Critical Care最新文献

{"title":"The mechanism of PLTP on sepsis-associated acute kidney injury: some hints","authors":"Lin Song, Wei Jiang, Yang Yu, Jiangquan Yu, Ruiqiang Zheng","doi":"10.1186/s13054-025-05333-7","DOIUrl":"https://doi.org/10.1186/s13054-025-05333-7","url":null,"abstract":"<p>Dear editor,</p><p>We appreciate the constructive comments provided by Liang and colleagues [1]. Our recent study [2] reported for the first time that PLTP is a key therapeutic target for sepsis-associated acute kidney injury (SA-AKI) in different levels. Regarding the aspects mentioned in the response above, we has been continuously and extensively investigating the mechanisms focusing PLTP in SA-AKI.</p><ol>\u0000<li>\u0000<span>1)</span>\u0000<p>Concerning the mitochondria, we have observed similar phenomena in other instances of sepsis-induced organ damage, suggesting that the protective effects of recombinant PLTP are closely linked to mitochondria. Moreover, as a member of the Tubular Lipid-binding (TULIP) superfamily, PLTP shares homology with the SMP (synaptobrevin-like, mitochondrial and peroxisomal lipid-binding protein) domain [3, 4]. The SMP domain facilitates the exchange between heterologous membranes of organelles, indicating that PLTP may play a crucial role in regulating the phospholipid composition of mitochondrial membrane. Continuous work is under way.</p>\u0000</li>\u0000<li>\u0000<span>2)</span>\u0000<p>Another article from our research team published in the Journal of Biological Chemistry (JBC) has demonstrated that PLTP in plasma is not a direct carrier of S1P, while may influence plasma S1P levels by regulating HDL metabolism [5]. However, whether PLTP affecting S1P signalling pathway in vivo remains further investigation.</p>\u0000</li>\u0000<li>\u0000<span>3)</span>\u0000<p>Concerning epigenetics mechanism, it is undeniable that post-translational modifications play a crucial role in sepsis, providing new avenues for the development of therapeutic targets and early-stage diagnosis [6, 7]. Previous studies have revealed that N-glycosylation is essential for the secretion capacity of PLTP. The site-specific removal of N-glycosylation significantly impacts both the cellular secretion of PLTP and its phospholipid transfer activity in a quantifiable manner [8, 9]. Similarly, we found that the transciptional level data and expression level data of PLTP are inconsistent in the renal tissues of CLP mice. We have also confirmed that PLTP undergoes epigenetic modifications. Currently, the relevant mechanism findings are being compiled and prepared for publication.</p>\u0000</li>\u0000</ol><p>We are deeply grateful for the attention and support from the authors and the editorial board. Please continuous pay attention to our upcoming works.</p><p>No datasets were generated or analysed during the current study.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Liang D, Li X. Gaps in PLTP mechanism research in sepsis-associated acute kidney injury and improvement strategies based on new evidence. Crit Care. 2025;29:83. https://doi.org/10.1186/s13054-025-05310-0.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"2.\"><p>Jiang W, Song L, Gong W, et al. The role of phospholipid transfer protein in sepsis-ass","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"92 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143661428","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 sepsis-associated acute kidney injury in the ICU with contemporary consensus definitions","authors":"Tomonori Takeuchi, Alexander H. Flannery, Lucas J. Liu, Lama Ghazi, Augusto Cama-Olivares, Kiyohide Fushimi, Jin Chen, Sarah C. Huen, Ashita J. Tolwani, Javier A. Neyra","doi":"10.1186/s13054-025-05351-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05351-5","url":null,"abstract":"The definition of sepsis-associated acute kidney injury (SA-AKI) was updated in 2023. This study aims to describe the epidemiology of SA-AKI using updated consensus definition and to evaluate clinical outcomes. The study was a retrospective cohort analysis conducted at two academic medical centers. Adult patients admitted to intensive care units (ICU) between 2010 and 2022 were included and categorized as SA-AKI, sepsis alone, or AKI alone. SA-AKI was further classified by time of onset (early < 2 days from sepsis diagnosis vs. late 2–7 days following sepsis diagnosis) and presence of septic shock. Clinical outcomes included hospital mortality and major adverse kidney events (MAKE = death, kidney replacement therapy, or reduced kidney function from baseline) at discharge. 