Critical Care最新文献

{"title":"Mind the drain: expanding TIMING-ICP discussion","authors":"Sergio Brasil, Samia Yasin Wayhs, Davi Jorge F. Solla, Raphael Bertani","doi":"10.1186/s13054-025-05607-0","DOIUrl":"https://doi.org/10.1186/s13054-025-05607-0","url":null,"abstract":"<p><b>To the Editor</b>,</p><p>We found the multicenter TIMING-ICP study by Mariani et al. [1] insightful, as it underscores time-related differences in severe brain injury management and the importance of efficient intracranial pressure (ICP) monitoring workflows. The study elegantly highlights practical time-dependent disparities in the management of severe brain injury and reinforces the need for streamlined workflows in ICP monitoring. While noninvasive multimodality strategies can reduce delays in neurological monitoring, invasive ICP monitoring remains essential in neurocritical care [2]. While we appreciate the authors’ efforts to reduce delays — a goal we strongly support — we respectfully believe some methodological concerns limit the study’s conclusions and clinical applicability.</p><p>The strength of the Timing-ICP study lies in demonstrating that initiating ICP monitoring earlier than current standard practice is feasible and potentially beneficial. However, the choice between monitoring modalities should be based on individual patient needs and the therapeutic capabilities required, not solely on procedural timing. In the study, intensivists treated predominantly severe TBI cases (82% vs. 49%), while neurosurgeons managed more SAH patients (27% vs. 11%). SAH patients typically require EVDs for hydrocephalus management and CSF blood clearance, while most severe TBI patients may be appropriately managed with parenchymal probes (bolts) alone. This indicates that device selection was based on clinical need rather than for study purposes, so comparing timing across different patient groups and situations is inappropriate.</p><p>Although the study utilizes an observational, non-randomized design, it is important to note that it evaluates inherently distinct procedures rather than different practitioners performing the same intervention. External ventricular drains (EVDs), when placed by neurosurgeons, fulfill both diagnostic and therapeutic roles by permitting cerebrospinal fluid (CSF) drainage for immediate ICP reduction. In contrast, bolts are limited to providing monitoring capabilities. While these probes are simpler to place, they do not facilitate CSF drainage—a critical component in the therapeutic management of intracranial hypertension.</p><p>EVDs enable precise ICP measurement and uniquely allow for dynamic regulation of ICP through CSF diversion, which is particularly beneficial for patients presenting with hydrocephalus, subarachnoid hemorrhage, or intraventricular hemorrhage [3]. On the other hand, measured intraparenchymal pressure can differ from ICP measured in the ventricles, with an average difference up to ± 6 mmHg [4]. Additional advantages of EVDs include their utility in CSF sampling for biomarker analysis [5] and the removal of intraventricular blood to enhance CSF flow [6]. EVDs are widely considered the gold standard for both diagnostic and therapeutic applications, especially in cases requiring long-term manageme","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"79 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144840118","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":"Impact of oxygen and carbon dioxide levels on mortality in moderate to severe traumatic brain injury: a systematic review and meta-analysis","authors":"Tariq Atkin-Jones, Maria Conchita Solorzano-Aldana, Amal Rezk, Abramo Aziz Rizk, Abhijit V. Lele, Marina Englesakis, Frederick A. Zeiler, Tumul Chowdhury","doi":"10.1186/s13054-025-05604-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05604-3","url":null,"abstract":"Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality worldwide. Secondary brain insults related to oxygenation and ventilation may affect outcomes in this high-risk population. The aim of this study was to perform a comprehensive review examining the relationship between oxygen and carbon dioxide thresholds and mortality to guide clinical care. Eleven databases, including: MEDLINE, MEDLINE In-Process, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, CINAHL, APA PsycINFO, Web of Science, Biosys, Scopus, and the Global Index Medicus, were systematically searched from inception to October 23, 2024. Included studies reported on adults ( $$ge$$ 18 years) with moderate to severe TBI (msTBI) (Glasgow Coma Scale <13 or Head Abbreviated Injury Scale $$ge$$ 3) and exposure to hypoxia, hypocapnia, or hypercapnia, with mortality or vegetative state data reported within 6 months. Vegetative state data was not reported, so all analyses were based on mortality. Pediatric or mild TBI studies, stroke-focused studies, and studies without mortality outcomes were excluded. The data were screened via Covidence software with multiple reviewers. No language or regional restrictions were applied. