Critical Care最新文献

{"title":"ORAKLE: Optimal Risk prediction for mAke30 in patients with sepsis associated AKI using deep LEarning","authors":"Wonsuk Oh, Marinela Veshtaj, Ashwin Sawant, Pulkit Agrawal, Hernando Gomez, Mayte Suarez-Farinas, John Oropello, Roopa Kohli-Seth, Kianoush Kashani, John A. Kellum, Girish Nadkarni, Ankit Sakhuja","doi":"10.1186/s13054-025-05457-w","DOIUrl":"https://doi.org/10.1186/s13054-025-05457-w","url":null,"abstract":"Major Adverse Kidney Events within 30 days (MAKE30) is an important patient-centered outcome for assessing the impact of acute kidney injury (AKI). Existing prediction models for MAKE30 are static and overlook dynamic changes in clinical status. We introduce ORAKLE, a novel deep-learning model that utilizes evolving time-series data to predict MAKE30, enabling personalized, patient-centered approaches to AKI management and outcome improvement. We conducted a retrospective study using three publicly available critical care databases: MIMIC-IV as the development cohort, and SiCdb and eICU-CRD as external validation cohorts. Patients with sepsis-3 criteria who developed AKI within 48 h of intensive care unit admission were identified. Our primary outcome was MAKE30, defined as a composite of death, new dialysis or persistent kidney dysfunction within 30 days of ICU admission. We developed ORAKLE using Dynamic DeepHit framework for time-series survival analysis and its performance against Cox and XGBoost models. We further assessed model calibration using Brier score. We analyzed 16,671 patients from MIMIC-IV, 2665 from SICdb, and 11,447 from eICU-CRD. ORAKLE outperformed the XGBoost and Cox models in predicting MAKE30, achieving AUROCs of 0.84 (95% CI: 0.83–0.86) vs. 0.81 (95% CI: 0.79–0.83) vs. 0.80 (95% CI: 0.78–0.82) in MIMIC-IV internal test set, 0.83 (95% CI: 0.81–0.85) vs. 0.80 (95% CI: 0.78–0.83) vs. 0.79 (95% CI: 0.77–0.81) in SICdb, and 0.85 (95% CI: 0.84–0.85) vs. 0.83 (95% CI: 0.83–0.84) vs. 0.81 (95% CI: 0.80–0.82) in eICU-CRD. The AUPRC values for ORAKLE were also significantly better than that of XGBoost and Cox models. The Brier score for ORAKLE was 0.21 across the internal test set, SICdb, and eICU-CRD, suggesting good calibration. ORAKLE is a robust deep-learning model for predicting MAKE30 in critically ill patients with AKI that utilizes evolving time series data. By incorporating dynamically changing time series features, the model captures the evolving nature of kidney injury, treatment effects, and patient trajectories more accurately. This innovation facilitates tailored risk assessments and identifies varying treatment responses, laying the groundwork for more personalized and effective management approaches.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"15 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144137148","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":"Detection of cytomegalovirus in the lower respiratory tract among patients with critical illness: uncovering enhanced potential benefits","authors":"Zhihui Zhang, Xuesong Liu, Rong Zhang, Dongdong Liu, Chun Yang, Sibei Chen, Yimin Li, Xiaoqing Liu","doi":"10.1186/s13054-025-05456-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05456-x","url":null,"abstract":"<p>We were highly interested in reading the clinical research conducted by Kim et al. [1]. This study is a single-center, retrospective clinical cohort investigation with a large sample size, focusing primarily on the significance of lower respiratory tract (LRT) cytomegalovirus (CMV) positivity in the prognosis of critically ill patients. The research departs from the traditional focus on CMV reactivation in blood samples and examines the epidemiological characteristics of critically ill patients with CMV positivity in the LRT. These findings demonstrate CMV positivity in the LRT as a significant risk factor for mortality in patients with critical illness. However, the detection of CMV positivity in the LRT may hold greater significance, and the comprehensiveness of this study could be further enhanced through additional refinements.</p><p>First, the direct definition of CMV detection positivity in the LRT as “reactivation” is debatable. Current CMV-related definitions do not explicitly address this issue [2, 3]. Moreover, the prevailing view is that “reactivation” should be defined based on the premise of CMV seropositivity (IgG) and the detection of a certain CMV viral load in blood samples [2,3,4]. Therefore, the term “CMV detection positivity” is more accurate. Additionally, the CMV viral load may vary among different LRT specimens. Theoretically, the CMV viral load in bronchoalveolar lavage fluid is higher than that in endotracheal aspirates, which may subsequently have different impacts on clinical outcomes. It is necessary to further evaluate the CMV detection positivity and viral load in different LRT specimens and their associations with clinical outcomes.