187,888 adult ICU patients were included, and SA-AKI was found in nearly half of sepsis patients and about 1 in 6 ICU admissions. 1 in 4 patients with SA-AKI died during hospitalization and 37.7% experienced at least one MAKE by hospital discharge. Compared to sepsis or AKI alone, SA-AKI was associated with higher mortality (adjusted HR 1.59; 95% CI 1.51–1.66) and higher odds of MAKE (adjusted OR 3.35; 95% CI 3.19–3.51). The early clinical phenotype of SA-AKI was most common, with incident AKI decreasing daily from sepsis onset. The presence of septic shock significantly worsened outcomes. Applying updated consensus definitions highlights the high prevalence of SA-AKI in the ICU and its significant associated morbidity and mortality. Outcomes differ based on clinical phenotypes, including the timing of SA-AKI onset and the presence of shock.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"21 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143661189","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":"Haloperidol in treating delirium, reducing mortality, and preventing delirium occurrence: Bayesian and frequentist meta-analyses","authors":"Shu-Li Cheng, Tien-Wei Hsu, Yu-Chen Kao, Chia-Ling Yu, Trevor Thompson, Andre F. Carvalho, Brendon Stubbs, Ping-Tao Tseng, Chih-Wei Hsu, Fu-Chi Yang, Yu-Kang Tu, Chih-Sung Liang","doi":"10.1186/s13054-025-05342-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05342-6","url":null,"abstract":"Although haloperidol is commonly used to treat or prevent delirium in intensive care unit (ICU) patients, the evidence remains inconclusive. This study aimed to comprehensively evaluate the efficacy and safety of haloperidol for delirium treatment and prevention in ICU patients. We searched MEDLINE, the cochrane central register of controlled trials, EMBASE, ClinicalTrial.gov, and PubMed without language restrictions from database inception to June 27, 2024. We included double-blind randomized controlled trials (RCTs) on haloperidol versus placebo for treating and preventing delirium in adult ICU patients. In addition to frequentist analyses, Bayesian analysis was used to calculate the posterior probabilities of any benefit/harm and clinically important benefit/harm (CIB/CIH). The primary outcomes for delirium treatment were all-cause mortality and serious adverse events (SAEs). For delirium prevention, the primary outcomes included incident delirium, all-cause mortality, and SAEs. The secondary outcomes for efficacy were delirium-or coma-free days, ventilator-free days, length of stay in ICU, length of stay in hospital, and rescue benzodiazepine use. The secondary outcomes for safety were QTc prolongation and extrapyramidal syndrome. We included seven RCTs on delirium treatment (n = 1767) and five on delirium prevention (n = 2509). The Bayesian analysis showed that, compared to placebo for delirium treatment, haloperidol had a 68% probability of achieving CIB (defined as risk difference [RD] < −0.02) in reducing all-cause mortality, a 2% probability of achieving CIH (RD > 0.02) in causing SAEs, and a 78% probability of achieving CIB (RD < −0.02) in reducing the need for rescue benzodiazepine use. The probabilities of haloperidol causing CIH (RD > 0.02) across all other safety outcomes were low (all < 50%). In frequentist analysis on delirium treatment, the pooled estimated RD for haloperidol compared to placebo was -0.05 (−0.09, −0.00; I2 = 0%) for rescue benzodiazepine use. In Bayesian analysis on delirium prevention, haloperidol had a 12% probability of achieving CIB in all-cause mortality, a 34% probability of achieving CIB in delirium incidence, and a 0% probability of achieving CIB in SAEs. Importantly, haloperidol had a 65% probability of causing CIH (risk ratio > 1.1) for QTc prolongation, while the posterior probabilities of achieving CIB across all efficacy outcomes were low (all < 50%). In frequentist analysis on delirium prevention, all primary and secondary outcomes were not statistically significant in frequentist analysis. Our study supported the use of haloperidol for delirium treatment in adult ICU patients, but not for delirium prevention.