Current Opinion in Critical Care最新文献

{"title":"Critical illness-based chronic disease: a new framework for intensive metabolic support.","authors":"Jeffrey I Mechanick","doi":"10.1097/MCC.0000000000001270","DOIUrl":"10.1097/MCC.0000000000001270","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review addresses the novel concept of critical illness as a potential chronic disease. The high clinical and economic burdens of chronic critical illness and post-ICU syndromes are mainly due to refractoriness to therapy and consequently lead to significant complications. Interventions need to be preventive in nature and therefore a robust disease model is warranted.</p><p><strong>Recent findings: </strong>There are three paradigms that are leveraged to create a new critical illness-based chronic disease (CIBCD) model: metabolic model of critical illness, intensive metabolic support (IMS; insulinization and nutrition support), and driver-based chronic disease modeling. The CIBCD model consists of four stages: risk, predisease, (chronic) disease, and complications. The principal goal of the CIBCD model is to expose early opportunities to prevent disease progression, particularly further morbidity, complications, and mortality. IMS is used to target seminal pathophysiological events such as immune-neuroendocrine axis (INA) activation and failure to downregulate INA activation because of preexisting chronic diseases and recurrent pathological insults.</p><p><strong>Summary: </strong>The CIBCD model complements our understanding of critical illness and provides needed structure to preventive actions that can improve clinical outcomes. Many research, knowledge, and practice gaps exist, which will need to be addressed to optimize and validate this model.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"417-427"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143742369","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Veno-arterial extracorporeal membrane oxygenation.","authors":"Uwe Zeymer, Dirk Westermann","doi":"10.1097/MCC.0000000000001295","DOIUrl":"10.1097/MCC.0000000000001295","url":null,"abstract":"<p><strong>Purpose of review: </strong>Despite improvements in reperfusion and adjunctive therapies cardiogenic shock associated with acute myocardial infarction is still associated with a mortality of 40-50%. Therefore, mechanical circulatory support devices are increasingly used. One option is veno-arterial extracorporal membrane oxygenation (VA-ECMO). VA-ECMO can be implanted percutaneously and blood is actively pumped into a tubing system outside the body which also incorporates an artificial lung for oxygenation and removal of carbon dioxide and then sent back retrograde in the aorta. This review summarizes the current evidence for the use of VA-ECMO in cardiogenic shock.</p><p><strong>Recent findings: </strong>Four randomized clinical trials including the large ECLS-SHOCK trial with 417 patients and two individual patient data meta-analyses did not show any mortality benefit with the routine use of VA-ECMO, but a consistent increase in bleeding and peripheral vascular ischemic complications. So far, patients with STEMI and a low likelihood of brain injury might be an attractive group for the use of VA-ECMO. In addition patients in need for oxygenation might benefit from VA-ECMO.</p><p><strong>Summary: </strong>The results of the ECLS-SHOCK trial and the meta-analyses call for a conservative approach regarding a routine unselected use of early VA-ECMO in patients with infarct-related cardiogenic shock.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"473-479"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144309685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Elusive guidance to dosing of protein in critical illness.","authors":"Stephen A McClave, Keith R Miller, Robert G Martindale","doi":"10.1097/MCC.0000000000001281","DOIUrl":"10.1097/MCC.0000000000001281","url":null,"abstract":"<p><strong>Purpose of review: </strong>Provision of adequate protein in the nutritional regimen remains a concern for clinicians in the intensive care setting, to counteract the accelerated catabolism, breakdown of skeletal muscle, and functional impairment with acquired weakness that occurs.</p><p><strong>Recent findings: </strong>The plasticity of skeletal muscle leads to complexity in determining optimal protein dosing, where steps to sustain protein synthesis are offset by anabolic resistance, disuse atrophy, intramuscular inflammation, and blunted mammalian target of rapamycin (mTOR) sensing with poor incorporation of exogenous amino acids into new muscle formation. High protein dosing in the early phases of critical illness is ineffective at improving clinical outcomes and may be toxic in an environment of mitochondrial dysfunction, where an elevated urea/creatinine ratio can be interpreted as a biomarker for poor tolerance, elevated ammonia production, and increasing muscle proteolysis.</p><p><strong>Summary: </strong>The most effective strategy to mitigate the adverse consequences of reduced muscle mass and strength is to provide low dose protein during the acute phases of critical illness, combine nutrient delivery with exercise and early mobilization, consider fish oil or specialized pro-resolving mediators to enhance resolution of inflammation, and subsequently increase protein provision to standard doses or higher as the patient progresses to recovery and rehabilitation.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"379-386"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144309633","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding the rationale for recent paradigm shifts in critical care nutrition.","authors":"Keith R Miller, Stephen A McClave","doi":"10.1097/MCC.0000000000001291","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001291","url":null,"abstract":"","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":"31 4","pages":"361-362"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144625554","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnosis and management of cardiogenic shock.","authors":"Lavanya Bellumkonda","doi":"10.1097/MCC.0000000000001288","DOIUrl":"10.1097/MCC.0000000000001288","url":null,"abstract":"<p><strong>Purpose of review: </strong>Cardiogenic shock continues to portend a poor prognosis. Despite ongoing efforts over the past few decades to help improve mortality, little progress has been made in improving the short-term and long-term outcomes of patients presenting with cardiogenic shock. This is especially true of those presenting with acute myocardial infarct related cardiogenic shock.