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Quality was assessed via the Newcastle-Ottawa Scale (NOS) for Cohort Studies, and certainty of evidence was rated using GRADE. Four authors independently extracted data with verification by a second reviewer. The primary outcome was measured using odds ratios (ORs) with 95% confidence intervals (CIs), calculated separately for crude and adjusted effect estimates. Twenty-one cohort studies with 41,980 patients were included. Hypoxia and hypocapnia were significantly associated with increased mortality (aOR, 1.39; 95% CI 1.11–1.75; p =.005; aOR, 1.64; 95% CI 1.25–2.15; p <.001). Hypercapnia was not significantly associated with mortality (aOR, 1.74; 95% CI 0.91–3.32; p =.09). In adults with msTBI, hypoxia and hypocapnia were independently associated with increased mortality, underscoring the importance of prompt recognition and targeted management of these secondary injuries. The role of hypercapnia remains unclear, warranting further investigation.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"104 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144840215","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":"Volatile sedation in critically ills adults undergoing mechanical ventilation: not all inhaled sedatives are equivalent!","authors":"Erwan L’Her, Christelle Teiten, Pierre Bailly","doi":"10.1186/s13054-025-05603-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05603-4","url":null,"abstract":"<p>We read with interest the meta-analysis by Yamamoto et al. [1] about volatile sedation within the ICU. While the results of the analysis appear clear, there are some major comments about the studies that were analysed that put its interpretation to question.</p><p>The overall outcome of the analysis is heavily impacted by one single study, the SESAR trial [2], which weighted 78.2% in the meta-analysis. The SESAR study used sevoflurane for prolonged time in the most severe ARDS patients with the aim of demonstrating better respiratory outcomes, following a promising preliminary study by the same group that showed benefits in terms of PaO₂/FIO₂ in ARDS patients [3]. While the negative outcome in SESAR is undeniable, sedation management during the trial deviated significantly from the original protocol and from what current guidelines recommend. Hence, drawing conclusions about a therapy based on an analysis that is largely built on this one study of a very specific population, seems unsound.</p><p>Importantly, sevoflurane and isoflurane are not the same. These drugs differ in their metabolic pathways and safety profiles, and the differences have been recognized as clinically important in the last few years [4]. For this reason, pooling studies of isoflurane and sevoflurane with regard to outcomes is not appropriate and resembles comparing oranges and apples, both producing juice but very different in flavour. In recent years, the link between exposure to sevoflurane for 48 h or longer with the occurrence of nephrogenic diabetes insipidus, polyuria and hypernatremia has been clearly shown [5]. In contrast, isoflurane is not associated with renal dysfunction. Isoflurane is the only drug that has undergone regulatory scrutiny with regard to safety and is approved for long-term sedation in ICU patients. In the most important RCT of isoflurane use within the ICU (weight 8.1% within the meta-analysis), no difference in terms of mortality was observed between the isoflurane and propofol groups [6]. Isoflurane’s safety is supported by the RCTs carried out in critical care as well as peer-reviewed real-world evidence, not included in the meta-analysis [7,8,9]. These studies indicate lower mortality and other beneficial 30-day outcomes. While not RCTs, these cohort studies of isoflurane are well-performed, peer-reviewed sources of clinically meaningful information and could thus have been considered within a systematic review to better inform readers about the currently available evidence.