</p><p>Second, of particular importance is the observation that CMV detection in the LRT precede its detection in the blood, especially in patients with septic shock [4, 5]. This phenomenon is likely attributed to the high levels of inflammation associated with sepsis. Under conditions of elevated inflammation, latent CMV infection can be reactivated, subsequently leading to CMV-related injury [6]. Notably, clinical studies have demonstrated a close association between CMV reactivation and pulmonary fibrosis in patients with acute respiratory distress syndrome [7], while animal studies have shown that CMV reactivation can induce pulmonary fibroproliferation [8], suggesting that CMV reactivation may trigger lung injury. Therefore, assessing CMV antiviral therapy based on the LRT findings may hold greater value, including both prophylactic and preemptive treatment strategies.</p><p>Third, subgroup analyses should be conducted to distinguish patients with different immune statuses, including immunosuppressed and non-immunosuppressed individuals, because the incidence of active CMV infection varies across different immune backgrounds, particularly with a higher rate observed in immunosuppressed patients [2,3,4, 9]. Sepsis patients, who are in an acute state of immunosuppression, merit spec","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"18 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144122992","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":"Application of one-way speaking valves in adult tracheostomy patients: the time should be earlier","authors":"Shi-Min Zhang, Yi-qi Qian, Yaxiaerjiang Muhetaer, Min-jie Ju, Kai Liu","doi":"10.1186/s13054-025-05425-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05425-4","url":null,"abstract":"<p>One-way speaking valves (OWV) can be used in tracheostomy patients. Their design enables inhalation via the tracheostomy tube due to an open diaphragm, that closes immediately before or during exhalation, thus restoring normal physiological exhalation pathways. This mechanism provides multiple physiological and psychological benefits, including enabling voice, re-establishes subglottic pressure, enhances peak expiratory flow rate, improved swallowing, and reduced aspiration risk [1, 2]. Additionally, OWV reestablish physiological expiratory positive pressure, which strengthens respiratory muscles, enhances lung capacity, and supports early mobilization [3].</p><p>Unlike intubated patients, adult tracheostomy patients experience asynchronous weaning and decannulation processes, often requiring a stepwise approach [4]. Accordingly, the timing of OWV intervention can be divided into three distinct phases: during mechanical ventilation, during a trial of unassisted or spontaneous breathing, and after successful weaning. While most studies focus on the use during spontaneous breathing or after successful weaning, research on its application during mechanical ventilation remains relatively limited [5, 6]. This comment aims to emphasize the importance of early initiation of OWV use and its potential to accelerate weaning and decannulation, and to provide criteria for early use and clinical practice considerations.</p><p>The use of OWV during mechanical ventilation not only offers unique advantages compared to their application during trials of unassisted/spontaneous breathing or after successful weaning but also demonstrates comparable safety [7]. Sutt et al. demonstrated through electrical impedance tomography that the use of OWV in mechanically ventilated patients significantly increased end-expiratory lung impedance without inducing regional hyperinflation, meanwhile, oxygen saturation and end-tidal carbon dioxide remained stable, and respiratory rate significantly decreased during OWV use [8, 9]. These findings provide physiological evidence for the use of OWV in line with the ventilator circuit in mechanically ventilated patients. Research by Freeman-Sanderson et al. demonstrated that under specific conditions early intervention with OWV in the ventilator circuit during mechanical ventilation significantly accelerates voice recovery, enhances communication and patient satisfaction, improves psychological health, and facilitates earlier decannulation in tracheostomy patient [10]. Additionally, a randomized controlled trial (RCT) compared the early use of OWV (within 12 ~ 24 h post-percutaneous tracheostomy) with standard use (48 ~ 60 h