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"26 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143661422","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":"Rethinking caution: a critical appraisal of extracorporeal blood purification in sepsis","authors":"Gabriella Bottari, V. Marco Ranieri, Can Ince, Antonio Pesenti, Filippo Aucella, Anna Maria Scandroglio, Claudio Ronco, Jean-Louis Vincent","doi":"10.1186/s13054-025-05353-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05353-3","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;We thank Stahl and colleagues for their commentary [1] on our paper [2]. Their observations provide an opportunity to further analyze and discuss key aspects of extracorporeal therapies in sepsis, as well as recently emerging data.&lt;/p&gt;&lt;p&gt;Stahl expresses concerns and disagreement with our conclusions on \"considerations for current clinical practice,\" citing potential harm and suggesting that extracorporeal therapies should be used only in clinical studies. Their position is primarily based on two distinct clinical studies: one on Continuous Plasma Filtration Adsorption (CPFA) [3] and the other on Hemoadsorption (HA), specifically the study by Wendel Garcia et al. (Intensive Care Med, 47(11):1334–1336, 2021) [4].&lt;/p&gt;&lt;p&gt;The latter study [4] is a retrospective, single-center observational study with a historic control group. This design inherently limits the conclusiveness of its findings and does not meet the standard of a randomized controlled trial (RCT), which, as the authors themselves note, remains the gold standard for clinical practice evidence. Furthermore, the study’s supplementary material raises concerns about the robustness of the data, even within an observational framework. For example, all Cytosorb patients underwent Continuous Veno-Venous Hemofiltration (CVVH), but the study does not provide data on how many control patients also received CVVH. In fact, there is no mention of whether any sepsis patients in the control group underwent CVVH, nor is there an analysis of whether CVVH itself could have contributed to the increased mortality observed in the Cytosorb group. This potential confounding factor is neither discussed nor accounted for in the study’s extensive statistical analysis.&lt;/p&gt;&lt;p&gt;Conversely, the authors express confidence in the superiority of Therapeutic Plasma Exchange (TPE), citing clinical studies that also warrant caution. The study by David et al. (cited in the commentary) [5] was a randomized controlled trial with early hemodynamic stabilization as its primary outcome, measured by norepinephrine reduction at six hours of TPE treatment. However, secondary outcomes such as mortality and changes in the SOFA score were not significant [5]. Notably, the mortality rate in the TPE arm was 60%, compared to 50% in the control group [5]. Similarly, the study by Knaup et al. [6], also cited by the authors, focused on the technique’s tolerance, with secondary endpoints assessing only short-term (&lt; 6 h) hemodynamic effects. The 28-day mortality rate in this study was 65% [6].&lt;/p&gt;&lt;p&gt;While these studies suggest potential benefits, their findings should be interpreted cautiously, especially given the lack of significant clinical outcomes, including mortality. Likewise, the Wendel-Garcia study should not be considered the definitive reference for evaluating HA, as previous studies involving similar patient populations and statistical methods have reported contradictory findings, including in long-term follow","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"61 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653326","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":"Questioning the classification of “high blood flow” versus “low blood flow” ECCO₂R in ultra-low tidal volume ventilation studies: a call for functional classification","authors":"Minmin Wang, Qiang Yao, Mingli Zhu","doi":"10.1186/s13054-025-05352-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05352-4","url":null,"abstract":"&lt;p&gt;We read with great interest the recent study by Monet et al. [1] investigating the feasibility and safety of ultra-low tidal volume ventilation (≤ 3 mL/kg) combined with ECCO₂R in acute respiratory failure. While the study provides valuable insights into lung-protective strategies, we wish to highlight a critical point in the authors' classification of ECCO₂R devices into “high blood flow” (HBF) and “low blood flow” (LBF) groups, which may undermine the validity of their conclusions.