Current Opinion in Critical Care最新文献

{"title":"Monitoring and dose adjustment of regional citrate anticoagulation for continuous renal replacement therapy.","authors":"Lenar Yessayan, Balazs Szamosfalvi, Ashita Tolwani","doi":"10.1097/MCC.0000000000001433","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001433","url":null,"abstract":"<p><strong>Purpose of review: </strong>Regional citrate anticoagulation (RCA) is the preferred anticoagulation strategy for many patients receiving continuous renal replacement therapy (CRRT). Safe implementation requires a coordinated prescription integrating citrate delivery, citrate removal within the extracorporeal circuit, individualized calcium replacement, CRRT fluid composition, and structured biochemical monitoring. This review summarizes practical approaches to RCA prescription, monitoring, and dose adjustment, emphasizing recent advances in citrate kinetics, calcium homeostasis, impaired citrate metabolism, metabolic complications, and systems-based safety.</p><p><strong>Recent findings: </strong>Randomized trials and meta-analyses continue to demonstrate that RCA prolongs circuit life and reduces bleeding compared with systemic heparin anticoagulation, although a mortality benefit has not been demonstrated. Recent studies have refined understanding of citrate dose, systemic citrate load, first-pass citrate extraction, individualized calcium replacement based on anticipated effluent calcium losses, and recognition of impaired citrate metabolism. They also support baseline ionized calcium assessment before CRRT initiation, integration of lactate trends into assessment of citrate metabolism, individualized CRRT fluid selection, and distinguishing true citrate accumulation from other metabolic effects of RCA.</p><p><strong>Summary: </strong>RCA is most effectively managed as an integrated CRRT prescription in which citrate delivery and removal, individualized calcium replacement, CRRT fluid composition, and operational parameters are coordinated to optimize circuit anticoagulation while maintaining electrolyte and acid-base homeostasis. Prescription adjustment should focus on four recurring clinical scenarios: inadequate circuit anticoagulation, negative calcium balance, excessive bicarbonate generation from citrate metabolism, and impaired citrate metabolism. Standardized protocols, structured monitoring, staff training, and workflow integration remain central to safe RCA implementation.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149001054","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":"Defibrillation in refractory cardiac arrest: knowledge gaps and future priorities.","authors":"Giovanni Babini, Alberto Cucino, Giuseppe Ristagno","doi":"10.1097/MCC.0000000000001435","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001435","url":null,"abstract":"<p><strong>Purpose of review: </strong>Refractory shockable cardiac arrest remains associated with poor outcomes despite prompt cardiopulmonary resuscitation and repeated defibrillation. This review summarizes recent evidence on ventricular fibrillation (VF) phenotyping, vector-change (VC) defibrillation, double sequential external defibrillation (DSED), waveform analysis, and emerging decision-support approaches.</p><p><strong>Recent findings: </strong>Refractory VF is increasingly recognized as a heterogeneous syndrome rather than a uniform failure of repeated shocks. True shock-refractory or incessant VF, recurrent VF, and mixed phenotypes differ in frequency, prognosis, and potential therapeutic targets. VC defibrillation using an antero-posterior pad configuration may improve defibrillation efficacy in selected patients, whereas DSED represents a more complex intervention whose effectiveness may depend on shock vector, timing, inter-shock interval, and system-level implementation. Physiological and electrical markers, including amplitude spectrum area (AMSA), transthoracic impedance (TTI), and ECG-based predictive models, may enable earlier identification of patients unlikely to respond to continued conventional defibrillation.</p><p><strong>Summary: </strong>Current evidence does not support a single rigid treatment algorithm for refractory VF. Future research should move beyond shock-count-based escalation and prospectively evaluate physiology-informed, adaptive strategies integrating rhythm phenotype, AMSA, TTI, CPR quality, machine-learning-based prediction, and operational feasibility within pragmatic clinical trials.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148988546","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":"Beating the clock: time-targeted and individualized extracorporeal cardiopulmonary resuscitation.","authors":"Adam L Gottula, Paul Rees, Demetris Yannopoulos","doi":"10.1097/MCC.0000000000001432","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001432","url":null,"abstract":"<p><strong>Purpose of review: </strong>Extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in selected patients with refractory cardiac arrest, but the benefit is steeply time-dependent. We examine the converging rationale for delivering resuscitation that is simultaneously time-targeted and individualized, and its translation into systems of care.</p><p><strong>Recent findings: </strong>Pooled randomized data confirms a clinically meaningful survival advantage for ECPR in refractory shockable out-of-hospital cardiac arrest, while observational cohorts show a steep fall in neurologically favorable survival as low-flow time lengthens beyond 30 min. Recent analyses demonstrate that faster cannulation is independently associated with survival, and prehospital and hybrid delivery models have demonstrated an increase in access to cannulation within the therapeutic window. In parallel, individualized selection integrating rhythm, cardiac arrest characteristics, and physiologic markers refine candidacy beyond rhythm alone.