Critical Care最新文献

{"title":"Prevention of ventilator-associated pneumonia by metal-coated endotracheal tubes: a meta-analysis","authors":"Yuxin Yang, Xuan Xiong, Xiaofei Wang, Qionglan Dong, Lingai Pan","doi":"10.1186/s13054-024-05095-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05095-8","url":null,"abstract":"This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54–0.95), P = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86–1.27), P = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (− 0.52, 1.72), P = 0.29, I2 = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (− 1.02, 1.95), P = 0.54, I2 = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236438","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":"Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients","authors":"Francisco José Parrilla-Gómez, Ferran Roche-Campo, Stefano Italiano, Andrés Parrilla-Gómez, Indalecio Morán, Jordi Mancebo, Tommaso Maraffi","doi":"10.1186/s13054-024-05092-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05092-x","url":null,"abstract":"Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value. Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure. In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236436","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":"Testing preload responsiveness by the tidal volume challenge assessed by the photoplethysmographic perfusion index","authors":"Chiara Bruscagnin, Rui Shi, Daniela Rosalba, Gaelle Fouqué, Julien Hagry, Christopher Lai, Katia Donadello, Tài Pham, Jean-Louis Teboul, Xavier Monnet","doi":"10.1186/s13054-024-05085-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05085-w","url":null,"abstract":"To detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%. In critically ill patients ventilated with Vt = 6 mL/kg PBW and no spontaneous breathing, haemodynamic (PICCO2 system) and photoplethysmographic (Masimo-SET technique, sensor placed on the finger or the forehead) data were recorded during a Vt-challenge and a PLR test. Among 63 screened patients, 21 (33%) were excluded because of an unstable PI signal and/or atrial fibrillation and 42 were included. During the Vt-challenge in the 16 preload responders, CI decreased by 4.8 ± 2.8% (percent change), PPV increased by 4.4 ± 1.9% (absolute change), PIfinger decreased by 14.5 ± 10.7% (percent change), PVIfinger increased by 1.9 ± 2.6% (absolute change), PIforehead decreased by 18.7 ± 10.9 (percent change) and PVIforehead increased by 1.0 ± 2.5 (absolute change). All these changes were larger than in preload non-responders. The area under the ROC curve (AUROC) for detecting preload responsiveness was 0.97 ± 0.02 for the Vt-challenge-induced changes in CI (percent change), 0.95 ± 0.04 for the Vt-challenge-induced changes in PPV (absolute change), 0.98 ± 0.02 for Vt-challenge-induced changes in PIforehead (percent change) and 0.85 ± 0.05 for Vt-challenge-induced changes in PIfinger (percent change) (p = 0.04 vs. PIforehead). The AUROC for the Vt-challenge-induced changes in PVIforehead and PVIfinger was significantly larger than 0.50, but smaller than the AUROC for the Vt-challenge-induced changes in PPV. In patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142234501","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 pleural gradient does not reflect the superimposed pressure in patients with class III obesity","authors":"Stefano Spina, Lea Mantz, Yi Xin, David C. Moscho, Roberta Ribeiro De Santis Santiago, Luigi Grassi, Alice Nova, Sarah E. Gerard, Edward A. Bittner, Florian J. Fintelmann, Lorenzo Berra, Maurizio Cereda","doi":"10.1186/s13054-024-05097-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05097-6","url":null,"abstract":"The superimposed pressure is the primary determinant of the pleural pressure gradient. Obesity is associated with elevated end-expiratory esophageal pressure, regardless of lung disease severity, and the superimposed pressure might not be the only determinant of the pleural pressure gradient. The study aims to measure partitioned respiratory mechanics and superimposed pressure in a cohort of patients admitted to the ICU with and without class III obesity (BMI ≥ 40 kg/m2), and to quantify the amount of thoracic adipose tissue and muscle through advanced imaging techniques. This is a single-center observational study including ICU-admitted patients with acute respiratory failure who underwent a chest computed tomography scan within three days before/after esophageal manometry. The superimposed pressure was calculated from lung density and height of the largest axial lung slice. Automated deep-learning pipelines segmented lung parenchyma and quantified thoracic adipose tissue and skeletal muscle. N = 18 participants (50% female, age 60 [30–66] years), with 9 having BMI < 30 and 9 ≥ 40 kg/m2. Groups showed no significant differences in age, sex, clinical severity scores, or mortality. Patients with BMI ≥ 40 exhibited higher esophageal pressure (15.8 ± 2.6 vs. 8.3 ± 4.9 cmH2O, p = 0.001), higher pleural pressure gradient (11.1 ± 4.5 vs. 6.3 ± 4.9 cmH2O, p = 0.04), while superimposed pressure did not differ (6.8 ± 1.1 vs. 6.5 ± 1.5 cmH2O, p = 0.59). Subcutaneous and intrathoracic adipose tissue were significantly higher in subjects with BMI ≥ 40 and correlated positively with esophageal pressure and pleural pressure gradient (p < 0.05). Muscle areas did not differ between groups. In patients with class III obesity, the superimposed pressure does not approximate the pleural pressure gradient, which is higher than in patients with lower BMI. The quantity and distribution of subcutaneous and intrathoracic adiposity also contribute to increased pleural pressure gradients in individuals with BMI ≥ 40. This study introduces a novel physiological concept that provides a solid rationale for tailoring mechanical ventilation in patients with high BMI, where specific guidelines recommendations are lacking.