&lt;/p&gt;&lt;p&gt;The study defines HBF as “blood flow ≥ 1000 mL/min” and LBF as “blood flow &lt; 500 mL/min” without citing standardized criteria. This dichotomy ignores two key issues:&lt;/p&gt;&lt;p&gt;Threshold variability: existing literature uses conflicting cutoffs (e.g., HBF as &gt; 800 mL/min in SUPERNOVA study [2]).&lt;/p&gt;&lt;p&gt;Functional disconnection: blood flow alone poorly predicts CO₂ clearance. For example, the Prismalung + ®(classified as LBF in the study) achieves 90 mL/min above CO₂ removal at 400–450 mL/min blood flow [3], surpassing some “HBF” devices at 500 mL/min with smaller membrane surfaces.&lt;/p&gt;&lt;p&gt;By prioritizing blood flow over CO₂ extraction rate (mL/min) and membrane efficiency (CO₂ clearance per L blood flow), the authors risk misclassifying device performance. A device with 500 mL/min above flow but low membrane efficiency may be functionally inferior to a 400 mL/min device with optimized design, yet both would be grouped differently in this analysis.&lt;/p&gt;&lt;p&gt;The HBF/LBF grouping aggregates fundamentally distinct technologies: HBF group includes pumpless arteriovenous devices (e.g., iLA Activve®) while LBF group combines with roller pump system (e.g., PrismaLung +®) and centrifugal pump system (e.g., Hemolung Respiratory Assist System®), ignoring their divergent hemodynamic impacts [4].&lt;/p&gt;&lt;p&gt;This heterogeneity introduces unmeasured confounding. For instance, the reported “no significant safety difference” between groups could mask device-specific risks (e.g., hemolysis in centrifugal pumps vs. thrombosis in pumpless systems).&lt;/p&gt;&lt;p&gt;The study’s primary endpoint—feasibility of ultra-low tidal volume ventilation—depends on precise CO₂ control, which is determined by ECCO₂R efficiency (CO₂ clearance/mL blood flow), not absolute flow rates. A functional classification based on CO₂ extraction capacity would possibly better predict the ability to maintain pH and PaCO₂ targets.&lt;/p&gt;&lt;p&gt;Therefore, to advance future ECCO₂R research, we propose:&lt;/p&gt;&lt;p&gt;&lt;i&gt;Standardized functional metrics&lt;/i&gt;: report CO₂ extraction rate (mL/min) normalized to blood flow (mL/min) and membrane surface area (m&lt;sup&gt;2&lt;/sup&gt;).&lt;/p&gt;&lt;p&gt;&lt;i&gt;Device-specific subgroup analyses&lt;/i&gt;: compare outcomes by technology type (e.g., centrifugal vs. roller pump systems) rather than arbitrary flow categories.&lt;/p&gt;&lt;p&gt;&lt;i&gt;Dynamic performance assessment&lt;/i&gt;: incorporate real-time CO₂ clearance data during dose titration, as static flow thresholds cannot capture device responsiveness to metabolic demands.&lt;/p&gt;&lt;p&gt;While Monet et ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653327","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 outcomes and peripheral tissue oxygen saturation monitoring of the knee region by near-infrared spectroscopy in circulatory shock: a prospective observational cohort study","authors":"Elina Varis, Maria Heliste, Johanna Hästbacka, Suvi T. Vaara, Markus B. Skrifvars, Ville Pettilä, Mitja Lääperi, Anne Kuitunen, Annukka Vahtera, Erika Wilkman","doi":"10.1186/s13054-025-05363-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05363-1","url":null,"abstract":"In circulatory shock, tissue hypoperfusion leads to adverse outcomes. We hypothesized that peripheral tissue oxygen saturation (StO2), measured with near-infrared spectroscopy (NIRS), could provide a non-invasive method for assessing tissue hypoperfusion and predicting pending organ dysfunction and mortality. ASSESS-SHOCK was a prospective, observational study enrolling circulatory shock patients from April 2019 to May 2023 in three intensive care units (ICU). Adult patients fulfilling the criteria for circulatory shock within 24 h of ICU admission were eligible. Patients underwent continuous 48 h StO2 (INVOS™) monitoring of the knee region. To express the burden of tissue hypoperfusion we calculated mean StO2 and areas below predefined StO2 thresholds. The primary outcome, change in Sequential Organ Failure Assessment (SOFA) score, was dichotomized to improvement or non-improvement in SOFA score from enrollment to day 7 or ICU discharge. Death within 7 days was considered as SOFA non-improvement. 