</p><p><strong>Summary: </strong>ECPR success depends on systems engineered to achieve rapid cannulation in appropriately selected patients. Prospectively testing advanced ECPR systems of care within a tightly constrained therapeutic window represents the next step in defining how time-targeted, individualized resuscitation should be delivered.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148988503","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":"Management of shock phenotypes after cardiac arrest: beyond cardiogenic shock.","authors":"Johannes Grand, Simon Schneekloth, Rasmus P Beske","doi":"10.1097/MCC.0000000000001434","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001434","url":null,"abstract":"<p><strong>Purpose of review: </strong>Postcardiac-arrest circulatory failure is commonly labeled cardiogenic shock, although its physiology is heterogeneous, dynamic, and frequently mixed. This review examines recent evidence and proposes a treatment-oriented framework.</p><p><strong>Recent findings: </strong>Hypotension, hyperlactatemia, vasopressor dependence, and myocardial dysfunction do not establish ongoing shock after cardiac arrest or identify its mechanism. Recent studies demonstrate clinically important discordance between arterial pressure, cardiac output, filling pressures, oxygen transport, metabolic recovery, and prognosis. Four primary hemodynamic phenotypes are proposed: vasoplegic-inflammatory shock; myocardial dysfunction and low-flow shock; hypovolemia; and right ventricular and pulmonary vascular dysfunction. Mixed shock is an overlap group, whereas reversible metabolic pseudoshock describes arrest-related hyperlactatemia that resolves without persistent hemodynamic compromise.</p><p><strong>Summary: </strong>Repeated multimodal assessment should determine whether circulatory dysfunction is resolving or persisting and identify the dominant mechanism. Treatment, advanced monitoring, and mechanical circulatory support should then be individualized, with neurological uncertainty incorporated into escalation decisions.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148988517","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":"Managing fluid status in patients receiving renal replacement therapy.","authors":"Matthieu Chivot, Jean-Christophe Richard, Laurent Bitker","doi":"10.1097/MCC.0000000000001426","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001426","url":null,"abstract":"<p><strong>Purpose of review: </strong>Net ultrafiltration (UFNET) may help correct fluid overload in patients receiving renal replacement therapy (RRT). Yet, how to set it safely at the bedside remains unsettled. This review addresses the hemodynamic aspects of UFNET setting, its time-dependent adjustments in relation phase-dependent balance target, and the contribution of fluid inputs to fluid balance control.</p><p><strong>Recent findings: </strong>Hemodynamic instability associated with RRT, the principal obstacle to active fluid removal, arises from vasomotor and cardiac mechanisms, which may or may not be related to UFNET. Fluid balance management, including UFNET setting, evolves across the resuscitation, optimization, stabilization and evacuation phases of care. The U-shaped association between UFNET and mortality is observational and should not be interpreted as a validated bedside target, while fixed prescriptions may prove difficult to deliver. Cardiac output monitoring, preload-dependence assessment and perfusion indices may help predict hemodynamic instability, although comparative evidence that these strategies improve outcomes is lacking. Finally, fluid overload is generated predominantly by nonresuscitation fluids, so that UFNET rate intensity is principally determined by the cumulative volume administered.</p><p><strong>Summary: </strong>Setting UFNET safely requires its titration using repeatedly reassessed hemodynamic tolerance, awareness to phase-dependent fluid balance targets and reduction of fluid inputs.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148886205","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":"Antimicrobial dosing in patients with renal dysfunction.","authors":"Ming G Chai, Leon V Smareglia, Andrew A Udy","doi":"10.1097/MCC.0000000000001428","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001428","url":null,"abstract":"<p><strong>Purpose of review: </strong>Many antimicrobials used in critically ill patients are predominantly eliminated by the kidneys. Optimizing dosing in this population is challenging as renal clearance is often altered by changes in organ function and presence of extracorporeal circuits. Extrapolating dosing recommendations derived from noncritically ill populations to these patients may not adequately account for these pharmacokinetic changes, increasing the risk of subtherapeutic or toxic drug exposures. This review summarizes contemporary strategies for optimizing antimicrobial dosing in critically ill patients, with a focus on renal dysfunction.</p><p><strong>Recent findings: </strong>In resource-limited settings, dosing nomograms developed from critically ill populations provide a practical and effective approach to improving antimicrobial target attainment. Therapeutic drug monitoring is increasingly recommended for a wider range of antimicrobials and can identify patients who require dose optimization. Model-informed precision dosing software has shown promise in improving antimicrobial exposures, although data supporting its impact on clinical outcomes are lacking. Emerging technologies for optimizing antimicrobial dosing include dosing software with artificial-intelligence and real-time monitoring of antimicrobial concentrations with biosensors.</p><p><strong>Summary: </strong>Alterations in renal clearance are a major contributor to suboptimal antimicrobial exposure in critical illness. Selection of dose optimization strategies should be guided by local resources and expertise (see Graphical Abstract).