Critical Care最新文献

{"title":"Effect of a generalized early mobilization and rehabilitation protocol on outcomes in trauma patients admitted to the intensive care unit: a retrospective pre–post study","authors":"Tsuyoshi Ichikawa, Asuka Tsuchiya, Yusuke Tsutsumi, Tatsuya Okawa, Daisuke Kubo, Yu Horimizu, Ryo Tsutsui, Hina Shukumine, Kento Noda, Katsuhiro Mizuno","doi":"10.1186/s13054-025-05570-w","DOIUrl":"https://doi.org/10.1186/s13054-025-05570-w","url":null,"abstract":"The impact of early mobilization and rehabilitation protocol (EMRP) on trauma patients admitted to the intensive care unit (ICU) remains unclear owing to limited randomized controlled trials and methodological limitations in observational studies. This study aimed to compare the clinical outcomes of trauma patients admitted to the ICU before and after EMRP implementation. A retrospective pre–post study was conducted on adult trauma patients having an Injury Severity Score ≥ 9 who were admitted to the ICU of a university hospital. Patients admitted from July 2021 to June 2022 comprised the pre-EMRP group, whereas those admitted from July 2022 to August 2023 comprised the post-EMRP group. Outcomes were compared between these two groups using propensity score matching to adjust for confounders. The primary outcome was the proportion of home discharge. The secondary outcomes were the Barthel Index score at hospital discharge, length of stay (LOS) in the ICU and hospital; Functional Status Score for the ICU at ICU discharge; and cumulative rate of patients reaching ICU Mobility Scale (IMS) levels ≥ 3, ≥4, and ≥ 7 within 28 days after ICU admission. Among 552 eligible patients, 254 and 298 were admitted during the pre-EMRP and post-EMRP phases, respectively. In the propensity score-matched cohort, the post-EMRP group showed a higher proportion of home discharge (52.1% vs. 41.1%, difference: 11.0%, 95% confidence interval [CI]: 1.7–20.2%), higher Barthel Index score at hospital discharge (95.0 [55.0–100.0] vs. 80.0 [40.0–100.0], P = 0.007), and shorter LOS in the ICU (5.0 [3.0–11.0] vs. 7.0 [4.0–11.0] days, P = 0.03) than the pre-EMRP group. EMRP was associated with a higher rate of patients reaching IMS levels ≥ 3 (hazard ratio [HR]: 1.29, 95% CI: 1.06–1.57), ≥ 4 (HR: 1.27, 95% CI: 1.03–1.56), and ≥ 7 (HR: 1.36, 95% CI: 1.08–1.70). Compared with pre-EMRP implementation, EMRP for adult trauma patients was associated with a higher proportion of home discharge, an improved Barthel Index score at hospital discharge, and a shorter LOS in the ICU. These findings indicate that EMRP may facilitate returning home by improved physical function.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"49 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144737634","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":"Not all pulse contour algorithms are created equal","authors":"Frederic Michard, Stefano Romagnoli","doi":"10.1186/s13054-025-05589-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05589-z","url":null,"abstract":"<p>We read with interest the article by Lamarche-Fontaneto et al. [1] on cardiac output (CO) monitors in septic shock. We fully agree that pulmonary artery catheterization and transpulmonary thermodilution have value in this context, not only for measuring CO but also for gaining additional insights, such as pulmonary artery pressures or extravascular lung water. However, we felt that pulse contour techniques were dismissed too quickly, without considering the differences between the underlying algorithms.</p><p>Pulse contour techniques are generally classified as either calibrated or non-calibrated, with the common belief that calibrated ones are more accurate and precise. It is important to note that the algorithms may be identical. For example, the PiCCO and the ProAQT systems (Getinge, Sweden) use the same pulse contour algorithm. Similarly, the LiDCOplus and LiDCOrapid systems rely on the same PulseCO algorithm (Masimo, USA). The former are simply calibrated or reset periodically using dilution methods, while the latter are not. Consequently, calibrated methods are seen as more accurate, not because they have superior algorithms, but primarily because they are regularly reset to reference values.