</p><p>In a recent study from our team [10], better outcomes with isoflurane compared to IV sedation were found in cardiac arrest patients. In this propensity score-matched analysis including 87 patients receiving IV sedatives paired with 87 patients receiving isoflurane, isoflurane sedation was associated with a lower incidence of delirium (16.1% vs. 32.2%, <i>p</i> = 0.03), a shorter duration of mechanical ventilation (78 h vs. 167 h, <i>p</i> = 0","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144840122","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":"Norepinephrine exacerbates LPS-induced cardiomyopathy via SIRT3/HO-1 axis-mediated ferroptosis","authors":"Dan Ma, Weilun Fang, Lei Cai, Wei Li, Han Su","doi":"10.1186/s13054-025-05602-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05602-5","url":null,"abstract":"Norepinephrine (NE) is a first-line vasopressor for patients with septic shock, and its overuse can lead to “catecholamine adverse effects”, including cardiovascular diseases. Lipopolysaccharide (LPS)-induced cardiomyopathy is one of the leading causes of mortality in septic patients. Previous studies have revealed that catecholamine can accentuate LPS-induced cardiomyopathy, but the underlying mechanisms remain elusive. Adult mice and H9c2 cells were exposed to LPS and NE. Structural changes, cardiac function and LDH assays were measured to verify the synergistic effects of LPS and NE in vivo and in vitro. Inhibitors of ferroptosis, heme oxygenase-1 (HO-1) and an activator of SIRT3 were used to reverse the synergistic effects. 4-hydroxynonenal (4-HNE)/MDA assays, immunofluorescence, transmission electron microscopy (TEM) and western blotting were used to measure ferroptosis in this study. In our study, conventional dosage of NE exacerbated LPS-induced cardiomyopathy in long term, followed by ferroptotic alternations of ferrous iron, reactive oxygen species (ROS), mitochondria shrinkage, lipid peroxidation and HO-1 expression. In addition, inhibition of ferroptosis suppressed cardiomyocyte death and cardiomyopathy induced by LPS and NE, indicating the critical contribution of ferroptosis to cardiac injury via the synergistic effects of NE and LPS. Our recent study identified SIRT3 as a therapeutic target for cardiac ferroptosis. In line with this, overexpression of SIRT3 alleviated the death of cardiomyocytes treated with NE + LPS, accompanied by attenuated ferroptosis and HO-1 level. Moreover, the suppression of HO-1 by zinc protoporphyrin (ZnPP) also attenuated ferroptosis in cardiomyocytes treated with NE and LPS. These data strongly indicate that long-term use of NE can further develop LPS-induced cardiomyopathy via SIRT3/HO-1 axis-mediated ferroptosis. NE didn’t result in myocardial impairment alone but could exacerbate LPS-induced cardiomyopathy via SIRT3/HO-1-mediated ferroptosis.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"16 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144825132","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":"Tranexamic acid is associated with improved intestinal barrier function in traumatic hemorrhagic shock: A clinical prospective cohort study","authors":"Fang Chen, Chengnan Chu, Xinyu Wang, Qianjin Shen, Anfang Wang, Danbing Shao, Weiwei Ding","doi":"10.1186/s13054-025-05605-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05605-2","url":null,"abstract":"&lt;p&gt;Tranexamic acid (TXA) is widely used as a hemostatic agent in emergency settings, particularly for traumatic hemorrhagic shock (THS) [1]. In 2010, the large-scale randomized controlled trial CRASH-2 demonstrated that TXA administration in patients with THS significantly reduced 28-day mortality, especially when given within 3 h post-injury [2]. However, clinical observations indicate that even after effectively controlling the primary cause of THS, many patients may still succumb to later complications, with intestinal source infections resulting from intestinal barrier dysfunction being a critical factor. This is because THS leads to decreased perfusion pressure, prompting selective vasoconstriction of the mesenteric arterioles to maintain perfusion of vital organs, but at the expense of intestinal ischemia [3].