Acute and Critical Care最新文献

{"title":"Association between 30-day mortality and serially measured hematologic markers in patients with septic shock in South Korea.","authors":"Seungho Jung, Jeongmin Kim, Sungwon Na","doi":"10.4266/acc.000858","DOIUrl":"10.4266/acc.000858","url":null,"abstract":"<p><strong>Background: </strong>Hematologic markers derived from complete blood counts have emerged as potential cost-effective prognostic indicators. Sepsis-induced left ventricular diastolic dysfunction (LVDD) is associated with increased mortality rates. We evaluated the predictive value of serially measured hematologic markers for 30-day mortality and their relationship with LVDD in patients with septic shock.</p><p><strong>Methods: </strong>This retrospective cohort study analyzed adult patients diagnosed with septic shock in the emergency department of a university hospital between March 2014 and May 2018. Serial neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio (LMR) values were recorded from admission to day 5. The relationship between hematologic markers and LVDD was evaluated in patients who underwent transthoracic echocardiography (TTE).</p><p><strong>Results: </strong>In total, 431 patients were included, with a 30-day mortality rate of 12.5%. The NLR on day 5 and NLR day 5/day 1 ratio had the highest predictive performance (area under the receiver operating characteristic curve [AUROC], 0.743 and 0.746, respectively). Similarly, the LMR on day 5 and the LMR day 5/day 1 ratio showed strong prognostic value (AUROC, 0.707 and 0.753, respectively). In the subgroup analysis of 204 patients who underwent TTE, a higher NLR at admission was significantly associated with LVDD (odds ratio, 1.016; 95% CI, 1.000-1.031; P=0.043).</p><p><strong>Conclusions: </strong>Serial measurements of the NLR and LMR showed better predictive value for 30-day mortality in patients with septic shock than measurements from a single time point. These findings support the use of hematologic markers as adjunctive tools for risk stratification of patients with septic shock.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 3","pages":"564-577"},"PeriodicalIF":2.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13575401/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148931690","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early prognostication of septic shock in Korean adults aged 80 years and over: serum albumin combined with Sequential Organ Failure Assessment Score.","authors":"Sang-Min Kim, Seung Mok Ryoo, Woon Yong Kwon, Kyuseok Kim, Tae Ho Lim, Sung Pil Chung, Sung-Hyuk Choi, Won Young Kim","doi":"10.4266/acc.005625","DOIUrl":"10.4266/acc.005625","url":null,"abstract":"<p><strong>Background: </strong>Septic shock requires careful risk stratification in patients aged 80 and over. Serum albumin levels reflect host status and, when combined with the severity of organ dysfunction, may enhance early prognostication. Here, we evaluated whether combining albumin levels with the Sequential Organ Failure Assessment (SOFA) score upon emergency department (ED) arrival can improve risk classification.</p><p><strong>Methods: </strong>We conducted an observational study from October 2015 to May 2022 using a prospective multicenter registry of septic shock from 12 EDs in the Korean Shock Society. We included 1,300 (18.8%) patients with septic shock aged ≥80 years. The SOFA score was calculated in the ED at the time of septic shock recognition. Patients were divided into three groups according to albumin levels (cutoff, 3.5 g/dl) and the initial SOFA score (cutoff, 7): A, normal albumin with low SOFA score; B, high SOFA with normal albumin or low SOFA with low albumin; and C, low albumin with high SOFA score. The primary outcome was 28-day mortality.</p><p><strong>Results: </strong>Groups A, B, and C included 175, 592, and 533 patients, with 28-day mortality rates of 12.0%, 26.9%, and 49.3%, respectively. Adjusted odds ratios (95% CI) for mortality were 3.02 (1.76-5.18) for group B and 5.80 (3.38-9.97) for group C vs. group A.</p><p><strong>Conclusions: </strong>Combining the SOFA score with the albumin level allows early classification of patients aged ≥80 years with septic shock in the ED, facilitating treatment discussions, particularly decision-making with patients and their families.