</p><p>Regarding uncalibrated pulse contour analysis, it is unclear why Lamarche-Fontaneto et al. [1] mentioned that “PRAM is not plug-and-play and waveform quality must be continuously verified and optimized.” Unlike the FloTrac and ProAQT algorithms, which require specific pressure transducers, the PRAM algorithm can analyze arterial pressure waveforms recorded with any standard pressure transducer. Therefore, it is easier to set up. This feature, shared with other algorithms (e.g., the MBA algorithm from Retia, USA), also offers the advantage of improving the sustainability and reducing the cost of CO monitoring [2]. Additionally, all algorithms that analyze waveform characteristics are affected by artifacts and damping phenomena, and we are not aware of any studies comparing how abnormal waveforms impact the performance of existing pulse contour algorithms. Notably, the PRAM algorithm now incorporates an electronic filter specifically designed to detect and correct underdamping phenomena [3], which may offer an advantage over other pulse contour methods. Regardless of the algorithm used, clinicians need to inspect the arterial pressure waveform for abnormalities and address them promptly. Failure to do so can lead to inaccurate blood pressure and CO measurements.</p><p>Clinical studies have reported significant variability in the performance of uncalibrated pulse contour algorithms. This variability likely stems from differences in clinical settings (operating room vs. ICU) and patient conditions (hemodynamic stability vs. instability). The heterogeneity of validation studies complicates any direct comparison between algorithms. However, a few studies [4,5,6,7,8] have directly compared several pulse contour algorithms against a reference CO measu","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"25 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144737747","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":"Climate change impacts: survival on, and of, intensive care","authors":"Hugh Montgomery","doi":"10.1186/s13054-025-05565-7","DOIUrl":"https://doi.org/10.1186/s13054-025-05565-7","url":null,"abstract":"<p>‘Greenhouse gases’ [GHG] such as carbon dioxide (CO₂) transmit shortwave solar radiation, but trap heat energy. We are adding vast and ever-increasing quantities to our atmosphere - the equivalent of 57 billion tonnes of CO₂ (3 × 10²⁵ litres) in 2024 alone [1]. Their concentrations are rising faster every year- CO₂ by 2.6 ppm/year, to a concentration of &gt; 427 ppm (from a preindustrial baseline of 280ppm), now trapping the energy equivalent of 8 Hiroshima Bomb’s/hour.</p><p>The oceans are gaining heat- in 2024, a (record) 16 × 10²¹ Joules was added to its top 2 km- enough to take 15 billion Olympic swimming pools from 0 ^oC to 100 ^oC [2]. The gaseous atmosphere is heating- to 1.6 ^oC above preindustrial levels in 2024- at an accelerating rate [3]. Ice melt- 28 trillion tonnes lost between 1994 and 2017- is accelerating, rising 57% (from 0.8 to 1.2 trillion tonnes/year) since the 1990 s [4]. Sea level rise, now nearly 1 cm every 2 years from land ice melt and thermal ocean expansion, has accelerated, its rate doubling in recent decades [5].</p><p>We now face ‘acceleration of these accelerations’ from interacting positive feedback loops. Snow and ice melt means less to reflect light back into space, and more exposed dark soil/ocean to absorb heat. This adds an energy gain equivalent of an extra 100ppm atmospheric CO₂. Emissions of methane (83x as potent a GHG as CO₂ over its first 20 years) from (rebranded) ‘Natural Gas’, belching cows, rubbish tips and more, is now supplemented by release from melting permafrost, heated carbonate rocks and wetland fermentation, and its atmospheric clearance reduced by fires (tree bark microbiomes break it down; carbon monoxide extends its atmospheric half-life). Wildfires release (GHG) CO₂, and (atmospheric heating/glacier melting) black soot. Water vapour from ocean evaporation is a high-altitude GHG, and tundra/rainforest heating is leading to both becoming net CO₂ emitters [6]. Finally, the full force of global heating is being revealed as loss of (reflective) low-altitude cloud occurs (reviewed in [7]).</p><p>Abrupt and catastrophic changes are occurring to global weather systems. Polar heating (<i>≤</i> 4x faster than the global average) is accelerating and moving the Northern Jet Stream, worsening Iberian droughts and Northern European flooding, and bringing even more extreme weather events. Collapse or severe slowing of the Atlantic Meridional Overturning Circulation (AMOC, transporting massive heat loads around the N hemisphere) is imminent. Massive sudden Arctic heating may soon accelerate these impacts and those on sea level (reviewed in [7]).