Critical Care最新文献

{"title":"Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study","authors":"Gyungah Kim, Dong Kyu Oh, Su Yeon Lee, Mi Hyeon Park, Chae-Man Lim","doi":"10.1186/s13054-024-05064-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05064-1","url":null,"abstract":"The potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU). We analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into ‘early MV’ and ‘delayed MV’ groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared. Out of 2440 patients on MV during ICU stay, 2119 ‘early MV’ and 321 ‘delayed MV’ cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in ‘early MV’ group than ‘delayed MV’ group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47–0.93; p = 0.015). ‘Early MV’ group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than ‘delayed MV’ group. Multivariable logistic regression model identified ‘early MV’ as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29–0.50; p < 0.001). In patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142160665","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":"Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines","authors":"Sung-Min Cho, Jaeho Hwang, Giovanni Chiarini, Marwa Amer, Marta V. Antonini, Nicholas Barrett, Jan Belohlavek, Daniel Brodie, Heidi J. Dalton, Rodrigo Diaz, Alyaa Elhazmi, Pouya Tahsili-Fahadan, Jonathon Fanning, John Fraser, Aparna Hoskote, Jae-Seung Jung, Christopher Lotz, Graeme MacLaren, Giles Peek, Angelo Polito, Jan Pudil, Lakshmi Raman, Kollengode Ramanathan, Dinis Dos Reis Miranda, Daniel Rob, Leonardo Salazar Rojas, Fabio Silvio Taccone, Glenn Whitman, Akram M. Zaaqoq, Roberto Lorusso","doi":"10.1186/s13054-024-05082-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05082-z","url":null,"abstract":"Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142142430","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":"Glucocorticoid treatment increases cholesterol availability during critical illness: effect on adrenal and muscle function","authors":"Lauren De Bruyn, Arno Téblick, Tim Van Oudenhove, Sarah Vander Perre, Inge Derese, Lies Pauwels, Sarah Derde, Greet De Vlieger, Greet Van den Berghe, Lies Langouche","doi":"10.1186/s13054-024-05079-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05079-8","url":null,"abstract":"Hypocholesterolemia hallmarks critical illness though the underlying pathophysiology is incompletely understood. As low circulating cholesterol levels could partly be due to an increased conversion to cortisol/corticosterone, we hypothesized that glucocorticoid treatment, via reduced de novo adrenal cortisol/corticosterone synthesis, might improve cholesterol availability and as such affect adrenal gland and skeletal muscle function. In a matched set of prolonged critically ill patients (n = 324) included in the EPaNIC RCT, a secondary analysis was performed to assess the association between glucocorticoid treatment and plasma cholesterol from ICU admission to day five. Next, in a mouse model of cecal ligation and puncture-induced sepsis, septic mice were randomized to receive either hydrocortisone (1.2 mg/day) (n = 17) or placebo (n = 15) for 5 days, as compared with healthy mice (n = 18). Plasma corticosterone, cholesterol, and adrenocortical and myofiber cholesterol were quantified. Adrenal structure and steroidogenic capacity were evaluated. Muscle force and markers of atrophy, fibrosis and regeneration were quantified. In a consecutive mouse study with identical design (n = 24), whole body composition was assessed by EchoMRI to investigate impact on lean mass, fat mass, total and free water. In human patients, glucocorticoid treatment was associated with higher plasma HDL- and LDL-cholesterol from respectively ICU day two and day three, up to day five (P < 0.05). Plasma corticosterone was no longer elevated in hydrocortisone-treated septic mice compared to placebo, whereas the sepsis-induced reduction in plasma HDL- and LDL-cholesterol and in adrenocortical cholesterol was attenuated (P < 0.05), but without improving the adrenocortical ACTH-induced CORT response and with increased adrenocortical inflammation and apoptosis (P < 0.05). Total body mass was further decreased in