90-day mortality was among the secondary outcomes. We included 256 patients. Due to several reasons, including the COVID-19 pandemic, the patient sample was not consecutive. The median of 48-h mean StO2 was 68.3% (interquartile range [IQR] 57.5–74.1) in SOFA-improvers (n = 171), compared to 63.5% (IQR 52.7–70.8, p = 0.020) in non-improvers (n = 85), and 68.7% (IQR 58.2–74.5) in 90-day survivors, versus 60.9% (IQR 49.5–67.1, p < 0.001) in non-survivors. There were no statistically significant differences in the areas below predefined StO2 thresholds between the SOFA-improvers and non-improvers but all the areas were larger in 90-day non-survivors. The 90-day mortality was 27.0% (n = 69). In multivariable analyses 48-h mean StO2 was associated with 90-day mortality (Odds ratio [OR] 0.97, 95% confidence interval [CI 95%] 0.94–1.00, p = 0.047) but not with SOFA change. The association with mortality was, however, no longer significant in multivariable analyses after exclusion of the last 6 hours of StO2 registration in the patients (n = 29) who died during the 48 h registration (OR 0.97, CI 95% 0.94–1.00, p = 0.062). Lower peripheral StO2 was associated with 90-day mortality in critically ill patients with circulatory shock but not with persisting or worsening organ dysfunction. NIRS shows promise as a non-invasive monitor of tissue perfusion in circulatory shock. Trial registration: ClinicalTrials.gov Identifier: NCT03814564, registered 15 January 2019.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"15 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143661419","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":"Intraosseous versus intravenous vascular access in out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized controlled trials","authors":"Sanam Alilou, Ari Moskowitz, Sina Rashedi","doi":"10.1186/s13054-025-05362-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05362-2","url":null,"abstract":"Rapid and reliable vascular access is crucial during cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). While intraosseous (IO) and intravenous (IV) access are used, their comparative effectiveness for patient outcomes remains uncertain. We searched PubMed, Embase, and ClinicalTrials.gov for RCTs comparing IO vs. IV access in adults with OHCA. The primary outcome was survival (30 days or until discharge), while secondary outcomes included sustained ROSC, favorable neurological outcome, successful first-attempt vascular access, and time from emergency medical service arrival to access. Pooled odds ratios (OR), mean differences (MD), and 95% confidence intervals (CI) were calculated. Four RCTs with 9475 patients were included. No significant differences were found between IO and IV groups in survival (6.6% vs. 6.9%, OR 0.99, 95% CI 0.84–1.18) or favorable neurological outcome (4.7% vs. 4.6%, OR 1.07, 95% CI 0.88–1.30). The sustained ROSC rate was numerically, but not significantly, lower in IO vs. IV access (24.6% vs. 27.0%, OR 0.92, 95% CI 0.80–1.06). IO access had a higher first-attempt success rate (92.3% vs. 62.3%; OR 6.18, 95% CI 3.50–10.91) and was 15 s faster than IV for vascular access (IO: 11.03 ± 5.57, IV: 11.35 ± 6.16 min, MD − 0.25, 95% CI − 0.48 to − 0.01). IO access had a higher first-attempt success rate and faster establishment than IV access, but no significant differences were found in survival or favorable neurological outcomes in adults with OHCA. Sustained ROSC was numerically lower with IO access than IV access, although the difference was not statistically significant. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"54 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653324","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":"Cardiovascular effects of lactate in healthy adults: D-lactate, the forgotten enantiomer","authors":"Neven Stevic, Laurent Argaud, Martin Cour","doi":"10.1186/s13054-025-05358-y","DOIUrl":"https://doi.org/10.1186/s13054-025-05358-y","url":null,"abstract":"&lt;p&gt;To the Editor&lt;/p&gt;&lt;p&gt;We read with great interest the article by Berg-Hansen et al&lt;i&gt;.&lt;/i&gt;, which provides valuable insights into the cardiovascular effects of hypertonic sodium lactate (HSL) administration in healthy volunteers [1]. This well-designed crossover study comparing HSL with iso-osmolar hypertonic sodium chloride suggests a benefit of HSL in improving cardiac function. According to the authors, HSL may be an advantageous resuscitation fluid in critically ill patients. However, we would like to focus on one key aspect to better interpret the findings, which is the use of a racemic lactate solution.