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-05-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268739/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147869871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Managing sepsis in the era of precision medicine: a narrative review.","authors":"Ho Jin Yong, Sung Min Kim, Dohhyung Kim","doi":"10.4266/acc.000884","DOIUrl":"10.4266/acc.000884","url":null,"abstract":"<p><p>For decades, the management of sepsis has adopted protocolized care bundles. However, the plateau in global survival rates suggests that the \"one-size-fits-all\" paradigm exemplified by early goal-directed therapy has reached its limits. The physiological and biological heterogeneity of sepsis necessitates a fundamental shift toward precision medicine. This review examines the transition from empirical resuscitation to individualized care across four critical domains. First, fluid strategy is evolving from aggressive loading to dynamic stewardship. Current evidence favors balanced crystalloids over saline and advocates restrictive dosing guided by dynamic responsiveness indices and venous congestion assessments to prevent iatrogenic harm. Second, hemodynamic support is shifting toward a catecholamine‑sparing strategy. To mitigate the metabolic and immunologic toxicities of high-dose norepinephrine, multimodal vasopressors, such as vasopressin and angiotensin II, are used to target specific biological phenotypes, such as high-renin states. Third, antibiotic management balances rapid administration with rigorous stewardship through pharmacokinetic optimization, including continuous infusions, diagnostic pauses for stable patients, and short-course regimens. Finally, corticosteroid therapy is moving beyond universal debate toward targeted application. Emerging data support their use in specific responder phenotypes, notably severe community-acquired pneumonia and distinct transcriptomic endotypes. In conclusion, modern critical care is moving beyond rigid protocols toward a personalized framework. By integrating bedside biomarkers and clinical phenotypes, clinicians can deliver \"the right drug, at the right dose, for the right patient,\" thereby optimizing outcomes in sepsis and septic shock.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"189-200"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268715/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220225","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The functional landscape of critical care: a nationwide study of volume, capability, and institutional variation in South Korea.","authors":"Ho Kyung Sung, Jeehye Lee, Min-Hwan Oh, Jin Young Kim, Young Kyun Choi, Jae Young Moon","doi":"10.4266/acc.004225","DOIUrl":"10.4266/acc.004225","url":null,"abstract":"<p><strong>Background: </strong>In Korea, intensive care units (ICUs) are defined mainly by administrative categories, which do not reflect functional capability. This study examined the relationship between hospital capacity and functional performance by analyzing nationwide patterns of volume, capability, and institutional variation.</p><p><strong>Methods: </strong>We analyzed adult emergency department-to-ICU admissions in 378 hospitals from 2016 to 2023. Admission and life-support intervention (LSI) volumes were measured; organ-supportive therapies such as mechanical ventilation and renal replacement therapy were considered LSIs, and the LSI rate (LSI admissions/total admissions) was used as a proxy for functional capability. Generalized additive models assessed non-linear relationships with bed capacity, and residual-based analysis was used to classify hospitals into functional phenotypes.</p><p><strong>Results: </strong>Critical care delivery was highly concentrated; the top 8% of hospitals provided 50% of LSIs. Admission and LSI volumes increased with hospital size but plateaued beyond approximately 1,300 beds, while the LSI rate continued to rise until approximately 1,700 beds. Hospitals of similar size showed wide variation in both volume and capability. Based on residuals, 42.4% of hospitals formed a central reference group, while others were classified as high-volume/high-capability (13.7%), low-volume/high-capability (15.0%), low-volume/low-capability (12.0%), or high-volume/low-capability (16.9%).</p><p><strong>Conclusions: </strong>The relationship between structural capacity and functional performance in Korean ICUs is complex and non-linear. Hospital size alone is insufficient to predict emergency critical care delivery, underscoring the importance of operational models alongside structural resources. These findings provide a foundation for capability-based ICU stratification to guide resource allocation and strengthen system resilience.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"270-281"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268735/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220211","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical variable-based decision-support model for rapid differentiation of hemorrhagic and ischemic stroke at emergency department presentation in South Korea.","authors":"Jae-Woo Kim, Jin-Heon Jeong, Moon-Ku Han, Sang-Hoon Han, Ka Hyun Kim, Seung Park, Dong-Ick Shin, Kyu Sun Yum","doi":"10.4266/acc.004925","DOIUrl":"10.4266/acc.004925","url":null,"abstract":"<p><strong>Background: </strong>Prompt differentiation between ischemic stroke (IS) and hemorrhagic stroke (HS) is critical because their treatment strategies fundamentally differ. While neuroimaging is essential, clinical decision-making often begins before imaging is completed, and conventional clinical scores have shown inconsistent performance. The objective of this study was therefore to develop and externally validate a machine-learning model that supports HS vs. IS subtype suspicion at emergency department (ED) presentation using only clinical variables.