post-percutaneous tracheostomy. The study found that patients in the early intervention group tolerated the valve for longer periods and achieved higher decannulation rates at discharge [11]. These findings confirm that the use of OWV during mechanical ventilation can be initiated as early as 48 h post-tracheostomy","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"140 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144122917","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 perfusion assessment of poor neurological outcome in comatose cardiac arrest patients (CANCCAP): a prospective study","authors":"Jai Shankar, Susan Alcock, Evan Wiens, Marco Ayroso, JaeYeon Park, Navjit Singh, Benjamin Blackwood, Reva Trivedi, Roman Marin, Namita Sinha, Anurag Trivedi, Iain Kirkpatrick, Marco Essig, Stephen Schaffer","doi":"10.1186/s13054-025-05454-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05454-z","url":null,"abstract":"Computed tomography perfusion (CTP) of the brain, are increasingly being employed for the assessment of critically ill patients admitted to intensive care units (ICU), including comatose cardiac arrest patients (CCAP). The purpose of our study was to validate the use of CTP in predicting in-hospital mortality in CCAPs. This prospective cohort study enrolled newly admitted adult CCAP, with an out of hospital cardiac arrest (OHCA) and were scheduled for admission to the ICU for further management. Just before ICU admission, CCAP underwent a routine CT scan of the head and CTP of whole head. The treating physicians remained blinded to the CTP results and all patients received standard management. The CTP maps were evaluated to determine a binary outcome of non-survivable brain injury (NSBI), by two independent neuroradiologists, blinded to each other’s assessment and to the clinical history of the patients. A total of 91 patients were enrolled and 90 (Male-78; mean age-62 years) were included in the final analysis. One patient declined consent. Of these, 42 individuals (47%) had in-hospital mortality. Patients with in-hospital mortality were older; had higher levels of creatinine, blood urea nitrogen, blood CO2 and lower pH, carbonate, and heart rate. In multivariate analysis, PCI was independently associated with reduction in-hospital mortality. CTP demonstrated exceptionally high specificity (100%; 95% CI 92–100%) and positive predictive value (100%; 95%CI 6.3–100%) for the prediction of NSBI. For CTP, Bennet’s S-score showed excellent agreement between the two readers (s = 0.82–0.95). CTP was safe and demonstrated very high specificity and positive predictive value and may be used as an additional diagnostic tool for identifying patients at high risk of in-hospital mortality.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"33 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144130358","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":"First dose target attainment with extended infusion regimens of piperacillin and meropenem","authors":"Gustaf Beijer, Maria Swartling, Elisabet I. Nielsen, Olof Breuer, Christian G. Giske, Erik Eliasson, Johan Petersson","doi":"10.1186/s13054-025-05445-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05445-0","url":null,"abstract":"Standard dosing regimens of meropenem and piperacillin-tazobactam frequently fail to achieve targeted plasma concentrations in critically ill patients. Extended or continuous regimens are often used to improve target attainment. Although prompt antibiotic initiation is a major determinant of survival, few studies have reported systemic concentrations early after treatment initiation. No prior study has reported concentrations immediately after the loading dose and first extended infusion. This study aimed to evaluate plasma target attainment during the first dosing interval with an extended infusion regimen in a general intensive care unit (ICU). Adult ICU patients were prospectively included in conjunction with the first administration of meropenem or piperacillin-tazobactam. Treatment was initiated with a 0.5 h loading dose immediately followed by a 3 h extended infusion; typically 4 + 4 g piperacillin or 1(− 2)g + 1(− 2)g meropenem, in line with the local ICU protocol. Patients requiring renal replacement therapy were excluded. Plasma concentrations were measured post-loading dose (Cmax), near the end of the first extended infusion, and at the end of the first dosing interval (Cmin). Samples were analyzed using validated tandem mass spectrometry (UHPLC-MS/MS) methods. The primary endpoint was the proportion of patients achieving 100% time above minimum inhibitory concentrations (fT > MIC) during the first dosing interval. This