&lt;/p&gt;&lt;p&gt;When discussing lactate in critical care, reference is made to L-lactate, which is the sole form that is routinely measured (e.g., on arterial blood gases). However, lactate exists as two enantiomers (i.e., non-superimposable mirror images of molecules, Fig. 1.), L-lactate and D-lactate, which differ in their sources, metabolic pathways, and physiological effects [2]. This difference is of paramount importance for clinicians, as L-lactate is easily and rapidly metabolized by the human body, whereas D-lactate is very poorly metabolized and potentially toxic. The human body produces approximately 1500 mmol of L-lactate per day, primarily through glycolysis. The molecule is catabolized via the L-lactate dehydrogenase (L-LDH) enzyme to fuel the Krebs or Cori cycle, leading to glucogenesis, ATP synthesis, and bicarbonate production, leading to alkalinization [3, 4]. Alternatively, the alkalizing effect of HSL can also be explained by the sodium load according to the Stewart model [5]. In contrast, D-lactate is present in negligible amounts in the human body, with plasma concentrations typically within the nanomolar range. The three sources of plasmatic D-lactate are dietary intake, production by gut bacteria, and endogenous production via the methylglyoxal pathway [2]. Unlike L-lactate, D-lactate is poorly catabolized, relying on a non-specific dehydrogenase with variable efficiency across different organs; a fraction of D-lactate is eliminated unchanged in the urine [6]. In therapeutics, exogenous L-lactate administration is a promising treatment. Based on the rationale that L-lactate is an energetic cellular substrate of choice for both the brain and the heart, as it is readily oxidable (unlike glucose), the L-lactate enantiomer has been logically chosen in studies to demonstrate benefits of HSL in pathologies encountered in critical care [4, 7, 8]. In their study, Berg-Hansen et al&lt;i&gt;.&lt;/i&gt; chose a racemic HSL solution, meaning that it contains 50% L-lactate and 50% D­lactate. Therefore, not only did healthy volunteers receive only half the dose of lactate that is expected to confer benefits on cardiovascular function but also received large amounts of D-lactate. Even though this study did not suggest any side effects related to the infusion of D-lactate, the administration of exogenous D-lactate should be cautious in critically ill pati","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653325","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":"ICU mortality of post-myocardial infarction ventricular septal defect complicated by cardiogenic shock: a retrospective multicentric cohort","authors":"Levi-Dan Azoulay, François Bagate, Clément Delmas, Sylvie Paulus, Nicolas Mongardon, Osama Abou-Arab, Pierre Squara, Michel Habis, Hélène Nougue, Tristan Morichau-Beauchant, Antoine Kimmoun, Aurélien Seemann, Costin Radu, Quentin de Roux, Henri Treille de Grandsaigne, Jean-Luc Fellahi, Christophe Beyls, Bernard Cholley, Thomas Klein, Antoine Gaillet, Armand Mekontso Dessap","doi":"10.1186/s13054-025-05321-x","DOIUrl":"https://doi.org/10.1186/s13054-025-05321-x","url":null,"abstract":"Post myocardial infarction ventricular septal defect (PMI-VSD) complicated by refractory cardiogenic shock is associated with an extremely high mortality rate. We sought to evaluate the factors associated with in-ICU mortality in patients with PMI-VSD-related cardiogenic shock. Patients with PMI-VSD complicated by cardiogenic shock, admitted in 10 French tertiary centers between 2008 and 2022, were retrospectively included. The primary outcome was in-ICU mortality. The timing of surgery was classified as early (≤ 7 days) or late (> 7 days). Multivariable analysis was performed to identify the variables associated with in-ICU mortality. A total of 138 patients were included (mean age 70 (± 10) years, female sex 54%). Of these, 116 patients (84%) received MCS, including 43 patients (31%) with VA-ECMO. VSD surgical closure was performed in 93 patients (67%, 60 early, 33 late). Only 2 patients had percutaneous closure without surgical repair. A total of 84 patients (61%) died. The type of surgical management strategy was significantly associated with in-ICU mortality (no surgery, 100%; early surgery, 45%; late surgery, 27%; ptrend < 0.001). In all patients, the variables independently associated with in-ICU mortality were: old age (adjusted OR = 1.1, 95%CI [1.02–1.12.], p = 0.004), SOFA score (adjusted OR = 1.2, 95%CI [1.07.