Intensive Care Medicine最新文献

{"title":"Liberal vs. restrictive transfusion strategies for acute brain injury: a systematic review and frequentist-Bayesian meta-analysis","authors":"Pierre-Louis Blot, Maxime Renaux, Timothée Ayasse, Lucie Collet, Arthur James, Jean-Michel Constantin, Rayan Braïk","doi":"10.1007/s00134-025-07807-2","DOIUrl":"https://doi.org/10.1007/s00134-025-07807-2","url":null,"abstract":"<h3 data-test=\"abstract-sub-heading\">Purpose</h3><p>To determine whether a liberal transfusion strategy (≥ 9 g/dL) improves neurological outcomes in adults with acute brain injury (ABI).</p><h3 data-test=\"abstract-sub-heading\">Method</h3><p>We systematically searched MEDLINE, EMBASE, the Cochrane Library, and trial registries for randomized controlled trials comparing liberal (≥ 9 g/dL) vs. restrictive (≥ 7 g/dL) transfusion in adults with ABI (traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage) and Glasgow Coma Scale ≤ 13. Frequentist, Bayesian, and trial sequential analyses were used. The primary outcome was favorable neurological status at 180 days.</p><h3 data-test=\"abstract-sub-heading\">Results</h3><p>Four randomized controlled trials (<i>N</i> = 1853; 922 liberal, 931 restrictive) were included. The pooled frequentist risk ratio (RR) for favorable neurological outcome was 0.84 (95% CI 0.65–1.09; <i>I</i>² = 58%). In a pre-specified sensitivity analysis including only low-risk-of-bias trials, the results suggested a potential benefit in favor of the liberal strategy (RR 0.74 [95% CI 0.63–0.87]) with no heterogeneity (<i>I</i>² = 0%). Subgroup analyses for patients with traumatic brain injury or stratified by initial Glasgow coma scale were consistent with the main findings. Bayesian analyses showed that the estimated treatment effect depended on the assumptions and priors used, with an unfavorable prior derived from one trial with distinct protocol appearing less likely than neutral or favorable priors. Trial sequential analysis indicated that current evidence is insufficient to confirm a definitive effect. Secondary outcomes did not differ significantly between groups.</p><h3 data-test=\"abstract-sub-heading\">Conclusions</h3><p>This review did not provide definitive evidence of a neurological benefit from liberal transfusion strategies in acute brain injury. Both frequentist and Bayesian analyses highlight the influence of a single trial on the overall effect estimate and heterogeneity. However, sensitivity analyses excluding this trial and focusing on studies with low risk of bias suggested that liberal transfusion strategies could improve neurological outcomes. Future research should focus on identifying patient subgroups most likely to benefit, guiding a more individualized approach.</p>","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"64 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434954","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effectiveness of bundle of care on tolerance of awake-prone positioning in patients with acute respiratory failure. A multicenter observational study","authors":"Matías Olmos, Nora Fuentes, Marina Busico, Adrian Gallardo, Alejandra Vitali, Eduardo L. V. Costa, Marcelo B. P. Amato, Alejandro Bruhn, Mariano Esperatti","doi":"10.1007/s00134-025-07804-5","DOIUrl":"https://doi.org/10.1007/s00134-025-07804-5","url":null,"abstract":"<h3 data-test=\"abstract-sub-heading\">Purpose</h3><p>This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO).</p><h3 data-test=\"abstract-sub-heading\">Methods</h3><p>In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), “double-robust” approximation (DR), traditional regression (TR), and mixed-effects model (MEM).</p><h3 data-test=\"abstract-sub-heading\">Results</h3><p>Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10–18) hours/day, compared to 10 (7–14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67–5.11), 3.35 (1.55–5.14), 3.95 (2.63–5.28), and 3.72 (2.5–4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15–0.76), 0.23 (0.10–0.50), 0.42 (0.23–0.77), and 0.48 (0.16–0.49), and for in-hospital mortality were 0.38 (0.11–1.27), 0.43 (0.14–1.26), 0.47 (0.22–0.91), and 0.46 (0.12–1.43) in the respective models.</p><h3 data-test=\"abstract-sub-heading\">Conclusion</h3><p>In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation.</p><h3 data-test=\"abstract-sub-heading\">Trial Registration Number</h3><p>ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022. Study Type: Observational.