hydrocortisone-treated septic mice (P < 0.01) compared to placebo, with no additional effect on muscle mass, force or myofiber size. The sepsis-induced rise in markers of muscle atrophy and fibrosis was unaffected by hydrocortisone treatment, whereas markers of muscle regeneration were suppressed compared to placebo (P < 0.05). An increased loss of lean body mass and total and free water was observed in hydrocortisone-treated septic mice compared to placebo (P < 0.05). Glucocorticoid treatment partially attenuated critical illness-induced hypocholesterolemia, but at a cost of impaired adrenal function, suppressed muscle regeneration and exacerbated loss of body mass. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142138348","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":"Divergent effects of tumor necrosis factor (TNF) in sepsis: a meta-analysis of experimental studies.","authors":"Christian Kassasseya, Ligia Iulia Torsin, Caroline Musset, Marc Benhamou, Irshad H Chaudry, Jean-Marc Cavaillon, Nathalie Grall, Renato Monteiro, Luc de Chaisemartin, Dan Longrois, Philippe Montravers, Christian de Tymowski","doi":"10.1186/s13054-024-05057-0","DOIUrl":"10.1186/s13054-024-05057-0","url":null,"abstract":"<p><strong>Introduction: </strong>Experimental studies in animals have yielded conflicting results on the role of Tumor Necrosis Factor (TNF) in sepsis and endotoxemia, with some reporting adaptive and others inappropriate effects. A meta-analysis of the available literature was performed to determine the factors explaining this discrepancy.</p><p><strong>Methods: </strong>The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The protocol was registered with PROSPERO (CRD42020167384) prior to data collection. PubMed and Embase were the databases queried. Risk of bias was evaluated using the SYRCLE Risk of Bias Tool. All animal studies investigating sepsis-related mortality and modified TNF signaling were considered eligible. The exclusion criteria were: lack of mortality data, 7-day mortality rates below 10% in both wild type and TNF-altered pathway animals, and absence of an English abstract. To determine the role of TNF according to the experimental protocol, three approaches were used: first an approach based on the statistical significance of each experiment, then the pooled mortality was calculated, and finally the weighted risk ratio for mortality was assessed.</p><p><strong>Results: </strong>A total of 175 studies were included in the analysis, comprising a total of 760 experiments and involving 19,899 animals. The main species used were mice (77%) and rats (21%). The most common method of TNF pathway modulation was TNF pathway inactivation that was primarily associated with an inappropriate secretion of TNF. At the opposite, TNF injection was associated with an adaptive role of TNF. Lipopolysaccharide (LPS) injection was the most used stimulus to establish an infectious model (42%) and was strongly associated with an inappropriate role of TNF. Conversely, live bacterial models, especially the cecal ligation and puncture (CLP) model, pneumonia, meningitis, and gastrointestinal infection, were associated with an adaptive role. This was particularly evident for Listeria monocytogenes, Streptococcus pneumoniae.</p><p><strong>Conclusion: </strong>The role of TNF during infection varies depending on the experimental model used. Models that mimic clinical conditions, based on virulent bacteria that cause high mortality even at low inocula, demonstrated an adaptive role of TNF. Conversely, models based on LPS or low-pathogenic live bacteria, administered at doses well above physiological thresholds and combined with early antibiotic therapy, were associated with an inappropriate role.