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142235010","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":"Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis","authors":"Paul Zajic, Teresa Engelbrecht, Alexandra Graf, Barbara Metnitz, Rui Moreno, Martin Posch, Andrew Rhodes, Philipp Metnitz","doi":"10.1186/s13054-024-05090-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05090-z","url":null,"abstract":"Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU). Retrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period. 415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40]. In a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142231452","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":"Scoring system: use and not use from the future to present","authors":"Charles-Hervé Vacheron, Louis Brac, Albrice Levrat, Jean Stéphane David","doi":"10.1186/s13054-024-05081-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05081-0","url":null,"abstract":"&lt;p&gt;We appreciated the letter from Wohlgemut and colleagues regarding the TIC score that we recently published in Critical Care [1, 2]. They highlight the value of this score for the early detection of traumatic coagulopathy, and recognize its ease of use upon hospital admission [2]. However, they challenged several points in our discussion regarding their Bayesian network score [3]. Briefly, they highlight the flexibility in modelling continuous variables, as well as the improved discrimination and calibration of their model. They suggest that prediction of coagulopathy is possible even with missing variables, which the TIC score theoretically cannot do. Finally, they suggest it may no longer be necessary to compromise model performance to achieve a simpler, more user-friendly model, due to advances in user interface design and user experience. It should be noted that we have deliberately chosen to compare our results with the model described by Yet B et al. because the model had good performance metrics and provides a realistic view of the causality of trauma-induced coagulopathy [3].&lt;/p&gt;&lt;p&gt;Their method relies on a set of data including clinical observation, physiological parameters, radiological findings and laboratory values being implemented automatically in a software application, enabling clinical decision making. Unfortunately, this does not currently match the reality of contemporary hospital care [4]. Furthermore, they argue that the Bayesian network scoring system can handle missing variables and estimate them from pre-existing data. We have chosen to include only pre-hospital parameters in our model, as they are immediately available at the time of admission or even during the pre-hospital phase of care. In our model, no parameters are missing at admission, except in rare cases when capillary hemoglobin measurement is not available. The score we described can be easily calculated mentally, driving immediate decision-making for the trauma patient [1]. The author's final point regarding the strength of Bayesian network analysis also reveals its weakness: weak diffusion. To our knowledge, the model has not been published and is therefore not reproducible by other centers, with the added difficulty of understanding and executing this analysis for the physician unfamiliar with such a model. There is also the “black box” issue, of using a model that obscures the weight of each variable, and its associated under-utilization in the medical field [5]. A simpler—but still accurate—scoring system not only provides a better understanding of the presence of trauma-induced coagulopathy, but also enables rapid and easy implementation of corrective therapy.&lt;/p&gt;&lt;p&gt;In conclusion, models such as Bayesian networks are currently rarely used, even though they represent a highly promising tool for the future of medicine. Until these techniques are ready for prime time, we believe it is still useful to have simple, pragmatic and easy-to-use tools to help doct","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142174818","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":"Should AI models be explainable to clinicians?","authors":"Gwénolé Abgrall, Andre L. Holder, Zaineb Chelly Dagdia, Karine Zeitouni, Xavier Monnet","doi":"10.1186/s13054-024-05005-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05005-y","url":null,"abstract":"In the high-stakes realm of critical care, where daily decisions are crucial and clear communication is paramount, comprehending the rationale behind Artificial Intelligence (AI)-driven decisions appears essential. While AI has the potential to improve decision-making, its complexity can hinder comprehension and adherence to its recommendations. “Explainable AI” (XAI) aims to bridge this gap, enhancing confidence among patients and doctors. It also helps to meet regulatory transparency requirements, offers actionable insights, and promotes fairness and safety. Yet, defining explainability and standardising assessments are ongoing challenges and balancing performance and explainability can be needed, even if XAI is a growing field.