&lt;/p&gt;&lt;p&gt;Recent studies have shown that TXA, as a serine protease inhibitor, can protect the intestinal barrier during THS. In 2015, Diebel et al. [4] first observed in vitro that early infusion of TXA protects intestinal Caco-2 cells from ischemia-reperfusion injury, alleviating mucosal degradation following THS and promoting the recovery of intestinal barrier function. Furthermore, our group’s previous investigations have revealed significant upregulation of CitH3 and MPO expression in the gut following THS, indicating elevated inflammation levels and reduced expression of tight junction proteins. TXA has been shown to alleviate intestinal barrier damage by inhibiting neutrophil extracellular traps formation [5].&lt;/p&gt;&lt;p&gt;Despite these findings, there is a lack of clinical prospective studies focusing on TXA’s potential to improve intestinal barrier function. We therefore conducted a pilot prospective cohort study to evaluate the protective effects of TXA on the intestinal barrier in patients with THS. We prospectively observed and analyzed clinical data from a cohort of 61 patients with THS admitted to the Jinling hospital and Sir Run hospital affiliated to Nanjing Medical University between August 2021 and August 2022. Serial plasma samples were collected at multiple time points(DAY1, DAY3, DAY5, and DAY7). The detailed study design and methodology are available in the supplementary materials.We compared intestinal injury markers and clinical outcomes between the TXA treatment group (&lt;i&gt;n&lt;/i&gt; = 33) and the control group (&lt;i&gt;n&lt;/i&gt; = 28)(Suppl. Table 1).The baseline clinical and demographic characteristics were well balanced between the two groups, including age, time from injury to admission, injury causes and site, as well as injury severity scores(ISS, APACHE II, GCS, SOFA).&lt;/p&gt;&lt;p&gt;Extensive research has established that intestinal fatty acid-binding protein (I-FABP) and D-lactate (D-LA) serve as crucial markers for intestinal injury. The analysis revealed that the level of I-FABP significantly changed over time (&lt;i&gt;P&lt;/i&gt; &lt; 0.001). The mean I-FABP level in the TXA group was lower than that in the control group at all four time points","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"42 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144824912","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":"Effectiveness of targeted post-acute interventions and follow-up services for sepsis survivors: a systematic review","authors":"Barbora Bircak-Kuchtova, Norman Rose, Christian Geis, Kathrin Finke, Mathias W. Pletz, Ha-Yeun Chung, Carolin Fleischmann-Struzek","doi":"10.1186/s13054-025-05585-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05585-3","url":null,"abstract":"The majority of sepsis survivors suffer from significant long-term consequences, including cognitive, psychological, and physical impairments. Despite growing recognition of these challenges, there is a lack of robust evidence regarding effective post-acute interventions to improve long-term outcomes. This systematic review aims to compile the present evidence on the effectiveness of post-acute interventions and follow-up services on patient-relevant long-term outcomes of sepsis survivors. PubMed, Web of Science and ClinicalTrials.gov were searched for relevant publications from 01/2013 until 08/2024. Studies evaluating the effect of targeted post-acute interventions and follow-up services compared to usual care were included. Risk of bias was assessed using the RoB2- and ROBINS-I tool. Fourteen studies including 383,680 patients from high-income-countries were identified. All included studies showed either a moderate risk of bias (non-randomized studies) or some concerns (randomized trials), primarily due to residual confounding, suboptimal blinding and outcome assessment. Interventions varied substantially in terms of measures, implementation time and outcomes addressed. Rehabilitation interventions were associated with long-term survival benefits until 10 years after sepsis according to three observational studies. Additionally, one randomized controlled trial with minimization found that an 8-week exercise-based intervention improved the anaerobic threshold in sepsis survivors. Interventions (n = 7) targeting care coordination and follow-up bundles led to reductions in rehospitalization rates and mortality