</p><p>None can have failed to notice the increasingly frequent and severe extreme weather events (storms, heatwaves, droughts, floods, fires): up 83% between 1980 and 1999 and 2000–2019 [7]. Heatwave exposure is rising [8]. The land","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"13 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144737635","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":"Vasopressin and its analogues in patients with septic shock: holy Grail or unfulfilled promise?","authors":"Quentin Lajoye, Arthur Orieux, Alexandre Boyer, Renaud Prevel, Mathieu Jozwiak","doi":"10.1186/s13054-025-05540-2","DOIUrl":"https://doi.org/10.1186/s13054-025-05540-2","url":null,"abstract":"The Surviving Sepsis Campaign (SSC) recommends norepinephrine as first-line vasopressor in patients with septic shock. For many years, there has been growing evidence that high doses of norepinephrine might have cardiac and immunological adverse effects and be associated with poorer outcomes. Current SSC guidelines therefore suggest adding vasopressin, a non-catecholaminergic vasopressor, as a second-line vasopressor rather than increasing the norepinephrine dose in patients requiring doses of norepinephrine base > 0.25–0.50 µg/kg/min, after excluding persistent hypovolemia and cardiac dysfunction. Vasopressin is a peptide hormone that causes vasoconstriction through its specific receptor, the arginine vasopressin receptor V1. Up to one-third of patients with septic shock may have vasopressin deficiency, which contributes to refractory septic shock. Vasopressin use is associated with a norepinephrine-sparing effect, which may in turn reduce the complications induced by high-doses of norepinephrine, by decreasing the vasopressor load: this is the concept of decatecholaminization. Nevertheless, the use of vasopressin in patients with septic shock has not yet demonstrated clear benefits in terms of patient outcomes, such as less cardiotoxicity, reduced use of renal replacement therapy or decreased mortality. The heterogeneity in the use of vasopressin and the definition of early vasopressin administration between different studies as well as many unresolved issues regarding the use of vasopressin in patients with septic shock could explain the absence of clear and relevant clinical benefits. Thus, the identification of subgroups of patients likely to benefit the most from vasopressin, the management of vasopressin administration (time to initiation, optimal doses, weaning strategy) and a better understanding of the interactions between vasopressin and corticosteroids represent major areas of research for future studies. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144719520","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":"Use of extracorporeal membrane oxygenation in adult trauma patients with refractory acute cardiopulmonary failure: guideline from the Chinese society of extracorporeal life support 2025","authors":"Hua Wang, Zhongran Cen, Xingxing Liu, Zhanguo Liu, Xiaotong Hou, Xiangdong Guan, Jianfeng Wu, Yimin Li, Yonghao Xu, Chengbin Zhou, Zhiyong Peng, Fachun Zhou, Tongwen Sun, Bingyu Qin, Jiandong Lin, Lina Zhang, Jinghui Li, You Shang, Songqiao Liu, Zhenhua Zeng, Xiaowu Wang, Qunqing Chen, Yanwu Guo, Changbiao Peng, Yang Wang, Songjian Li, Chunyao Wang, Shulin Xiang, Zhou Cheng, Peihua Cao, Jie Jiang, Yihao Chen, Duoduo Yu, Wenzhan Liao, Ye Liao, Xiaoqin Cheng, Limei Chen, Yuxuan He, Jie He, Qingling Guo, Zenghui Yue, Ke Deng, Ying Tang, Bo Huang, Cuiping Liu, Sheng Peng, Jing Cai, Yaru Zhu, Kai Wang, Yangyang Wang, Qianwen Wang, Jingjing Yang, Maoyou Shichen, Zhuo Li, Manli Guo, Xueshan Luo","doi":"10.1186/s13054-025-05504-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05504-6","url":null,"abstract":"Adult trauma patients with refractory acute cardiopulmonary failure suffer from high morbidity and mortality. In the past decade, a growing body of researches has shown survival benefits of extracorporeal membrane oxygenation (ECMO) in trauma patients who fail to respond to optimal damage control resuscitation (DCR), and there is an opportunity to formulate clinical practice guidelines to guide clinicians in implementing trauma ECMO at the bedside. The Chinese Society of Extracorporeal Life Support (CSECLS) convened a domestic panel of interdisciplinary experts to develop this guideline, adhering to the principles of the World Health Organization (WHO) Manual for Guideline Development and the policy of conflict of interest. Clinical key questions pertaining to trauma ECMO use were informed from expert interviews and literature reviews, and formulated as PICO (Population/Intervention/Comparison/Outcome) format for literature retrieval of original studies supporting the question. Then, panelists were assigned to address specific clinical questions, synthesize evidence, formulate recommendations and determine their strength, following the Recommendations Assessment, Development and Evaluation (GRADE) framework. The guideline steering committee and stakeholders approved the final document. Eleven recommendations regarding trauma ECMO use in adult patients were formulated, focusing on the following topics: (1) indications; (2) patient screening; (3) timing of initiation; (4) multidisciplinary approach; (5) trauma ECMO management; and (6) complication prevention. Supporting evidences are elaborated in detail, and expert opinions on clinical application and future research provided. Although the quality of the body of evidence is low to very-low, most researches have shown that ECMO improves the survival of adult trauma patients with varied injury mechanisms. However, decision-making should consider the individual characteristics, benefits and potential harms, patients’ values and preferences, and long-term outcomes. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"26 1","pages":"334"},"PeriodicalIF":15.1,"publicationDate":"2025-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144737746","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":"Candida auris infections in ICU patients: risk factors, outcomes, and antifungal resistance patterns","authors":"Satyajit Choudhury, Kalpana Majhi, Pragati Jena, Sritam Mohanty, Yallawar Nipun Narayan, Pragnya Paramita Jena, Shakti Bedanta Mishra, Sagarika Panda","doi":"10.1186/s13054-025-05544-y","DOIUrl":"https://doi.org/10.1186/s13054-025-05544-y","url":null,"abstract":"Candida auris has emerged as a major nosocomial pathogen in intensive care units worldwide due to its multidrug resistance, environmental persistence, and high transmission potential. While several outbreak reports exist, there remains limited comparative data on clinical features, resistance profiles, and outcomes between Candida auris and non-auris Candida candidemia, particularly in Indian ICU settings. This study aimed to evaluate the incidence, risk factors, antifungal resistance, and clinical outcomes of Candida auris bloodstream infections in comparison to non-auris Candida infections among ICU patients. This retrospective cohort study was conducted over four years (January 2020–December 2023) in the ICU of a tertiary care hospital in eastern India. Adult patients (≥ 18 years) with culture-confirmed candidemia were included and stratified into Candida auris and non-auris groups. Demographic, clinical, therapeutic, and microbiological data were extracted. Antifungal susceptibility testing was performed as per CLSI and CDC guidelines. Multivariate logistic regression identified risk factors associated with Candida auris infection. Survival analysis were compared using Kaplan–Meier and Cox regression analysis. Of 267 ICU patients with candidemia, 38 (14.2%) had Candida auris infection. Candida auris patients were older (median age 60 vs. 53 years) and had lower SOFA scores at admission (median 7 vs. 8; p = 0.02). On multivariate analysis, increasing age (OR 1.10, p = 0.0003) and female sex (OR 16.35, p = 0.012) were independently associated with Candida auris infection. Fluconazole resistance was 94.7% in Candida auris isolates, with amphotericin B and echinocandin resistance in 39.5% and 7.9%, respectively. ICU mortality did not differ significantly between Candida auris and non-auris groups (31.6% vs. 34.5%; p = 0.854), and survival analysis showed no statistically significant difference (log-rank p = 0.07). This study highlights the growing burden of Candida auris in intensive care unit settings, demonstrating a substantial incidence without increased mortality compared to non-auris Candida species. Advancing age and female sex emerged as significant independent risk factors, emphasizing the need for continued surveillance and targeted risk assessment in regions where Candida auris is endemic.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"12 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144719521","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":"Gingival capillary refill time: a new approach to assess tissue perfusion","authors":"Matthias Jacquet-Lagrèze, Martin Ruste, Elodia Noumedem, Nourredine Bouhamri, Philippe Portran, Jean-Luc Fellahi","doi":"10.1186/s13054-025-05555-9","DOIUrl":"https://doi.org/10.1186/s13054-025-05555-9","url":null,"abstract":"&lt;p&gt;Acute circulatory is a life-threatening condition, marked by inadequate tissue perfusion and oxygen delivery, leading to cellular dysfunction. Capillary refill time (CRT) is a widely used bedside marker of tissue perfusion but has limitations due to its sensitivity to temperature, pigmentation, and peripheral vascular disease [1, 2]. In veterinary medicine, gingival capillary refill time (GRT) is used to assess circulatory status via mucosal microcirculation, but its relevance in humans is unexplored [3]. GRT may provide a more robust alternative by directly assessing mucosal microcirculation and mitigating CRT limitations.&lt;/p&gt;&lt;p&gt;We conducted an ancillary analysis of the PeachCART cohort (NCT02248025) [4] to evaluate the feasibility, reproducibility, and clinical relevance of GRT in critically ill patients receiving fluid resuscitation for acute circulatory failure. We hypothesized that GRT would be feasible, correlate with CRT, and be a reliable predictor of perfusion-based fluid responsiveness.