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11373197/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142124996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cerebral physiologic insult burden in acute traumatic neural injury: a Canadian High Resolution-TBI (CAHR-TBI) descriptive analysis","authors":"Kevin Y. Stein, Alwyn Gomez, Donald Griesdale, Mypinder Sekhon, Francis Bernard, Clare Gallagher, Eric P. Thelin, Rahul Raj, Marcel Aries, Logan Froese, Andreas Kramer, Frederick A. Zeiler","doi":"10.1186/s13054-024-05083-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05083-y","url":null,"abstract":"Over the recent decades, continuous multi-modal monitoring of cerebral physiology has gained increasing interest for its potential to help minimize secondary brain injury following moderate-to-severe acute traumatic neural injury (also termed traumatic brain injury; TBI). Despite this heightened interest, there has yet to be a comprehensive evaluation of the effects of derangements in multimodal cerebral physiology on global cerebral physiologic insult burden. In this study, we offer a multi-center descriptive analysis of the associations between deranged cerebral physiology and cerebral physiologic insult burden. Using data from the Canadian High-Resolution TBI (CAHR-TBI) Research Collaborative, a total of 369 complete patient datasets were acquired for the purposes of this study. For various cerebral physiologic metrics, patients were trichotomized into low, intermediate, and high cohorts based on mean values. Jonckheere–Terpstra testing was then used to assess for directional relationships between these cerebral physiologic metrics and various measures of cerebral physiologic insult burden. Contour plots were then created to illustrate the impact of preserved vs impaired cerebrovascular reactivity on these relationships. It was found that elevated intracranial pressure (ICP) was associated with more time spent with cerebral perfusion pressure (CPP) < 60 mmHg and more time with impaired cerebrovascular reactivity. Low CPP was associated with more time spent with ICP > 20 or 22 mmHg and more time spent with impaired cerebrovascular reactivity. Elevated cerebrovascular reactivity indices were associated with more time spent with CPP < 60 mmHg as well as ICP > 20 or 22 mmHg. Low brain tissue oxygenation (PbtO2) only demonstrated a significant association with more time spent with CPP < 60 mmHg. Low regional oxygen saturation (rSO2) failed to produce a statistically significant association with any particular measure of cerebral physiologic insult burden. Mean ICP, CPP and, cerebrovascular reactivity values demonstrate statistically significant associations with global cerebral physiologic insult burden; however, it is uncertain whether measures of oxygen delivery provide any significant insight into such insult burden.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142130729","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":"Novel cortisol trajectory sub-phenotypes in sepsis","authors":"Fei Leng, Zhunyong Gu, Simeng Pan, Shilong Lin, Xu Wang, Ming Zhong, Jieqiong Song","doi":"10.1186/s13054-024-05071-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05071-2","url":null,"abstract":"Sepsis is a heterogeneous syndrome. This study aimed to identify new sepsis sub-phenotypes using plasma cortisol trajectory. This retrospective study included patients with sepsis admitted to the intensive care unit of Zhongshan Hospital Fudan University between March 2020 and July 2022. A group-based cortisol trajectory model was used to classify septic patients into different sub-phenotypes. The clinical characteristics, biomarkers, and outcomes were compared between sub-phenotypes. A total of 258 patients with sepsis were included, of whom 186 were male. Patients were divided into two trajectory groups: the lower-cortisol group (n = 217) exhibited consistently low and slowly declining cortisol levels, while the higher-cortisol group (n = 41) showed relatively higher levels in comparison. The 28-day mortality (65.9% vs.16.1%, P < 0.001) and 90-day mortality (65.9% vs. 19.8%, P < 0.001) of the higher-cortisol group were significantly higher than the lower-cortisol group. Multivariable Cox regression analysis showed that the trajectory sub-phenotype (HR = 5.292; 95% CI 2.218–12.626; P < 0.001), APACHE II (HR = 1.109; 95% CI 1.030–1.193; P = 0.006), SOFA (HR = 1.161; 95% CI 1.045–1.291; P = 0.006), and IL-1β (HR = 1.001; 95% CI 1.000–1.002; P = 0.007) were independent risk factors for 28-day mortality. Besides, the trajectory sub-phenotype (HR = 4.571; 95% CI 1.980–10.551; P < 0.001), APACHE II (HR = 1.108; 95% CI 1.043–1.177; P = 0.001), SOFA (HR = 1.270; 95% CI 1.130–1.428; P < 0.001), and IL-1β (HR = 1.001; 95% CI 1.000–1.001; P = 0.015) were also independent risk factors for 90-day mortality. This study identified two novel cortisol trajectory sub-phenotypes in patients with sepsis. The trajectories were associated with mortality, providing new insights into sepsis classification.