until 12 months post-discharge and were associated with improvements in long-term physical function and PTSD symptoms. An ICU-specific virtual reality-based intervention may reduce symptoms of PTSD and depression up to six months after exposure. Post-acute interventions, such as care coordination, bundle approaches, and rehabilitation can improve patient-relevant outcomes in sepsis survivors. However, the overall number of existing studies is small, all studies may be affected by certain forms of bias and for some domains of post-sepsis impairment no specific interventions have yet been identified. Therefore, further high-quality prospective follow-up studies are needed to strengthen the evidence regarding the effectiveness and acceptability of interventions across all domains of post-sepsis impairments, particularly cognitive impairments.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"736 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144797112","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":"Cost-effectiveness of rapid, ICU-based, syndromic PCR in hospital-acquired pneumonia: analysis of the INHALE WP3 multi-centre RCT","authors":"Adam P. Wagner, Virvel Enne, Vanya Gant, Susan Stirling, Julie A. Barber, David M. Livermore, David A. Turner","doi":"10.1186/s13054-025-05428-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05428-1","url":null,"abstract":"Hospital-acquired and ventilator-associated pneumonia (HAP and VAP) are pneumonias arising > 48 h after admission or intubation respectively. Conventionally, HAP/VAP patients are given broad-spectrum empiric antibiotics at clinical diagnosis, refined after 48–72 h, once microbiology results become available. Molecular tests offer swifter results, potentially improving patient care. To investigate whether this potential is realisable, we conducted a pragmatic multi-centre RCT (‘INHALE WP3’) of rapid, syndromic polymerase chain reaction (PCR) in ICU HAP/VAP compared with standard of care. As the use of molecular tests impact on hospital resources, it is important to consider their potential value-for-money to make fully informed decisions. Consequently, INHALE WP3 included an economic evaluation, presented here. Its aim was to estimate the cost-effectiveness of an in-ICU PCR (bioMérieux BioFire FilmArray Pneumonia Panel) in HAP/VAP, informing whether to implement such technology in routine NHS care. We collected data on patient resource use and costs. These data were combined with INHALE WP3’s two primary outcome measures: antibiotic stewardship at 24 h and clinical cure at 14 days. Cost-effectiveness analyses were carried out using regression models adjusting for site. Sensitivity analyses explored assumptions and sub-group analyses explored differential impacts. We found lower total ICU costs (including PCR costs) in the intervention (PCR-guided therapy) group. Average costs were £40,951 for standard of care compared with £33,149 for the intervention group, a difference of − £7,802 (95% CI: − £15,696, £92). For antibiotic stewardship, the PCR-guided therapy was both less costly and more effective than routine patient management. For clinical cure, we did not find PCR-guided therapy to be cost-effective due to fewer cases being cured in the intervention group. We found lower average ICU costs with the Pneumonia Panel. The pneumonia panel was cost-effective in terms of antibiotic stewardship, but not clinical cure. Trial registration: Registered as ISRCTN16483855 on 5th August 2019.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"31 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144797115","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":"Incidence, kinetics, and clinical impact of thrombocytopenia in venovenous ECMO: insights from the multicenter observational PROTECMO study","authors":"Nina Buchtele, Kenichi Tanaka, Fabio Tuzzolino, Cara Agerstrand, Ali Ait Hssain, Jordi Riera, Peter Schellongowski, Matthieu Schmidt, Raj Ramanan, Martin Balik, Lars Mikael Broman, Nicolo Rizzitello, Konstanty Szułdrzyński, Whitney D. Gannon, Vito Fanelli, Brian Trethowan, Hergen Buscher, Huda Alfoudri, Marco Giani, Alain Combes, Giacomo Grasselli, Roberto Lorusso, Antonio Arcadipane, Daniel Brodie, Gennaro Martucci","doi":"10.1186/s13054-025-05569-3","DOIUrl":"https://doi.org/10.1186/s13054-025-05569-3","url":null,"abstract":"Thrombocytopenia is a recognized risk factor for bleeding