-1.37], p = 0.003), and VA-ECMO (adjusted OR = 2.9, 95%CI [1.2–7.7], p = 0.02). In patients with VSD surgical closure, a longer delay between ICU admission and VSD surgical closure was independently associated with decreased in-ICU mortality (adjusted OR = 0.9, 95%CI [0.79–0.96], p = 0.003). Delayed VSD closure is associated with improved outcomes in PMI-VSD complicated by cardiogenic shock. #CE SRLF 19-34, #CNIL MR004 2224973, retrospectively registered 04 July 2019 Abbreviations: d day; ICU intensive care unit; SOFA sequential organ failure assessment; VA-ECMO veno-arterial extracorporeal membrane oxygenation; VSD ventricular septal defect; w with.VSD repair is equivalent to VSD surgical closure and do not include the patients (n=2) who underwent percutaneous closure only. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"25 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653328","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":"Early exercise therapy in patients with severe traumatic spinal cord injury: is it feasible in the ICU?","authors":"Antoine Dionne, David Magnuson, Andréane Richard-Denis, Yvan Petit, Dorothy Barthélémy, Francis Bernard, Jean-Marc Mac-Thiong","doi":"10.1186/s13054-025-05297-8","DOIUrl":"https://doi.org/10.1186/s13054-025-05297-8","url":null,"abstract":"&lt;p&gt;Following traumatic spinal cord injury (SCI), patients remain immobilized in the intensive care unit (ICU) and the wards for several weeks before they are transferred to rehabilitation [1]. Unfortunately, this places them at high risk for deconditioning and developing immobility-associated complications [2]. In addition, immobility during the acute stages after TSCI could potentially hinder adaptive neuroplasticity and limit long-term neurological recovery, while early mobilization/exercise could improve outcomes [3]. Until now, early exercise therapy (EET) had never been attempted in humans due to practical obstacles for bedridden patients and potential concerns for safety, especially for patients in the ICU. In this context, the PROMPT-SCI trial is the first trial designed to evaluate the safety and feasibility of EET in patients with acute severe TSCI (ClinicalTrials.gov: NCT04699474) [4]. In this Correspondence, we aim to report specifically on our patients who were hospitalized in the ICU.&lt;/p&gt;&lt;p&gt;As part of the PROMPT-SCI trial, 45 adult patients were recruited from a single Level-1 trauma center in Montreal, Canada, between April 2021 and August 2023. All had sustained a severe TSCI leading to an American Spinal Injury Association Impairment Scale (AIS) grade A, B or C injury. After immediate medical stabilization and resuscitation, MAP therapy was instituted (target MAP≈ 85 mmHg) and surgery was performed within 48 h to decompress the spinal cord and stabilize the spine. The intervention consisted of daily 30-min sessions of continuous passive in-bed leg cycling for 14 consecutive days, starting within 48 h of surgery based on the initiation criteria described in Table 1. During cycling, MAP, heart rate (HR), respiratory rate (RR) and blood oxygen saturation (SpO2) were monitored, and adverse events were noted. Sessions were stopped if patients requested termination, if vital signs fluctuated outside of the following ranges in a sustained fashion: MAP: 60–110 mmHg; HR: 40–140 bpm; SpO2: ≥ 90%, or if there were other signs of medical instability (e.g.hypo/hypertension, cardiac anomaly, etc.). Vasopressors were titrated to achieve a MAP≈ 85 mmHg and maintained at stable levels during sessions. After each session, complete neurological exams were performed to ensure safety.&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"table-caption\"&gt;Table 1 Baseline characteristics of the 40 ICU patients who participated in the PROMPT-SCI trial&lt;/b&gt;&lt;/figcaption&gt;&lt;span&gt;Full size table&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;&lt;/svg&gt;&lt;/figure&gt;&lt;p&gt;Forty participants initiated the 14-day protocol in the ICU within 3 days of the SCI. Of these 40 participants, 33 (82.5%) managed to complete their first full session of cycling &lt; 48 h after spine surgery, while the 7 remaining patients managed to do so the next day (&lt; 72 h of surgery)","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"33 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143653331","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}