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123527","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":"Association between arterial oxygen partial pressure and mortality in sepsis","authors":"Xinyuan Ding, Shangzhong Chen","doi":"10.1186/s13054-024-05038-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05038-3","url":null,"abstract":"&lt;p&gt;To the editor,&lt;/p&gt;&lt;p&gt;The appropriate arterial oxygen partial pressure (PaO&lt;sub&gt;2&lt;/sub&gt;) in sepsis patients has been investigated in dozens of studies. However, no consensus has been reached. In a recent study [1], Dr. Hyun et al. investigated the association between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality in critically ill sepsis patients. Data on PaO&lt;sub&gt;2&lt;/sub&gt; of 4147 sepsis patients from the Korea Sepsis Alliance Registry (KSA) during the first three days was extracted, and patients were divided into conservative PaO&lt;sub&gt;2&lt;/sub&gt; group (&lt; 80mmHg) and liberal PaO&lt;sub&gt;2&lt;/sub&gt; group (≥ 80mmHg). Statistical methods, including propensity score matching, mixed linear model, and competitive risk models, were used to explore potential causal relationships. The results showed higher PaO&lt;sub&gt;2&lt;/sub&gt; (≥ 80 mm Hg) during the first three ICU days was associated with a lower 28-day mortality than conservative PaO&lt;sub&gt;2&lt;/sub&gt;. Several issues should be noted when interpreting these findings.&lt;/p&gt;&lt;p&gt;First, dividing the entire cohort into groups based on the cut-off value of one continuous variable is a common strategy in observational studies. In the current research, a cut-off value of 80 mmHg of PaO&lt;sub&gt;2&lt;/sub&gt; was used. However, the results may be biased when the correlation between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality is non-linear. For instance, previous studies [2, 3] have pointed out that there may be a U-shaped correlation between PaO&lt;sub&gt;2&lt;/sub&gt; and death, which means either extremely high or low PaO&lt;sub&gt;2&lt;/sub&gt; may be associated with increased mortality compared to normal PaO&lt;sub&gt;2&lt;/sub&gt;. In this case, whether there is a difference between the conservative and liberal PaO&lt;sub&gt;2&lt;/sub&gt; groups can be significantly affected by the cut-off value. For instance, in the current study, the restrictive cubic spline between PaO&lt;sub&gt;2&lt;/sub&gt; and mortality showed that the PaO&lt;sub&gt;2&lt;/sub&gt; with the lowest mortality possibility was around 100mmHg. Thus, when using 80mmHg as the cut-off value, the comparison between conservative (PaO&lt;sub&gt;2min&lt;/sub&gt; &lt; 80mmHg) and liberal (PaO&lt;sub&gt;2min&lt;/sub&gt; ≥ 80mmHg) PaO&lt;sub&gt;2&lt;/sub&gt; groups was actually comparing the low PaO&lt;sub&gt;2&lt;/sub&gt; group with the normal PaO&lt;sub&gt;2&lt;/sub&gt; group combined with the high PaO&lt;sub&gt;2&lt;/sub&gt; group (&lt; 80mmHg vs. (80 – 110mmHg + &gt; 110mmHg)), which thus lead to a potentially biased result that liberal PaO&lt;sub&gt;2&lt;/sub&gt; was associated with low mortality rate. Similarly, the difference in mortality rate between the two groups may also be affected by the proportion of patients with high PaO&lt;sub&gt;2&lt;/sub&gt;. In the current study, we noted that the PaO&lt;sub&gt;2&lt;/sub&gt; was relatively low even in the liberal PaO&lt;sub&gt;2&lt;/sub&gt; group (median values were 107, 110, and 106 during three days). In the case of a low proportion of patients with high PaO&lt;sub&gt;2&lt;/sub&gt;, using 80mmHg as the cut-off value may actually be the comparison between the low PaO&lt;sub&gt;2&lt;/sub&gt; group and the normal PaO&lt;sub&gt;2&lt;/sub&gt; group, which may also be one factor for the i","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123563","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":"Mitochondrial dysfunction in sepsis: mechanisms and