</p>","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"12 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434955","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":"INHALE WP3, a multicentre, open-label, pragmatic randomised controlled trial assessing the impact of rapid, ICU-based, syndromic PCR, versus standard-of-care on antibiotic stewardship and clinical outcomes in hospital-acquired and ventilator-associated pneumonia","authors":"Virve I. Enne, Susan Stirling, Julie A. Barber, Juliet High, Charlotte Russell, David Brealey, Zaneeta Dhesi, Antony Colles, Suveer Singh, Robert Parker, Mark Peters, Benny P. Cherian, Peter Riley, Matthew Dryden, Ruan Simpson, Nehal Patel, Jane Cassidy, Daniel Martin, Ingeborg D. Welters, Valerie Page, Hala Kandil, Eleanor Tudtud, David Turner, Robert Horne, Justin O’Grady, Ann Marie Swart, David M. Livermore, Vanya Gant","doi":"10.1007/s00134-024-07772-2","DOIUrl":"https://doi.org/10.1007/s00134-024-07772-2","url":null,"abstract":"<h3 data-test=\"abstract-sub-heading\">Purpose</h3><p>INHALE investigated the impact of seeking pathogens by PCR on antibiotic stewardship and clinical outcomes in hospital-acquired and ventilator-associated pneumonia (HAP and VAP).</p><h3 data-test=\"abstract-sub-heading\">Methods</h3><p>This pragmatic multicentre, open-label RCT enrolled adults and children with suspected HAP and VAP at 14 ICUs. Patients were randomly allocated to standard of care, or rapid in-ICU syndromic PCR coupled with optional prescribing guidance. Co-primary outcomes were superiority in antibiotic stewardship at 24 h and non-inferiority in clinical cure of pneumonia 14 days post-randomisation. Secondary outcomes included mortality, ICU length of stay and evolution of clinical scores.</p><h3 data-test=\"abstract-sub-heading\">Results</h3><p>554 eligible patients were recruited from 5th July 2019 to 18th August 2021, with a COVID-enforced pause from 16th March 2020 and 9th July 2020. Data were analysed for 453 adults and 92 children (68.4% male; 31.6% female). ITT analysis showed 205/268 (76.5%) reviewable intervention patients receiving antibacterially appropriate and proportionate antibiotics at 24 h, versus 147/263 (55.9%) standard-of-care patients (estimated difference 21%; 95% CI 13–28%). However, only 152/268 (56.7%) intervention patients were deemed cured of pneumonia at 14 days, versus 171/265 (64.5%) standard-of-care patients (estimated difference − 6%, 95% CI − 15 to 2%; predefined non-inferiority margin -13%). Secondary mortality and ΔSOFA outcomes narrowly favoured the control arm, without clear statistical significance.</p><h3 data-test=\"abstract-sub-heading\">Conclusions</h3><p>In-ICU PCR for pathogens resulted in improved antibiotic stewardship. However, non-inferiority was not demonstrated for cure of pneumonia at 14 days. Further research should focus on clinical effectiveness studies to elucidate whether antibiotic stewardship gains achieved by rapid PCR can be safely and advantageously implemented.</p>","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"51 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434953","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 bicarbonate challenge test, another legacy of Dr. Gattinoni that we must preserve","authors":"Enrique Monares-Zepeda, Christopher Barrera-Hoffmann","doi":"10.1007/s00134-025-07818-z","DOIUrl":"https://doi.org/10.1007/s00134-025-07818-z","url":null,"abstract":"","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"49 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434984","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":"ESICM consensus-based recommendations for the management of very old patients in intensive care","authors":"Michael Beil, Laura Alberto, Richard S. Bourne, Nathan E. Brummel, Bas de Groot, Dylan W. de Lange, Paul Elbers, Marielle Emmelot-Vonk, Hans Flaatten, Yonathan Freund, Alessandro Galazzi, Ana Garcia-Martinez, Bertrand Guidet, Iva Holmerova, Jeremy M. Jacobs, Gavin M. Joynt, Susannah Leaver, Marc Leone, Bairbre McNicholas, David McWilliams, Victoria Metaxa, Christian H. Nickel, Daniele Poole, Chiara Robba, Kevin Roedl, Marc Romain, Anne-Françoise Rousseau, Sigal Sviri, Wojciech Szczeklik, Helene Vallet, James van Oppen, Christian Jung","doi":"10.1007/s00134-025-07794-4","DOIUrl":"https://doi.org/10.1007/s00134-025-07794-4","url":null,"abstract":"<h3 data-test=\"abstract-sub-heading\">Purpose</h3><p>The heterogeneity of very old patients (age ≥ 80 years) and the prevalence of complex geriatric syndromes in this cohort constitute major challenges for the classical methods of evidence-based medicine to inform clinical practice. The lack of robust guidance for the management of critical conditions in these patients contributes to considerable uncertainty among practitioners and unwarranted variations of care. The European Society of Intensive Care Medicine (ESICM) initiated a Delphi study to translate the empirical knowledge of experts in this field into consensus-based recommendations for clinical practice.</p><h3 data-test=\"abstract-sub-heading\">Methods</h3><p>A multi-national group of specialists in intensive care, emergency, and geriatric medicine provided opinions on managing very old patients with critical conditions. Strong or moderate consensus was defined as having at least 90% or 80% of experts, respectively, expressing agreement or disagreement on the three highest or lowest levels of a 9-points Likert scale.