</p><p><strong>Recent findings: </strong>Cardiogenic shock should be understood as a continuum. Patients can move from one stage of shock to another and hence should be assessed on an ongoing basis. Cardiogenic shock should be assessed based on the severity, the phenotypic presentation and the concomitant processes that influence prognosis. Right ventricular cardiogenic shock and mixed cardiogenic shock have been recognized as predictors of worse overall prognosis. Incorporating detailed classification of cause of cardiogenic shock into routine clinical practice and will help with standardizing nomenclature and aid in understanding of the disease process and assist in refining interventions.</p><p><strong>Summary: </strong>Early identification, risk stratification and understanding the nuances of presentation may help with selecting appropriate treatment strategies. Aggressive management should include multidisciplinary team-based approaches to help escalate care as needed.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"428-436"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144474191","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enriching patient populations in ICU trials: reducing heterogeneity through machine learning.","authors":"Wonsuk Oh, Marinela Veshtaj, Ankit Sakhuja","doi":"10.1097/MCC.0000000000001280","DOIUrl":"10.1097/MCC.0000000000001280","url":null,"abstract":"<p><strong>Purpose of review: </strong>Despite the pivotal role of randomized controlled trials (RCTs) in critical care research, many have failed to demonstrate significant benefits, particularly in nutrition interventions. This review highlights how patient heterogeneity affects trial outcomes and explores how artificial intelligence and machine learning can address this issue by identifying subgroups with distinct treatment responses, improving trial design, and enhancing the precision of nutritional interventions.</p><p><strong>Recent findings: </strong>RCTs estimate the average treatment effect, which can obscure heterogeneous treatment effects, where some patients benefit while others experience no effect or harm. Recent studies highlight that artificial intelligence techniques such as clustering, predictive modeling, causal artificial intelligence, and reinforcement learning have the potential to individualize treatments and decrease heterogeneity in trials. Digital twins and artificial intelligence-driven adaptive trial designs further enable personalized interventions, optimizing study populations and improving treatment precision.</p><p><strong>Summary: </strong>The integration of artificial intelligence and machine learning into clinical trials offers a powerful strategy to refine patient selection, reduce variability, and enhance the detection of meaningful treatment effects. These advancements hold significant potential to transform critical care nutrition research, leading to more precise, personalized, and effective interventions.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"410-416"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12259358/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144301268","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The intra-aortic balloon pump: a modern practical perspective.","authors":"Luca Baldetti, Lorenzo Cianfanelli, Anna Mara Scandroglio","doi":"10.1097/MCC.0000000000001283","DOIUrl":"10.1097/MCC.0000000000001283","url":null,"abstract":"<p><strong>Purpose of review: </strong>After more than 50 years from its invention, the intra-aortic balloon pump (IABP) is still one of the most widely used mechanical circulatory support devices to treat cardiogenic shock (CS). This review aims to describe the role of IABP in current clinical practice.</p><p><strong>Recent findings: </strong>In recent years the better understanding of the variable hemodynamic profiles that characterize the CS condition has led to a reappraisal of the IABP role in select CS phenotypes. Combining a \"mechanical\" afterload reduction with an increase in mean arterial pressure, this device appears particularly suited to treat acute decompensated heart failure-CS and the mechanical complications of an acute myocardial infarction, as these conditions would greatly benefit from systemic afterload reduction. Notwithstanding the negative results of IABP support for acute myocardial infarction-related CS, this document reviews other potential established and emerging settings of application.</p><p><strong>Summary: </strong>In this scoping review, we discuss the IABP design and hemodynamic effects, with a pathophysiology-oriented outlook to its clinical use. Different options for IABP device insertion, potential complications, and optimal device synchronization with cardiac cycle are also summarized with the aim to provide an updated, pragmatic guide to critical care physicians using these devices.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"451-463"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144301271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does nutrition therapy alter the pathophysiology of severe acute pancreatitis?","authors":"Lin Gao, Yizhen Xu, Lu Ke","doi":"10.1097/MCC.0000000000001284","DOIUrl":"10.1097/MCC.0000000000001284","url":null,"abstract":"<p><strong>Purpose of review: </strong>The primary aim of this review is to summarize the value of nutrition therapy in reversing or altering the core pathophysiology during severe acute pancreatitis (SAP) and how it may impact short-term and long-term clinical outcomes.