&lt;/p&gt;&lt;p&gt;The protocol was approved by the institutional review board; Oral and written information was given to all patients or relatives. Signed consent was waived by the ethics committee. GRT and CRT were recorded using an iPhone 6™ (8 MP camera). GRT involved applying calibrated pressure to the gingival mucosa with a 2 mL air-filled syringe compressed to 1 mL for 7 s. Four videos were taken per step by a single investigator and analyzed by two blinded readers. CRT was measured on chest skin using a 10 mL syringe compressed to 7 mL, as previously described. Volume expansion consisted of 500 mL lactated Ringer over 20 min, without changes in sedation or vasoactive drugs. Patients were monitored with PiCCO™ and thermodilution was performed before and after volume expansion. Metabolic and hemodynamic parameters, general patient characteristics, and Fitzpatrick skin phototype were also recorded. Primary outcomes were GRT feasibility and reproducibility; secondary outcomes included its correlation with CRT, predictive value for perfusion based fluid responsiveness (≥ 25% CRT reduction) [4], and association with hemodynamic and metabolic parameters.&lt;/p&gt;&lt;p&gt;Thirty-two patients were analyzed (median age: 62 [54–69] years, median SOFA score: 9 (6–11), SAPS II: 43 (33–51), and 84% on mechanical ventilation). Median GRT was 2.3 (1.6–3.2) s, and median CRT was 2.9 [2.4–3.8] s. Based on our linear regression model, the classical threshold of 3 s to define abnormal CRT corresponds to an estimated GRT of approximately 2.12 s. GRT was feasible in all patients, with a slightly lower interobserver coefficient of variation (5.2% [95% CI 0.9–9.6]) compared to CRT (7.3% [95% CI 3.9–10.2]). The median Fitzpatrick skin phototype was 3, GRT was easier to read in patients with phototype 1 and 4 as illustrated in Fig. 1. GRT was successfully measured in 97% of patients. No major adverse events were reported, except mild discomfort in one patient.&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-t","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"27 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144719522","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":"Evaluation of the impact of artificial intelligence-assisted image interpretation on the diagnostic performance of clinicians in identifying endotracheal tube position on plain chest X-ray: a multi-case multi-reader study","authors":"Alex Novak, Sarim Ather, Abdala T. Espinosa Morgado, Giles Maskell, Gordon W. Cowell, Douglas Black, Akshay Shah, James S. Bowness, Amied Shadmaan, Claire Bloomfield, Jason L. Oke, Hilal Johnson, Mark Beggs, Fergus Gleeson, Peter Aylward, Aqib Hafeez, Moustafa Elramlawy, Kin Lam, Benjamin Griffiths, Mirae Harford, Louise Aaron, Claire Seeley, Matthew Luney, James Kirkland, Louise Wing, Zahi Qamhawi, Indrajeet Mandal, Thomas Millard, Michelle Chimbani, Athirah Sharazi, Emma Bryant, Wendy Haithwaite, Aurora Medonica","doi":"10.1186/s13054-025-05566-6","DOIUrl":"https://doi.org/10.1186/s13054-025-05566-6","url":null,"abstract":"Incorrectly placed endotracheal tubes (ETTs) can lead to serious clinical harm. Studies have demonstrated the potential for artificial intelligence (AI)-led algorithms to detect ETT placement on chest X-Ray (CXR) images, however their effect on clinician accuracy remains unexplored. This study measured the impact of an AI-assisted ETT detection algorithm on the ability of clinical staff to correctly identify ETT misplacement on CXR images. Four hundred CXRs of intubated adult patients were retrospectively sourced from the John Radcliffe Hospital (Oxford) and two other UK NHS hospitals. Images were de-identified and selected from a range of clinical settings, including the intensive care unit (ICU) and emergency department (ED). Each image was independently reported by a panel of thoracic radiologists, whose consensus classification of ETT placement (correct, too low [distal], or too high [proximal]) served as the reference standard for the study. Correct ETT position was defined as the tip located 3–7 cm above the carina, in line with established guidelines. Eighteen clinical readers of varying seniority from six clinical specialties were recruited across four NHS hospitals. Readers viewed the dataset using an online platform and recorded a blinded classification of ETT position for each image. After a four-week washout period, this was repeated with assistance from an AI-assisted image interpretation tool. Reader accuracy, reported confidence, and timings were measured during each study phase. 14,400 image interpretations were undertaken. Pooled accuracy for tube placement classification improved from 73.6 to 77.4% (p = 0.002). Accuracy for identification of critically misplaced tubes increased from 79.3 to 89.0% (p = 0.001). Reader confidence improved with AI assistance, with no change in mean interpretation time at 36 s per image. Use of assistive AI technology improved accuracy and confidence in interpreting ETT placement on CXR, especially for identification of critically misplaced tubes. AI assistance may potentially provide a useful adjunct to support clinicians in identifying misplaced ETTs on CXR.