</p><p><strong>Methods: </strong>We conducted a retrospective multicenter cohort study of 2,998 adult patients with a final diagnosis of acute IS or HS treated at three comprehensive stroke centers (July 2020-January 2024). Patients from hospitals A and B comprised the development/internal validation cohort (n=2,418), while patients from hospital C served as an independent external validation cohort (n=580). An extreme gradient boosting (XGBoost) algorithm was trained using four-fold cross-validation, and feature contributions were assessed using Shapley additive explanation (SHAP) values.</p><p><strong>Results: </strong>Internal validation showed an area under the receiver operating characteristic curve (AUROC) of 0.937 (95% CI, 0.922-0.950) with a sensitivity 0.828, specificity of 0.932, and accuracy of 0.905. Independent external validation yielded an AUROC of 0.841 (95% CI, 0.792-0.883) with a sensitivity 0.758, specificity of 0.789, and accuracy of 0.783. SHAP analysis identified headache and higher National Institutes of Health Stroke Scale item 1a (level of consciousness) as factors increasing the model output toward HS, whereas atrial fibrillation shifted predictions toward IS.</p><p><strong>Conclusions: </strong>A clinical variable-only model can support early HS vs. IS subtype suspicion at ED presentation among patients managed in an acute-stroke pathway without requiring laboratory tests. Performance decreased on independent external validation, suggesting potential site-related differences and the need for prospective evaluation and calibration. Stroke mimics were not included and should be addressed in future studies.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"364-377"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268717/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prioritizing the patient through a continuum of personalized care: insights from the 2026 Surviving Sepsis Campaign guidelines.","authors":"Gyungah Kim, Won-Young Kim","doi":"10.4266/acc.004550","DOIUrl":"10.4266/acc.004550","url":null,"abstract":"","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"419-427"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268726/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When ethics is not enough: institutional governance of critical care allocation under crisis conditions.","authors":"Ho Kyung Sung, Ungki Jung, Kyungdo Lee","doi":"10.4266/acc.001872","DOIUrl":"10.4266/acc.001872","url":null,"abstract":"<p><p>Ethical principles such as maximizing benefit, fairness, and procedural justice are frequently invoked in discussions on critical care resource allocation during public health emergencies. The coronavirus disease 2019 (COVID-19) pandemic, however, demonstrated that the mere presence of ethical principles does not ensure their operation in real-world crisis settings. In Lombardy and New York, allocation decisions defaulted to individual clinicians under extreme pressure. This review examines the institutional and governance prerequisites for ethical allocation of critical care resources during surge conditions. Rather than proposing normative allocation criteria, we analyze how ethical principles are translated-or fail to be translated-into practice through institutional arrangements. Using Ontario, Canada, as an empirical reference point, we conduct a comparative analysis of crisis standards of care, governance structures, regional coordination mechanisms, data infrastructures, and legal protections that support collective decision-making in critical care. We propose a multilevel analytical framework comprising three interdependent levels: national and governance, hospital and regional operations, and individual clinical application. Across international experiences, failures in critical care allocation arise when key functions are absent or misaligned across these levels, concentrating ethical, legal, and emotional burdens on frontline clinicians. Applying this framework to the Korean context, we identify structural gaps in crisis standard activation, governance authority, coordination mechanisms, and institutional decision-making capacity, indicating that ethical allocation is not solely a moral challenge, but a systems-level governance problem requiring institutional preparedness beyond ethical consensus.