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142170549","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":"Cardiopulmonary bypass and VA-ECMO induced immune dysfunction: common features and differences, a narrative review","authors":"Mathieu Lesouhaitier, Félicie Belicard, Jean-Marc Tadié","doi":"10.1186/s13054-024-05058-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05058-z","url":null,"abstract":"Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation are critical tools in contemporary cardiac surgery and intensive care, respectively. While these techniques share similar components, their application contexts differ, leading to distinct immune dysfunctions which could explain the higher incidence of nosocomial infections among ECMO patients compared to those undergoing CPB. This review explores the immune modifications induced by these techniques, comparing their similarities and differences, and discussing potential treatments to restore immune function and prevent infections. The immune response to CPB and ECMO involves both humoral and cellular components. The kinin system, complement system, and coagulation cascade are rapidly activated upon blood contact with the circuit surfaces, leading to the release of pro-inflammatory mediators. Ischemia–reperfusion injury and the release of damage-associated molecular patterns further exacerbate the inflammatory response. Cellular responses involve platelets, neutrophils, monocytes, dendritic cells, B and T lymphocytes, and myeloid-derived suppressor cells, all of which undergo phenotypic and functional alterations, contributing to immunoparesis. Strategies to mitigate immune dysfunctions include reducing the inflammatory response during CPB/ECMO and enhancing immune functions. Approaches such as off-pump surgery, corticosteroids, complement inhibitors, leukocyte-depleting filters, and mechanical ventilation during CPB have shown varying degrees of success in clinical trials. Immunonutrition, particularly arginine supplementation, has also been explored with mixed results. These strategies aim to balance the inflammatory response and support immune function, potentially reducing infection rates and improving outcomes. In conclusion, both CPB and ECMO trigger significant immune alterations that increase susceptibility to nosocomial infections. Addressing these immune dysfunctions through targeted interventions is essential to improving patient outcomes in cardiac surgery and critical care settings. Future research should focus on refining these strategies and developing new approaches to better manage the immune response in patients undergoing CPB and ECMO. Although often considered similar, CPB and ECMO have distinct immune repercussions. Numerous immunomodulatory strategies have been tested in cardiac surgery patients undergoing CPB to mitigate the induced immunoparesis, but no clinical trials have been conducted for patients on ECMO. C5aR (complement component 5a receptor), CPB (cardiopulmonary bypass), DC (dendritic cells), ECMO (extracorporeal membrane oxygenation), HLA-DR (human leukocyte antigen-DR isotype), NETs (neutrophil extracellular traps), PD-1 (program cell death protein 1), ROS (reactive oxygen species), TLR (toll-like receptor). Created with BioRender.com ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142166281","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":"Exploration of different statistical approaches in the comparison of dopamine and norepinephrine in the treatment of shock: SOAP II","authors":"Fernando G. Zampieri, Sean M. Bagshaw, Hassane Njimi, Jean-Louis Vincent, Daniel DeBacker","doi":"10.1186/s13054-024-05016-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05016-9","url":null,"abstract":"Exploring clinical trial data using alternative methods may enhance original study’s findings and provide new insights. The SOAP II trial has been published more than 10 years ago; but there is still some speculation that some patients may benefit from dopamine administration for shock management. We aimed to reanalyse the trial under different approaches and evaluate for heterogeneity in treatment effect (HTE). All patients enrolled in SOAP II were eligible for reanalysis. We used a variety of methods including the win-ratio (WR), a Bayesian reanalysis stratified according to shock type, and both a risk-based and effect-based explorations for HTE. The methods were applied to different endpoints, including a hierarchy of death, new