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"49 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144715322","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 impact of intensive care strain on patients’ outcomes—a multinational observational cohort (UNITE-COVID) study","authors":"Katharina Kohler, Thomas De Corte, Massimiliano Greco, Pedro Povoa, Maurizio Cecconi, Marlies Ostermann, Jan De Waele, Andrew Conway Morris","doi":"10.1186/s13054-025-05521-5","DOIUrl":"https://doi.org/10.1186/s13054-025-05521-5","url":null,"abstract":"Intensive care unit (ICU) strain is associated with increased mortality. Most strain metrics focus on ‘simple’ measures such as bed occupancy or admission rates. There is limited data on mitigation strategies, such as procedure teams or staff well-being services on strain, or the impact of increased patient-to-nurse ratios and non-ICU trained nurses working in ICU. Using the multi-national UNITE-COVID study, collecting data from ICUs on their day of peak bed occupancy in two periods (2020 and 2021) of the COVID-19 pandemic, we evaluated metrics of strain (Bed occupancy, patient: nurse ratio, use of non-ICU staff and shortages of consumables) and potential mitigators (procedural support teams and staff well-being interventions). We examined how these related to outcomes (mortality, complications, length of stay). In both epochs, ICUs experienced significant strain, with ICU bed expansion to 133% and 163% respectively, whilst patient-to-nurse ratios increased by 0.4 and 0.3. Consumable shortages were widespread in 2020. Mortality was inversely correlated with staff well-being interventions in both epochs. Complications were inversely correlated with procedure support teams, and positively correlated with staffing ratios. In regression models, pressure sores were reduced in presence of support teams (p = 0.004) and increased with increasing patients per nurse (p = 0.05) whilst unplanned extubations were related to non-ICU trained staff working in ICU(p = 0.02). COVID-19 induced ICU strain had effects beyond mortality, including increases in complications. Staff pressure and lack of ICU training were related to specific complications, whilst support teams and well-being interventions were associated with improved outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"27 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144715324","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":"Effects of inhaled nitric oxide on ventilation/perfusion mismatch assessed by electrical impedance tomography in patients with ARDS: a prospective observational study","authors":"Hongling Zhang, Xuehui Gao, Yongran Wu, Yaqi Ouyang, Xiangzhi Fang, Ruiting Li, Huaqing Shu, Xiaobo Yang, Hong Qi, Xiaojing Zou, You Shang","doi":"10.1186/s13054-025-05543-z","DOIUrl":"https://doi.org/10.1186/s13054-025-05543-z","url":null,"abstract":"Our study aimed to assess the effects of inhaled nitric oxide (iNO) on ventilation/perfusion mismatch, and individual variability in patients with acute respiratory distress syndrome (ARDS) by electrical impedance tomography (EIT). This single-center, prospective physiological study enrolled mechanically ventilated ARDS patients. All patients initially received 5 ppm iNO; responders (≥ 20% increase in PaO2/FiO2 at 30 min) maintained this dose, while non-responders had their dose doubled every 30 min, up to 40 ppm, until achieving a ≥ 20% improvement. The trial lasted 3 h. EIT data and clinical respiratory and hemodynamic parameters were collected at baseline (0 h), and at 30 min and 3 h after iNO initiation. At 30 min, 36.7% (11/30) of patients responded, associated with younger age and lower prevalence of hypertension. Among responders, the proportion of ventral perfusion significantly increased at 3 h, with this change already observed at 30 min. Responders also showed a significant reduction in the proportion of only perfused units in the dorsal region at 30 min; at the whole-lung level, the proportions of only perfused units and unmatched units decreased. In contrast, non-responders showed an increased proportion of only perfused units in both the dorsal region and whole lung at 3 h compared to baseline, following prolonged high-dose iNO administration. The response to iNO varied. In responders, EIT showed a potential redistribution of lung perfusion toward ventral regions, with reductions in the proportions of only perfused units and unmatched units in the whole lung.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"144 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144712320","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}