</p><h3 data-test=\"abstract-sub-heading\">Results</h3><p>Twenty-eight members of the expert steering group and 82 additional experts completed two Delphi rounds. After discussing the results, the steering group issued recommendations for 48 statements and 2 checklists for which consensus was achieved. In addition to determining fundamental principles, they include advice on goals of care and the decision-making about admission to and treatment of patients in intensive care and the management after discharge.</p><h3 data-test=\"abstract-sub-heading\">Conclusion</h3><p>A multi-disciplinary group of experts achieved consensus on recommendations concerning intensive care for very old patients, which were approved and endorsed by ESICM. The implementation requires a careful analysis of available healthcare resources and should proceed in a stepwise fashion.</p>","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"10 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434979","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":"Invasive fungal infections in patients with liver disease: immunological and clinical considerations for the intensive care unit","authors":"Oleg Epelbaum, Alice Gallo de Moraes, Jody C. Olson, Michail S. Lionakis","doi":"10.1007/s00134-025-07797-1","DOIUrl":"https://doi.org/10.1007/s00134-025-07797-1","url":null,"abstract":"<p>Patients with liver disease in the intensive care unit (ICU) face a unique susceptibility to infection due to the complex immune dysfunction resulting from hepatic failure. Bacterial infections are commonly present in these patients upon arrival to the hospital, often being the primary reason for ICU admission. In contrast, invasive fungal infections (IFIs) afflict a smaller percentage of patients and are usually discovered in the course of the ICU stay. IFI diagnosis in the ICU, particularly in patients with liver disease, is often delayed or overlooked, contributing to the extremely high ICU mortality associated with IFI in these patients despite the availability of effective (and largely safe) antifungal therapy. Thus, to improve outcomes, it is crucial for intensive care clinicians to be vigilant for IFIs in patients with liver disease. This review aims to contribute to the intensive care literature in this regard. We begin with an overview of normal antifungal immunity followed by a summary of how it may become compromised in the setting of hepatic dysfunction. Next, a general discussion of IFIs in liver disease is presented and then the three most relevant fungal pathogens, namely <i>Candida</i>, <i>Aspergillus</i>, and <i>Cryptococcus</i>, are individually examined. This review concludes by highlighting key knowledge and practice gaps that require attention by the scientific and clinical communities in the coming years.</p>","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"80 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434978","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":"Cultivating cultural competence in ICU communication","authors":"Shahla Siddiqui, Victoria Metaxa","doi":"10.1007/s00134-025-07829-w","DOIUrl":"https://doi.org/10.1007/s00134-025-07829-w","url":null,"abstract":"","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":"3 1","pages":""},"PeriodicalIF":38.9,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434980","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":"Continuous infusion of beta-lactam antibiotics in critically ill patients with sepsis: insights from daily clinical practice.","authors":"Isabel Spriet, Matthias Gijsen, Marijke Peetermans, Yves Debaveye, Charlotte Quintens","doi":"10.1007/s00134-025-07819-y","DOIUrl":"https://doi.org/10.1007/s00134-025-07819-y","url":null,"abstract":"","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":" ","pages":""},"PeriodicalIF":27.1,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143440739","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":"Buffering in critical illness: keeping it simple.","authors":"Lorenzo Giosa, Luigi Camporota, Thomas Langer","doi":"10.1007/s00134-025-07832-1","DOIUrl":"https://doi.org/10.1007/s00134-025-07832-1","url":null,"abstract":"","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":" ","pages":""},"PeriodicalIF":27.1,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143440737","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 value of pilot trials in studies of postoperative sedation in critical care.","authors":"Michael C Reade, David Liu","doi":"10.1007/s00134-025-07814-3","DOIUrl":"https://doi.org/10.1007/s00134-025-07814-3","url":null,"abstract":"","PeriodicalId":13665,"journal":{"name":"Intensive Care Medicine","volume":" ","pages":""},"PeriodicalIF":27.1,"publicationDate":"2025-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143440759","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}