</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148879434","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":"Albumin and the kidney, a friend or foe.","authors":"Yahya Shehabi, Mayurathan Balachandran, Neil Glassford","doi":"10.1097/MCC.0000000000001424","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001424","url":null,"abstract":"<p><strong>Purpose of review: </strong>Albumin preparations are the most common colloids used in critically ill patients worldwide. This review is to provide the physiological rationale and evidence for benefits and harms in different clinical settings.</p><p><strong>Recent findings: </strong>There is a strong physiological rationale for intravenous albumin administration in critically ill patients. Iso-oncotic and hyperoncotic albumin have both been used for volume resuscitation and to maintain effective plasma volume at an optimal fluid balance. This practice, however, has not proven to be superior to using crystalloids or balanced solutions with no significant reduction in kidney injury or time on vasopressors. In patients with septic shock and hypoalbuminaemia, albeit limitations, subgroup analysis of a randomized trial suggested reduced mortality with albumin supplementation. Similarly, guidelines strongly recommend the use of albumin in hepatic-induced kidney injury and hepatorenal syndrome. Albumin also improved diuresis when combined with diuretics and may improve intradialytic hypotension. Conversely, hyperoncotic albumin infusion increased the risk of kidney injury and red cell transfusion in high-risk cardiac surgery.</p><p><strong>Summary: </strong>Hyperoncotic, and albumin administration in general, is a double-edged sword, its use should be tailored to specific clinical scenarios. The use of hyperoncotic albumin in high-risk cardiac surgery should be discouraged.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148860437","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":"Sodium bicarbonate for metabolic acidosis.","authors":"Boris Jung, Ary Serpa Neto, Tomoko Fujii","doi":"10.1097/MCC.0000000000001425","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001425","url":null,"abstract":"<p><strong>Purpose of review: </strong>The purpose of this review is to discuss the consequences of severe metabolic acidosis on organ function, examine the physiological controversies surrounding pH correction with sodium bicarbonate, and review the results of recent randomized clinical trials evaluating the effects of sodium bicarbonate on patient-centered outcomes in patients with metabolic acidosis.</p><p><strong>Recent findings: </strong>Recent evidence has primarily focused on the results of large multicenter randomized clinical trials, which have shown that sodium bicarbonate administration does not improve mortality in unselected patients with moderate to severe metabolic acidosis, with or without acute kidney injury. However, sodium bicarbonate may delay or reduce the need for kidney replacement therapy in some patients.</p><p><strong>Summary: </strong>Severe metabolic acidosis is associated with organ dysfunction, and its correction with sodium bicarbonate, alongside treatment of the underlying cause, can be performed safely. Although a mortality benefit remains unlikely based on current evidence, sodium bicarbonate administration may be associated with a reduced need for kidney replacement therapy. Future studies aimed at identifying patient phenotypes that may benefit from this intervention are warranted.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":""},"PeriodicalIF":3.8,"publicationDate":"2026-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863383","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":"Personalized protein delivery in critical care: from phenotyping and endotyping to post-ICU recovery.","authors":"Noortje Maria Petronella Overwater, Michelle Carmen Paulus, Lara Schepers, Arthur Raymond Hubert van Zanten","doi":"10.1097/MCC.0000000000001398","DOIUrl":"10.1097/MCC.0000000000001398","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review examines the importance of optimizing protein delivery during and in the convalescence of critical illness, with a focus on the challenges associated with individual protein dosing strategies.</p><p><strong>Recent findings: </strong>Muscle mass depletion often begins within the first days of intensive care unit (ICU) admission, emphasizing the need for adequate protein intake. However, many ICU patients fail to meet recommended targets. Large-scale studies have shown mixed results on high-protein intake, with some suggesting no added benefit or even harm in certain groups. This review highlights the need for individualized protein dosing guided by phenotyping and endotyping and discusses the challenges in assessing body composition, illustrated by a case study. The potential role of biomarkers in optimizing protein dosing is also explored, alongside factors that hinder adequate protein intake.</p><p><strong>Summary: </strong>Further research is needed to determine the optimal protein strategy for critically ill patients, with a focus on enhancing functional outcomes and quality of life, particularly for survivors who face long-term physical and cognitive challenges. Future guidelines should incorporate individualized approaches, leveraging emerging technologies and patient-centred data to tailor protein delivery and enhance recovery outcomes.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":" ","pages":"325-336"},"PeriodicalIF":3.8,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13336750/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148263063","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":"Editorial introduction.","authors":"","doi":"10.1097/MCC.0000000000001402","DOIUrl":"10.1097/MCC.0000000000001402","url":null,"abstract":"","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":"32 4","pages":"v"},"PeriodicalIF":3.8,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148374755","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}