during extracorporeal membrane oxygenation (ECMO). This study determines the incidence, risk factors, and clinical relevance of thrombocytopenia and platelet transfusions during venovenous (VV) ECMO. The multicenter, prospective observational PROTECMO study included 652 adult patients who received VV ECMO for respiratory failure. Thrombocytopenia was classified as mild (100–149·109/L), moderate (50–99·109/L), or severe (< 50·109/L). Bleeding events were evaluated using a modified Bleeding Academy Research Consortium score. Cox proportional hazards and logistic regression analyses were done to identify predictors, and quantify the association between platelet counts and bleeding risk. A total of 182 patients (27.9%) had thrombocytopenia at baseline (mild in 14.7%, moderate in 8.7%, and severe in 4.4%). Thrombocytopenia during ECMO, at least once in 80.2% of patients, was mild in 21.3% of cases, moderate in 32.2%, and severe in 26.7%. A 10·109/L decrease in platelet count was associated with a 3.7% (95% CI: 2.4–5.0%) increase in risk of bleeding. There was no strong evidence of nonlinear relationship within the platelet count range between 25,000 and 300,000. This relation remained consistent across all ECMO weeks. Mild thrombocytopenia increased the risk of experiencing a bleeding event by 61% (hazard ratio (HR) 1.611, 95% CI 1.230–2.109, p = 0.0005), while moderate and severe thrombocytopenia increased the risk by roughly 90% (moderate: HR 1.944 (CI 1.484–2.545), p < 0.0001; severe: HR 1.876 (CI 1.275–2.7680), p = 0.0014). The risk for thrombocytopenia < 100·109/L during ECMO significantly increased with ICU days prior to ECMO start, postoperative admission, immunocompromised state, renal replacement therapy, septic shock, low hemoglobin, and circuit exchange. Thrombocytopenia is highly prevalent in VV ECMO, and associated with a significant increase in the risk of bleeding, and a reduction in 6-month survival, particularly at platelet counts below 100·109/L. Further research is needed to better define the outcomes associated with specific thresholds for transfusion of platelets.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"115 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144792636","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":"Real-world evaluation of eadyn as a predictor of vasopressor weaning success in critically ill patients: a retrospective cohort study","authors":"Yoshihiro Nagai, Shohei Ono, Shigehiko Uchino, Shinshu Katayama, Yusuke Iizuka","doi":"10.1186/s13054-025-05592-4","DOIUrl":"https://doi.org/10.1186/s13054-025-05592-4","url":null,"abstract":"&lt;p&gt;Dynamic arterial elastance (Eadyn), defined as the ratio of pulse pressure variation (PPV) to stroke volume variation (SVV) [1], has been reported in previous studies as a reliable index for assessing pressure responsiveness to volume expansion and vasopressor weaning. Its clinical utility has also been studied by randomized controlled trials [2, 3]. Among the available methods for measuring SVV, FloTrac® sensor (Edwards Lifesciences, Irvine, CA, USA) is particularly advantageous due to its ease and ability to provide continuous measurements. However, concerns have been raised regarding the issue of mathematical coupling, which can occur when both PPV and SVV are derived from the same arterial pressure waveform, potentially leading to biased estimates [4]. Additionally, some studies using FloTrac® for SVV measurement have reported low area under the receiver operating characteristic curve (AUROC) values for Eadyn. Given these concerns and the small sample sizes in previous studies, we conducted a larger analysis to validate the clinical utility of Eadyn using FloTrac®.&lt;/p&gt;&lt;p&gt;This is a single-center, retrospective cohort study using data from ACSYS® (Advanced Critical Care System, Philips Japan, Tokyo, Japan) from August 2017 to July 2024. Patients included in this study were those aged 18 years or older, who received vasopressors within 24 h of ICU admission, met the criteria for vasopressor reduction, and were monitored with FloTrac® (Supplementary document 1 and 2). Patient demographics and physiological parameters were collected as described in Supplementary document 3. SVV was measured using FloTrac® sensor, and PPV was measured using the same arterial pressure waveform as that used by FloTrac®. Positive responses were defined as a ≥ 15% decrease in mean