was evaluated using observed Cmin above 2 mg/L (meropenem) and 20 mg/L (piperacillin). Additionally, published pharmacokinetic models were applied to the observed data for %fT > MIC estimation, using an a posteriori Bayesian approach. We included 65 meropenem and 142 piperacillin measurements from 22 and 48 patients, respectively. Many patients (45% meropenem, 38% piperacillin) failed to reach 100% fT > MIC with the standard regimens used. Target non-attainment was associated with high estimated glomerular filtration rates (eGFR) and suspected augmented renal clearance (ARC). All meropenem patients that failed to reach target had eGFR > 90 mL/min/1.73 m2, as did 76% of corresponding piperacillin patients. Patients with suspected ARC frequently exhibited a tenfold or greater peak-to-trough decline (Cmin/Cmax < 0.1). Despite aggressive dosing, plasma concentrations often fail to reach 100% fT > MIC during the first dosing interval. Alternative regimens and early plasma concentration measurements followed by adaptive dose adjustments should be considered to improve target attainment.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144113955","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":"Cerebral perfusion pressure targets after traumatic brain injury: a reappraisal","authors":"Stefan Yu Bögli, Ihsane Olakorede, Erta Beqiri, Xuhang Chen, Andrea Lavinio, Peter Hutchinson, Peter Smielewski","doi":"10.1186/s13054-025-05458-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05458-9","url":null,"abstract":"Cerebral perfusion pressure (CPP) management is central to neurocritical care management after traumatic brain injury (TBI). While the Brain Trauma Foundation recommends a target of 60–70 mmHg, it is unclear whether this range reflects the lower limit or the optimal level, when viewed through the prism of cerebrovascular autoregulation. Autoregulation aims at stabilizing cerebral blood flow and can be estimated continuously using the pressure reactivity index (PRx). Personalized CPP targets can be derived from PRx including CPPopt (optimal CPP), LLA, and ULA (lower and upper limit of autoregulation). Emerging data suggests an asymmetric relationship around CPPopt, with more pronounced autoregulation deterioration with decreasing compared to increasing CPP. Based on the hypothesis that higher CPP levels may be less harmful than lower CPP levels, we aimed to reassess rigorously the prognostic value of the different CPP targets. We analyzed 809 adult TBI patients admitted from 2002 to 2023 who underwent invasive intracranial pressure monitoring and had available 6-month outcomes. CPPopt, LLA, and ULA were estimated using previously published methodologies. Deviations of CPP from fixed or personalized targets were assessed describing the overall dose, the hourly dose and the percentage time spent outside of these targets and examined using Chi-squared tests, logistic regressions, heatmaps, ordinal analyses, and group-based trajectory modelling. Our data confirms an asymmetric CPP/PRx relationship with steeper increases in PRx with decreasing and only modest elevations with increasing CPP. Even small decreases below CPPopt were consistently linked to worse outcomes (OR 1.04 (CI 1.02–1.06) and 1.09 (CI 1.04–1.15) for hourly dose and percentage time spent below CPPopt, p < 0.001 and p = 0.001 respectively). The strength of association increased with further decreases in CPP away from CPPopt towards the LLA with OR of 1.11 (CI 1.07–1.14) and 1.26 (CI 1.18–1.35) for hourly dose and percentage time spent below LLA respectively (p < 0.001). Conversely, higher-than CPPopt levels generally showed no association to worse outcomes. Distinct trajectories in the relationship between CPPopt and LLA (introduced as the Lower Limit Margin) could be identified with worse outcomes in those with decreasing distance between these targets (Mortality of 18% vs. 45% for patients with increasing vs. decreasing lower limit margins, p = 0.003). Our findings corroborate experimental work suggesting that TBI patients are more vulnerable to CPP reductions below as compared to elevations above personalized thresholds. The results highlight the need for individualized CPP management strategies that prioritize avoidance of lower CPP levels and suggest using CPPopt as the lower CPP limit.