoided to target a lung- and diaphragm- protective ventilation. Herein, we propose a conceptual model, supported by actual data, to describe how patient and ventilator share the generation of tidal volume (Vt) in PSV and how respiratory system compliance (Crs) affects this interaction. We describe the presence of a patient-specific range of PSV levels, within which the inspiratory effort (Pmus) is modulated, keeping Vt relatively steady on a desired value (Vttarget). This range of assistance may be considered the “adequate PSV assistance” required by the patient, while higher and lower levels may result in over- and under-assistance respectively. As we also show, the determinants of over- and under- assistance borders depend on the combination of Crs and the inspiratory effort which the patient is able to sustain over a period of time. These concepts can be applied at the bedside to understand if the level of assistance is adequate to patient’s demand, focusing on the variation of relevant parameters (Vt, Pmus and pressure-muscle-index) as patient reaction to a change in the level of assistance.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142588766","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":"Commenting on baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study","authors":"James Cheng Chung Wei, Poi Kuo, Po-Cheng Shih","doi":"10.1186/s13054-024-05116-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05116-6","url":null,"abstract":"&lt;p&gt;We read with great interest the article by You et al., which provides valuable insights into the comparative efficacy of baricitinib and tocilizumab in mechanically ventilated COVID-19 patients [1]. While the study’s findings are important, especially regarding the lower 30-day mortality in the baricitinib group, we believe that the issue of confounding by indication was not sufficiently addressed and may have significantly influenced the results.&lt;/p&gt;&lt;p&gt;Confounding by indication occurs when treatment assignment is influenced by disease severity, leading to a bias in outcome comparison between treatment groups. In this study, patients in the tocilizumab group appeared to be more severely ill at baseline compared to those in the baricitinib group. Although the authors employed propensity score matching (PSM) to balance baseline characteristics, the data suggest that the tocilizumab group had a higher severity of illness, which could explain some of the observed differences in mortality. Notably, patients in the tocilizumab group had longer durations of mechanical ventilation prior to drug administration, higher use of extracorporeal membrane oxygenation (ECMO), and more severe comorbidities, as detailed in the supplementary tables. These factors strongly suggest that tocilizumab was more likely administered to patients in critical condition, potentially skewing the mortality comparison in favor of baricitinib.&lt;/p&gt;&lt;p&gt;Furthermore, while PSM is effective at balancing observable variables, it may not fully account for unmeasured or residual confounders, such as the timing of drug administration relative to disease progression or the specific clinical criteria that influenced treatment choices. Baricitinib was administered for a median of 8 days, while tocilizumab was often given as a single dose. This difference in treatment duration and pharmacodynamics could have further impacted the results. Baricitinib, with its broader anti-inflammatory effects and prolonged administration, may have provided a more sustained reduction in inflammation, whereas the single-dose nature of tocilizumab could have limited its efficacy in severely ill patients.&lt;/p&gt;&lt;p&gt;Additionally, the study does not provide sufficient detail regarding the criteria used to determine whether a patient received baricitinib or tocilizumab beyond the similar indications in general consideration [2]. Without understanding the clinical decision-making process, it is difficult to evaluate the extent to which confounding by indication may have influenced the results. If tocilizumab was preferentially administered to patients with more rapidly progressing or refractory disease, the higher mortality rate in this group might reflect underlying disease severity rather than a difference in drug efficacy [3]. &lt;/p&gt;&lt;p&gt;It may be beneficial to consider a subgroup analysis excluding patients requiring total parenteral nutrition (TPN), as those unable to tolerate enteral nutrition typically represent a mor","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142580091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What every intensivist needs to know about mpox","authors":"Siyao Zeng, Yue Li, Zhipeng Yao, Junbo Zheng, Hongliang Wang","doi":"10.1186/s13054-024-05114-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05114-8","url":null,"abstract":"&lt;p&gt;The mpox virus is a zoonotic orthopoxvirus with a DNA genome. Based on genetic characteristics, the mpox virus is categorized into two main clades: clade I and clade II. Clade I is further subdivided into subclades Ia and Ib [1]. Clade I is predominantly found in Central Africa, while clade II primarily circulates in West Africa [2]. The clade IIb subclade of clade II caused the global mpox outbreak from 2022 to 2023, during which 86% of cases were among men who have sex with men (MSM) [1]. More than half of the reported mpox cases involve individuals who are co-infected with the human immunodeficiency virus (HIV) [3]. The 2024 mpox outbreak in the Democratic Republic of the Congo and neighboring countries is primarily caused by clade Ia [4]. Only in 2024, as of September 15, the Democratic Republic of the Congo has reported 25,757 cases of mpox, with 806 deaths [3]. In April 2024, scientists identified a new variant of clade I, named Ib, by analyzing samples collected in South Kivu Province, Democratic Republic of the Congo, from late 2023 to early 2024. Reports of infections caused by the Ib variant have increased over the past few months. The proportion of women infected with clade Ib was significantly higher (52%), with nearly one-third identifying as sex workers [1]. On August 15, Sweden reported its first case of mpox caused by the Ib variant. Thailand confirmed its first Ib variant mpox case on August 22 [4]. Compared to clade IIb, which caused the global mpox outbreak in 2022, clade Ia exhibits stronger human-to-human transmissibility and higher mortality and severity rates. As for the clade Ib, its characteristics remain unclear [5].&lt;/p&gt;&lt;p&gt;As the mpox outbreak intensifies, by August 31, 2024, a total of 106,310 confirmed cases have been reported across 123 countries worldwide, resulting in 234 laboratory-confirmed deaths [3]. In Africa, the confirmed and suspected mpox cases in 2024 have surpassed 17,500, far exceeding the 15,000 cases reported in 2023. In response to this escalating situation, the Africa Centers for Disease Control and Prevention (Africa CDC) declared mpox a “Public Health Emergency of Security Concern” (PHESC) for the first time on August 13, 2024. The following day, the World Health Organization (WHO) declared the mpox outbreak a “Public Health Emergency of International Concern” (PHEIC), urging global cooperation to prevent further spread [5]. The current mpox outbreak may pose new challenges for intensivists worldwide.&lt;/p&gt;&lt;p&gt;Mpox mainly spreads through transmission between animals and humans or from person to person. Animal-to-human transmission can happen through direct contact with an infected animal, being bitten or scratched, or consuming undercooked meat from an infected animal. Human-to-human transmission primarily occurs through direct contact with an infected individual’s skin or mucous membrane lesions, oral secretions, upper respiratory secretions (such as nasal discharge and mucus), and items contamina","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"63 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574402","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":"Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics","authors":"Ola Stenqvist","doi":"10.1186/s13054-024-05125-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05125-5","url":null,"abstract":"&lt;p&gt;In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.&lt;/p&gt;&lt;p&gt;In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).&lt;/p&gt;&lt;p&gt;Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.&lt;/p&gt;&lt;h3&gt;Background physiology&lt;/h3&gt;&lt;p&gt;The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properti","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"87 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574405","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":"Biochemical analysis of soft tissue infectious fluids and its diagnostic value in necrotizing soft tissue infections: a 5-year cohort study","authors":"Kai-Hsiang Wu, Po-Han Wu, Hung-Sheng Wang, Hsiu-Mei Shiau, Yung-Sung Hsu, Chih-Yi Lee, Yin-Ting Lin, Cheng-Ting Hsiao, Leng-Chieh Lin, Chia-Peng Chang, Pey-Jium Chang","doi":"10.1186/s13054-024-05146-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05146-0","url":null,"abstract":"Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"32 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142562090","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}