therapeutic perspectives","authors":"Dongxue Hu, Harshini Sheeja Prabhakaran, Yuan-Yuan Zhang, Gaoxing Luo, Weifeng He, Yih-Cherng Liou","doi":"10.1186/s13054-024-05069-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05069-w","url":null,"abstract":"Sepsis is a severe medical condition characterized by a systemic inflammatory response, often culminating in multiple organ dysfunction and high mortality rates. In recent years, there has been a growing recognition of the pivotal role played by mitochondrial damage in driving the progression of sepsis. Various factors contribute to mitochondrial impairment during sepsis, encompassing mechanisms such as reactive nitrogen/oxygen species generation, mitophagy inhibition, mitochondrial dynamics change, and mitochondrial membrane permeabilization. Damaged mitochondria actively participate in shaping the inflammatory milieu by triggering key signaling pathways, including those mediated by Toll-like receptors, NOD-like receptors, and cyclic GMP-AMP synthase. Consequently, there has been a surge of interest in developing therapeutic strategies targeting mitochondria to mitigate septic pathogenesis. This review aims to delve into the intricate mechanisms underpinning mitochondrial dysfunction during sepsis and its significant impact on immune dysregulation. Moreover, we spotlight promising mitochondria-targeted interventions that have demonstrated therapeutic efficacy in preclinical sepsis models.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142123526","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 anesthetics for lung- and diaphragm-protective sedation","authors":"Lukas M. Müller-Wirtz, Brian O’Gara, Marcelo Gama de Abreu, Marcus J. Schultz, Jeremy R. Beitler, Angela Jerath, Andreas Meiser","doi":"10.1186/s13054-024-05049-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05049-0","url":null,"abstract":"This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100850","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":"Variability in forgoing life-sustaining treatment practices in critically Ill patients with hospital-acquired bloodstream infections: a secondary analysis of the EUROBACT-2 international cohort","authors":"Hannah Wozniak, Alexis Tabah, Jan J. De Waele, Jean-François Timsit, Niccolò Buetti","doi":"10.1186/s13054-024-05072-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05072-1","url":null,"abstract":"The decision to forgo life-sustaining treatment in intensive care units (ICUs) is influenced by ethical, cultural, and medical factors. This study focuses on a population of patients with hospital-acquired bloodstream infections (HABSI) to investigate the association between patient, pathogen, center and country-level factors and these decisions. We analyzed data from the EUROBACT-2 study (June 2019–January 2021) from 265 centers worldwide, focusing on non-COVID-19 patients who died in the hospital or within 28 days after HABSI. We assessed whether death was preceded by a decision to forgo life-sustaining treatment, examining country, center, patient, and pathogen variables. To assess the association of each potentially important variable with the decision to forgo life-sustaining treatment, univariable mixed logistic regression models with a random center effect were performed. Among 1589 non-COVID-19 patients, 519 (32.7%) died, with 191 (36.8%) following a decision to forgo life-sustaining treatment. Significant geographical differences were observed, with no reported decisions to forgo life-sustaining treatment in African countries and fewer in the Middle East compared to Western Europe, Australia, and Asia. Once a center effect was considered, only health expenditure (Odds ratio 1.79, 95%CI: 1.45–2.21, p < 0.01) and age (Odds ratio 1.02, 95%CI: 1.002–1.05, p = 0.03) were significantly associated with decisions to forgo life-sustaining treatment, while other patient and pathogen factors were not. Economic and regional disparities significantly impact end-of-life decision-making in ICUs. Global policies should consider these disparities to ensure equitable end-of-life care practices.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100853","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}