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"44 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144113957","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":"Endotoxin hemoadsorption in refractory septic shock with multiorgan dysfunction and extreme endotoxin activity","authors":"Juan Carlos Ruiz-Rodríguez, Luis Chiscano-Camón, Ivan Bajaña, Adolf Ruiz-Sanmartin, Juliana Bastidas, Carolina Maldonado, Pablo Nicolás-Morales, Sergi Cantenys-Molina, Juan José González, Nieves Larrosa, Ricard Ferrer","doi":"10.1186/s13054-025-05371-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05371-1","url":null,"abstract":"Endotoxin septic shock is marked by severe organ failure and mortality rate that exceeds fifty percent, underscoring the critical need to tailor management strategies. Monitoring -endotoxin activity can guide the initiation and direction of adjunctive treatment for refractory septic shock through hemoadsorption. Thus, intervening based on the pathophysiological foundation may potentially improve outcomes. This represents a step towards precision medicine in the management of septic shock adjunctive therapies, addressing a knowledge gap in this pathology that remains insufficiently defined. Despite its potential, in the setting of refractory septic shock and multiorgan dysfunction with extreme endotoxin activity (EAA ≥ 0.9), the data about efficacy of endotoxin hemoadsorption is scarce.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"55 1","pages":"206"},"PeriodicalIF":15.1,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144104544","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":"Biomarkers in acute kidney injury settings to predict interventions and outcomes: the MARKISIO study","authors":"Khalil Chaïbi, Adrien Picod, Marouane Boubaya, Sarah Tubiana, Vincent Jullien, Sophie Magreault, Sandrine Placier, Jérémie Mallet, Guillaume Louis, Laurent Martin-Lefevre, Dimitri Titeca-Beauport, Béatrice La Combe, Sébastien Besset, Julio Badie, Guillaume Chevrel, Nicolas Chudeau, Saber Barbar, Christophe Vinsonneau, Jean-Marie Forel, Didier Thevenin, Guillaume Lacave, Saad Nseir, Johanna Oziel, Julien Mayaux, Kada Klouche, Jean Reignier, Jean-Damien Ricard, Jean-Pierre Quenot, Alexandre Mebazaa, Feriel Azibani, Didier Dreyfuss, Stéphane Gaudry","doi":"10.1186/s13054-025-05439-y","DOIUrl":"https://doi.org/10.1186/s13054-025-05439-y","url":null,"abstract":"Predicting the need for renal replacement therapy (RRT) in acute kidney injury (AKI) remains challenging. The utility of biomarkers was explored during previous studies which were biased as RRT indications relied on clinician opinion rather than evidence. Those studies preceded trials that clarified RRT initiation criteria. We aimed to assess biomarkers in predicting criteria for RRT initiation in severe AKI patients. This is an ancillary study of the AKIKI2 trial. Patients with severe AKI (stage 3) receiving invasive mechanical ventilation and/or vasopressors were included. Blood and urine samples were collected within 12 h after the occurrence of severe AKI when feasible, depending on the availability of trained research staff and appropriate sample storage infrastructure. The primary endpoint was the onset of precise criteria for RRT initiation within 72 h after severe AKI. We analyzed routine serum biomarkers (pH, serum potassium, serum creatinine) and novel urinary and serum biomarkers (CCL14, KIM1, nicotinamide and its metabolites, cDPP3, plasma proenkephalin A 119-159). Among the 256 patients, 101 (39%) met at least one criterion for RRT initiation or died within 72 h. No biomarker demonstrated satisfactory predictive performance for the primary endpoint. No novel biomarker was significantly associated with the occurrence of MAKE60. In multivariable analysis, ‘SAPSIII’ and ‘Serum potassium level at D0’ were significantly associated with the occurrence of MAKE60. Neither routine nor novel biomarkers demonstrated conclusive predictive accuracy for the need for RRT in severe AKI patients. Given evidence-based criteria for initiating RRT, the tested biomarkers may not effectively guide RRT initiation. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"40 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144097467","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":"Circular material flow of medication in the intensive care unit","authors":"Jasper Klasen, Silke Rijcks, Diederik Gommers, Jan Carel Diehl, Nicole Hunfeld","doi":"10.1186/s13054-025-05434-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05434-3","url":null,"abstract":"Intensive care units (ICUs) contribute significantly to healthcare's environmental footprint, with medications playing a major role. This study performed a comprehensive Material Flow Analysis (MFA) of medications in a large academic ICU to quantify material flows and identify opportunities for sustainability. A single-center MFA was conducted at a 50-bed ICU, analyzing all medications delivered in 2023. Medication and packaging components were weighed and categorized