</p><p><strong>Recent findings: </strong>Early, intense inflammation is ubiquitous during the acute phase of SAP, and specific nutrients like vitamins C, D, and omega-3 fatty acids may modulate inflammation. Omega-3 fatty acids supplementation shows promise in small studies, especially when given parenterally, though results from large randomized trials are pending. Moreover, SAP commonly causes gastrointestinal dysfunction, evidenced by impaired barrier function and motility. Early enteral nutrition (EN) can reduce mucosal inflammation and protect barrier function, with glutamine supplementation potentially offering additional benefits. For impaired motility, which often presents as intra-abdominal hypertension, the commencement of early EN could aid bowel movement, though careful monitoring for ischemia is needed. Long-term outcomes in SAP patients remain understudied, and the impact of nutritional therapy on postdischarge physical function and quality of life warrants further research.</p><p><strong>Summary: </strong>Nutrition therapy may intervene in the pathophysiology of SAP in many aspects, thereby improving both short-term and long-term outcomes. However, there is a substantial lack of high-quality evidence concerning this topic.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"401-409"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144309632","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Temporary circulatory support for cardiogenic shock.","authors":"Grégoire Del Marmol, Quentin Moyon, Alain Combes","doi":"10.1097/MCC.0000000000001282","DOIUrl":"10.1097/MCC.0000000000001282","url":null,"abstract":"<p><strong>Purpose of review: </strong>Temporary circulatory support (TCS) devices play a crucial role in stabilizing patients with refractory cardiogenic shock. They provide essential hemodynamic support and serve as a bridge to recovery, decision-making, heart transplantation, or long-term mechanical circulatory support. However, despite their increasing use, recent trials challenge their impact on survival. This review summarizes recent findings and discusses challenges in optimizing patient selection and device use.</p><p><strong>Recent findings: </strong>The intra-aortic balloon pump (IABP) remains the most used TCS device. However, evidence suggests it is ineffective as a standalone therapy. Its value may lie in combination strategies, such as pairing with VA-ECMO, to enhance ventricular unloading. Recent randomized trials on VA-ECMO, including ECLS-SHOCK, have been disappointing. They show no survival benefit in acute myocardial infarction-related cardiogenic shock. Even well conducted trials face limitations, including heterogeneous patient populations and challenges in endpoint selection, making definitive conclusions difficult. The Impella device showed promising results in the DanGer Shock trial, with reduced mortality compared to standard care. However, concerns persist about patient selection and the unexpectedly high mortality rate in the control group. Meanwhile, the role of temporary right ventricular assist devices is increasingly recognized, particularly in facilitating hemodynamic stability during left ventricular assist device implantation.</p><p><strong>Summary: </strong>TCS has revolutionized the management of cardiogenic shock, but significant challenges remain. Further research is needed to refine patient selection, improve device integration, and optimize outcomes. Emerging technologies, including biocompatible materials and artificial intelligence for device monitoring, hold promise for advancing the field. Future studies should also prioritize multicenter collaborations and real-world data to address current limitations in evidence.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"444-450"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144301270","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring the role of glucagon-like peptide-1 receptor agonists in critical illness: mechanisms, benefits, and clinical implications.","authors":"Vidit G Jogani, Osman Mohamed Elfadil, Jithinraj Edakkanambeth Varayil, Manpreet S Mundi","doi":"10.1097/MCC.0000000000001294","DOIUrl":"10.1097/MCC.0000000000001294","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review aims to synthesize current evidence on the expanding role of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) beyond glycemic control, particularly in the context of critical illness. With growing recognition of their anti-inflammatory, immunomodulatory, and organ-protective properties, GLP-1RAs show promise in managing complications such as sepsis, acute respiratory distress syndrome (ARDS), acute kidney injury, and multiorgan dysfunction. This review explores their mechanisms across vital systems - including cardiovascular, pulmonary, renal, hepatic, neuropsychiatric, and gut-lung-microbiome axes - highlighting preclinical and clinical data. By consolidating emerging findings, this review aims to inform future translational research and support the integration of GLP-1RAs into critical care strategies.</p><p><strong>Recent findings: </strong>Recent evidence highlights GLP-1RAs as promising adjuncts in critical illness due to their multiorgan protective effects. In cardiovascular systems, GLP-1RAs improve endothelial function, reduce ischemia-reperfusion injury, and modulate autonomic tone. In the CNS, they provide neuroprotection by reducing neuroinflammation and pyroptosis. In the lungs, they attenuate ARDS by decreasing cytokine production, enhancing surfactant secretion, and restoring alveolar-capillary integrity. Renally, they reduce acute injury and preserve filtration function. In the gut, GLP-1RAs modulate the microbiome, enhance barrier integrity, and lower systemic inflammation via the gut-lung axis. Additionally, they reduce hepatic inflammation and support pancreatic beta-cell survival, improving insulin sensitivity and metabolic stability in critical care.</p><p><strong>Summary: </strong>GLP-1 receptor agonists hold promise as multiorgan protective agents in critical illness, offering benefits beyond glucose control. Their anti-inflammatory, metabolic, and vaso-protective properties may be harnessed to prevent or attenuate organ failure, support recovery, and improve long-term outcomes in critically ill patients. Further clinical trials are warranted to define their safety, efficacy, and optimal application across ICU populations.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"370-378"},"PeriodicalIF":3.5,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144289324","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}