use of renal-replacement therapy (RRT), and new-onset arrhythmia; 28-day mortality; a composite endpoint (mortality, new use of RRT, and new-onset arrhythmia), and days alive and free of ICU at 28-days (DAFICU28). A total of 1679 patients were included (average age was 64.9 years, 57% male, 62% with septic and 17% with cardiogenic shock). All analysis favoured norepinephrine over dopamine. Under the WR approach, dopamine had fewer wins compared to norepinephrine (WR 0.79; 95% confidence intervals [CI] 0.68–0.92; p = 0.003), evident in both cardiogenic and septic shock subgroups. The Bayesian reanalysis for type of shock showed, for dopamine, a probability of harm of 0.95 for mortality, > 0.99 probability of harm for composite endpoint, and 0.91 probability of harm for DAFICU28. The fewer DAFICU28 with dopamine was more apparent in those with cardiogenic shock (0.92). Under the risk-based HTE, there was a high probability that dopamine resulted fewer DAFICU28 in the highest quartile of predicted mortality risk. The effect-based HTE assessment model did not recommended dopamine over norepinephrine for any combination of possible modifiers including age, type of shock, presence of cardiomyopathy, and SOFA score. Receiving dopamine when the effect-based model recommended norepinephrine was associated with an absolute increase in composite endpoint of 6%. The harm associated with the use of dopamine for the management of shock appears to be present in both septic and cardiogenic shock patients. There was no suggestion of any subgroup in which dopamine was found to be favourable over norepinephrine.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142160663","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":"Cytomegalovirus end-organ disease in immunocompromised critically ill patients: key concerns demanding attention","authors":"Zhihui Zhang, Junlu Sun, Xuesong Liu, Rong Zhang, Yimin Li, Xiaoqing Liu","doi":"10.1186/s13054-024-05070-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05070-3","url":null,"abstract":"&lt;p&gt;We delved into the clinical research conducted by Sara Fernández et al. [1] with great interest. This study is a multicenter, international research initiative spanning over a decade, primarily focusing on cytomegalovirus end-organ disease (CMV-EOD) among immunosuppressed patients with critical illness. The study revealed distinctive clinical features, risk factors, and adverse clinical outcomes in immunocompromised critically ill patients with CMV-EOD, marking it as a seminal work in the field. However, there is scope for enhancing the comprehensiveness of this study with further refinements.&lt;/p&gt;&lt;p&gt;First, within the specific population of immunocompromised critically ill patients, certain subjects (such as those with sepsis, trauma, and other prolonged illnesses) have been overlooked and excluded. Sepsis, a significant global health concern characterized by severe response to infection that causes organ failure, leads to over 5.3 million deaths yearly, with a mortality rate of around 30% [2,3,4]. Sepsis is currently understood to induce an imbalance in the immune system (innate and adaptive), leading to phenomenon known as \"immune paralysis\" [5,6,7]. The early stages (characterized by overwhelming inflammation) and the later stages (characterized by refractory inflammation, immunosuppression, and risk of secondary infections) of sepsis are both conducive to CMV reactivation [5,6,7,8]. The incidence of CMV reactivation in septic patients seems to be similar to other common immunosuppressed patients [8]. Our team's research indicates the incidence of CMV reactivation in critically ill patients with concurrent sepsis increases by at least 30%, and sepsis is an independent risk factor for CMV reactivation [9, 10]. This aligns with other mainstream research findings, where the underlying mechanism is associated with sepsis-induced immunosuppression, promoting CMV replication [11]. Therefore, definition of immunosuppressed population in CMV-EOD research should be broadened, and more effective immune function assessment indicators are required to clearly define \"immunocompromised\", moving beyond reliance on clinical disease types for judgment.&lt;/p&gt;&lt;p&gt;Second, assessing the impact of CMV load levels on clinical characteristics and outcomes in CMV-EOD population is essential. Additionally, it is necessary to evaluate CMV seropositivity, both qualitatively and quantitatively, as recent studies indicate a close relationship between CMV seropositivity and poor prognosis [12]. A combined assessment of CMV load and IgG in blood may enable earlier identification of high-risk patients, allowing for antiviral treatment to improve adverse outcomes. Third, the antiviral medications used for the subjects with CMV-EOD in this study may exert a negative influence on prognosis, primarily due to bone marrow suppression leading to a decrease in immune cell levels [13]. The use of the latest anti-CMV drugs Letermovir and Maribavir may mitigate these adverse effects [14]","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142160664","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}