by active pharmaceutical ingredients (APIs), excipients, and packaging type. Total annual mass as well as daily medication and packaging waste per patient were calculated. The annual medication inflow totaled 234,337 kg, including 194,411 kg of medication content (5287 kg APIs, 189,124 kg excipients) and 39,923 kg of packaging. APIs constituted only 2.3% of the total medication mass. On average, patients received 89.5 medication units daily, totaling 5.0 kg of medication and generating 1.7 kg of packaging waste. Waste outflow comprised 194,413 kg to the sewage system, 21,894 kg for incineration, and 18,030 kg recycled, consisting primarily of continuous renal replacement therapy (CRRT) bags. This MFA highlights significant opportunities to enhance ICU medication sustainability by targeting CRRT-related waste, optimizing fluid formulations to reduce excipient use, and minimizing packaging. These findings support the development of targeted interventions to reduce the environmental footprint of critical care.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144097465","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":"Re-evaluating the association between alcohol use and in-hospital survival: the role of collider bias","authors":"Tomoko Yasuda, Taisuke Shibata, Atsushi Shiraishi","doi":"10.1186/s13054-025-05442-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05442-3","url":null,"abstract":"&lt;p&gt;Recent studies have reported paradoxical associations between alcohol use and trauma outcomes, sparking debate in public health, trauma surgery, and emergency medicine [1,2,3]. In a recent paper published in Critical Care, Kazuma Sasaki et al. [4] explored the relationship between pre-injury alcohol consumption and traumatic brain injury (TBI) outcomes of hospitalized patients in Japan, reporting a potential direct protective effect of alcohol in conferring survival advantage. While the authors acknowledge the observational nature of their findings, we draw attention to an important methodological issue—namely, collider bias—which may have distorted the reported associations in terms of causal inference. In this Matters Arising, we demonstrate how collider bias can arise in such analyses and discuss the need for caution in the causal interpretation of non-randomized observational studies of this nature.&lt;/p&gt;&lt;p&gt;Collider bias arises when two exposure variables both influence a third collider variable &lt;i&gt;W&lt;/i&gt;, and the analysis conditions on &lt;i&gt;W&lt;/i&gt;. This causal relationship can be illustrated using a directed acyclic graph (DAG), where &lt;i&gt;W&lt;/i&gt; is located at the collision point of the two arrowheads from two independent variables &lt;i&gt;Z&lt;/i&gt;1 and &lt;i&gt;Z&lt;/i&gt;2 (Fig. 1A). In this structure, adjusting for &lt;i&gt;W&lt;/i&gt;, or selecting or stratifying the sample population based on &lt;i&gt;W&lt;/i&gt;, can introduce a collider bias [5]. Such paths with colliders can be a source of selection bias, introducing a methodological flaw to observational research and misleading conclusions when unidentified in study design.&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%2Fs13054-025-05442-3/MediaObjects/13054_2025_5442_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"693\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-025-05442-3/MediaObjects/13054_2025_5442_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;&lt;b&gt;A&lt;/b&gt; DAG illustrating &lt;i&gt;W&lt;/i&gt; as a collider variable in the path &lt;i&gt;Z&lt;/i&gt;1 → &lt;i&gt;W&lt;/i&gt; ← &lt;i&gt;Z&lt;/i&gt;2. Before conditioning on &lt;i&gt;W&lt;/i&gt;, the relationship between &lt;i&gt;X&lt;/i&gt; and &lt;i&gt;Y&lt;/i&gt; may be confounded by the path &lt;i&gt;X&lt;/i&gt;-&lt;i&gt;Z&lt;/i&gt;1-&lt;i&gt;W&lt;/i&gt;-&lt;i&gt;Y&lt;/i&gt;. However, conditioning on &lt;i&gt;W&lt;/i&gt; opens an otherwise closed non-causal pathway &lt;i&gt;X&lt;/i&gt;-&lt;i&gt;Z&lt;/i&gt;1-&lt;i&gt;W&lt;/i&gt;-&lt;i&gt;Z&lt;/i&gt;2-&lt;i&gt;Y&lt;/i&gt;, creating an apparent association between &lt;i&gt;X&lt;/i&gt; and &lt;i&gt;Y&lt;/i&gt; [5]. &lt;b&gt;B&lt;/b&gt; In the analytic model of this study by Sasaki et al., conditioning on hospitalization with TBI may introduce a non-causal association between alcohol use and in-hospital survival via covariates &lt;i&gt;Z&lt;/i&gt;1 and &lt;i&gt;Z&lt;/i&gt;2&lt;/p&gt;&lt;span&gt;Full size image&lt;/span&gt;&lt;svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"&gt;&lt;use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"&gt;&lt;/use&gt;","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144097583","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}