arterial pressure (MAP) or the need for additional vasopressors (Supplementary document 2). ROC curves were generated to assess predictive performance, with AUROC, optimal cutoff, sensitivity, specificity, and diagnostic odds ratio reported. Subgroup analyses were conducted according to several variables including primary diagnosis at ICU admission, type of vasopressor administered, vasopressor dose prior to reduction, extent of dose reduction and modality of respiratory support. Several sensitivity analyses were also conducted by applying the following alternative assumptions: (1) the first vasopressor dose reduction event per patient, (2) a positive response as a ≥ 10% decrease in MAP; (3) baseline values obtained from 15 to 5 min before dose reduction; (4) post-reduction values obtained from either 15 to 25 min or 35 to 45 min after the intervention. (Supplementary document 4).&lt;/p&gt;&lt;p&gt;Among 10,710 patients admitted to the ICU, 542 patients were included in the analysis, with a total of 3,867 vasopressor de-escalation events (Supplementary Figure). Demographics and clinical information of the included patients are presented in Supplementary Table 1, and the characteristics of each vasopre","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"35 1","pages":"350"},"PeriodicalIF":15.1,"publicationDate":"2025-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144797114","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":"Neurofilament light chain for prognostication after cardiac arrest-first steps towards validation","authors":"Martin A. S. Meyer, Rasmus P. Beske, Simon Mølstrøm, Johannes Grand, Laust E. R. Obling, Sebastian Wiberg, Britt Borregaard, Simon Schneekloth, Sif Grau Kaad, Pernille M. Christensen, Christina Christoffersen, Ruth Frikke-Schmidt, Henrik Schmidt, Jacob E. Møller, Jesper Kjaergaard, Christian Hassager","doi":"10.1186/s13054-025-05579-1","DOIUrl":"https://doi.org/10.1186/s13054-025-05579-1","url":null,"abstract":"After cardiac arrest, many patients remain comatose, and a substantial proportion do not survive. Neuroprognostication is essential for identifying patients with potential for recovery, and those with severe, irreversible hypoxic-ischemic brain injury. Neurofilament light chain (NfL) is a blood-based marker of neuronal injury that is under evaluation for neuroprognostication. NfL have potential advantages over the currently only guideline recommended blood biomarker for neuroprognostication, neuron-specific enolase, including earlier applicability. However, there is no consensus on optimal NfL cut-off levels. A previous large investigation in OHCA patients, identified NfL thresholds with high specificity for poor outcome, and the purpose of the present investigation is to validate these cutoffs. The Blood Pressure and Oxygenation Targets in Post Resuscitation Care (BOX) trial included OHCA patients who were comatose at admission. Patients with at least one plasma biobank sample available at 24–48 h were included in this investigation. NfL was quantified by ELISA. Cerebral performance category score was estimated at 1 year. Diagnostic precision of NfL for prediction of poor neurologic outcome (CPC > 2) was determined by area under the receiver operator curve (AUROC), and the performance of previously identified cut-offs for a specificity of 100% were investigated. A total of 638 patients had a NfL measurement at either 24 or 48 h. The AUROC for prediction of poor neurologic outcome was 0.95 and 0.95 at 24 and 48 h, respectively. At 24 h, a cut-off of 1232 pg/mL had a specificity of 98%, for prediction of poor neurologic outcome, and false-positive results for 7 patients (1.4%). At 48 h, a cut-off of 1539 pg/ml similarly had a specificity of 98%, and false-positive results for 7 patients (1.3%). The results of this investigation confirm the prognostic value of NfL for identification of risk of poor neurologic outcome after cardiac arrest. Previously identified cut-offs of 1232 pg/mL at 24 h, and 1539 pg/mL at 48 h, performed excellent with a very high specificity. This indicates that application of NfL will allow for reliable neuroprognostication as early as 24 h after cardiac arrest. ClinicalTrials.gov NCT03141099, registered April 30 2017","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"728 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144786541","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}