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"213-225"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268740/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictors of intermediate syndrome after organophosphorus poisoning and its management in Nepal.","authors":"Kishor Khanal, Saroj Poudel","doi":"10.4266/acc.002825","DOIUrl":"10.4266/acc.002825","url":null,"abstract":"<p><p>Organophosphorus (OP) poisoning is a global public health challenge, is common in agricultural regions, and is associated with high morbidity and mortality. Intermediate syndrome (IMS) is a delayed complication of OP poisoning that usually occurs 24-96 hours post-exposure and is characterized by proximal muscle weakness, cranial nerve palsies, and respiratory failure. The syndrome significantly increases mortality if not identified and managed promptly. This review comprehensively examines the predictors of IMS, including clinical, biochemical, and electrophysiological markers, and evaluates current management strategies. The key predictors are severe initial poisoning, low initial acetylcholinesterase level, and specific electrophysiological abnormalities. Management involves early recognition, antidote administration (atropine and oximes), respiratory support, and emerging therapies like magnesium sulfate. Challenges such as diagnostic uncertainty and resource constraints in low-income settings are discussed, alongside future directions for research and prevention. Understanding these predictors and optimizing management protocols are critical to improving outcomes in IMS following OP poisoning.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":" ","pages":"262-269"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268731/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147699911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Developing consensus-based indicators for intensive care unit capacity and capability in South Korea: a modified Delphi study.","authors":"Jeehye Lee, Ho Kyung Sung, Min-Hwan Oh, Jin Young Kim, KyoungHo Kim, Jae Young Moon","doi":"10.4266/acc.000676","DOIUrl":"10.4266/acc.000676","url":null,"abstract":"<p><strong>Background: </strong>Intensive care units (ICUs) are essential components of modern healthcare systems, but South Korea lacks capability-based standards for ICU classification. Critically ill patients are frequently assigned based on bed availability rather than clinical need, creating mismatches between patient acuity and ICU capability. The aim of this study was to develop consensus-based indicators for assessing ICU capacity and capability in South Korea.</p><p><strong>Methods: </strong>A modified Delphi study was conducted with 24 multidisciplinary experts, including members of the Korean Society of Critical Care Medicine (SCCM) Standardization Committee. Based on a systematic review of international ICU frameworks (SCCM, European Society of Intensive Care Medicine, Australian and New Zealand Intensive Care Society), 42 candidate indicators across six domains were evaluated over three rounds (April-July 2025). Consensus was defined as a content validity ratio ≥ a preset critical threshold and ≥75% expert agreement.</p><p><strong>Results: </strong>The response rates were 79.2%-91.7% across rounds. The final framework comprises 29 indicators across four domains: Capacity (staffing, facilities, bed management), Capability (life support, specialized care), Human resources (physician and allied health coverage), and Space and equipment infrastructure (monitoring and safety systems). The experts prioritized functional capabilities over structural metrics: nurse-to-bed ratios were rated more important than physician numbers, and 24/7 service availability was prioritized over personnel counts. Ward support, education, and research indicators did not reach consensus.</p><p><strong>Conclusions: </strong>This study establishes the first expert consensus framework for ICU capability assessment in South Korea. The 29 indicators provide a foundation for a capability-oriented classification system that prioritizes patient safety and efficient resource allocation. Future research should validate these indicators against clinical outcomes and explore real-time ICU capacity monitoring strategies.</p>","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"282-294"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impacts of inspired oxygen concentration and arterial oxygen tension on venous and tissue oxygen saturation.","authors":"Kwok Ming Ho","doi":"10.4266/acc.003500","DOIUrl":"10.4266/acc.003500","url":null,"abstract":"","PeriodicalId":44118,"journal":{"name":"Acute and Critical Care","volume":"41 2","pages":"436-437"},"PeriodicalIF":2.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13268729/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148220169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}