Critical care explorations最新文献

{"title":"Diagnostic Performance of the Radiographic Assessment of Lung Edema Score for Acute Respiratory Distress Syndrome-Post Hoc Analysis of the \"Validating Acute Lung Injury Biomarkers for Diagnosis\" Study.","authors":"Claudio Zimatore, Matthieu Jabaudon, Luigi Pisani, Tatsuki Koyama, Marcus J Schultz, Lorraine B Ware","doi":"10.1097/CCE.0000000000001495","DOIUrl":"10.1097/CCE.0000000000001495","url":null,"abstract":"<p><strong>Objectives: </strong>To determine the diagnostic accuracy of the Radiographic Assessment of Lung Edema (RALE) score for acute respiratory distress syndrome (ARDS) and its interobserver reliability.</p><p><strong>Design: </strong>Post hoc analysis of a prospective observational cohort study.</p><p><strong>Setting: </strong>ICUs at Vanderbilt University Medical Center participating in the Validating Acute Lung Injury Biomarkers for Diagnosis study.</p><p><strong>Patients: </strong>Adult patients receiving invasive ventilation for at least two consecutive days, with chest radiographs available on the first 2 ICU days.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Chest radiographs from the first 2 ICU days were scored independently by at least two experienced raters; scores were averaged per radiograph, and the highest averaged score from ICU day 1 or 2 was selected for analysis. The primary outcome was ARDS according to the Berlin definition during the first 2 ICU days. Of 236 patients, 92 (39%) had ARDS. The median RALE score was higher in patients with ARDS than in those without (29.5 [22.2-34.5] vs. 12.2 [7.5-17.8]; p < 0.01). The area under the receiver operating characteristic curve was 0.93 (95% CI, 0.90-0.96). At the optimal cutoff of 20, sensitivity was 85%, specificity 83%, positive predictive value 76%, and negative predictive value 90%. Interobserver reliability was high, with pairwise intraclass correlation coefficients ranging from 0.81 to 0.87.</p><p><strong>Conclusions: </strong>In patients invasively ventilated for at least 2 days, the RALE score demonstrated excellent diagnostic accuracy for ARDS at a cutoff of 20, together with high interobserver reliability, supporting its potential role as a standardized radiographic tool in the diagnosis of ARDS.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1495"},"PeriodicalIF":2.9,"publicationDate":"2026-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149229614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Proenkephalin A and Heterogeneity of Hydrocortisone Treatment Effect in Septic Shock: A Post Hoc Analysis of the VANISH Trial.","authors":"David B Antcliffe, Florian Uhle, Dominic C Marshall, Ashleigh D Green, Anthony C Gordon, Lui G Forni","doi":"10.1097/CCE.0000000000001496","DOIUrl":"10.1097/CCE.0000000000001496","url":null,"abstract":"<p><strong>Objectives: </strong>Heterogeneity of treatment effect is thought to drive conflicting results for the benefits of corticosteroids in sepsis. Proenkephalin A (PENK) is a biomarker of renal function. Given the kidney's role in sepsis pathophysiology and corticosteroid metabolism, we hypothesized that baseline renal function, assessed using PENK, would be associated with hydrocortisone efficacy.</p><p><strong>Design: </strong>A post hoc analysis of a double-blind, randomized clinical trial in septic shock (Effect of Early Vasopressin vs. Norepinephrine on Kidney Failure in Patients with Septic Shock [VANISH]).</p><p><strong>Setting: </strong>ICUs across the United Kingdom.</p><p><strong>Patients: </strong>One hundred seventy-three patients admitted to ICU with septic shock.</p><p><strong>Interventions: </strong>Norepinephrine vs. vasopressin and hydrocortisone vs. placebo.</p><p><strong>Measurements and main results: </strong>PENK was measured in plasma, and patients were dichotomized using a PENK concentration above 89 pmol/L. PENK greater than or equal to 89 pmol/L was associated with 28-day mortality (odds ratio, 3.24; 95% CI, 1.62-6.74). We found no interaction between PENK and randomization to vasopressin or norepinephrine on outcome. However, there was a significant interaction between the PENK groups and hydrocortisone or placebo use in those patients who reached the maximum vasopressor threshold (n = 111) for kidney failure-free days (high PENK [≥ 89 pmol/L] placebo 26 [13-28], hydrocortisone 11 [0-26] and low PENK placebo 28 [15-28], hydrocortisone 28 [28-28]; p = 0.01). Patients with high PENK receiving hydrocortisone had the fewest kidney failure-free days. Although we found no significant interaction for 28-day mortality (p = 0.14), the patients with high PENK who received hydrocortisone had the highest mortality (high PENK hydrocortisone 50%, placebo 32% and low PENK hydrocortisone 14%, placebo 24%).</p><p><strong>Conclusions: </strong>This exploratory analysis identified a possible interaction between baseline PENK and hydrocortisone treatment on kidney failure-free days. These findings require validation in independent and prospective studies.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1496"},"PeriodicalIF":2.9,"publicationDate":"2026-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149229651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Integrated Use of Extracorporeal Membrane Oxygenation and Molecular Adsorbent Recirculating System for Refractory Cardiotoxic Ingestion: A Single-Center Case Series.","authors":"Tori Ehrhardt, C Christopher Zalesky, Aaron Shepherd, Joshua L Chan, Ram M Subramanian, Craig S Jabaley, Melissa Morris, Laura Franco, Casey Miller, Terrance Oster, Katherine L Nugent, Christina Creel-Bulos, Emily Kiernan, Sagar B Dave","doi":"10.1097/CCE.0000000000001499","DOIUrl":"10.1097/CCE.0000000000001499","url":null,"abstract":"<p><strong>Background: </strong>Cardiotoxic ingestions of calcium-channel blockers and beta-adrenergic antagonists are highly lethal, often causing refractory vasoplegic shock and noncardiogenic pulmonary edema. While venoarterial extracorporeal membrane oxygenation (ECMO) is a recognized rescue therapy for cardiogenic shock, the roles of venovenous ECMO and albumin dialysis-specifically the molecular adsorbent recirculating system (MARS)-as well as the effectiveness of linking patients to therapy through a coordinated referral process remain underexplored.</p><p><strong>Case summary: </strong>We describe five consecutive patients with severe cardiotoxic ingestions managed via a regionally triggered transfer pathway. Patients presented with profound hypotension and respiratory failure despite standard therapies. All five patients received MARS for drug clearance and vasoplegia management; two required venovenous ECMO for refractory hypoxemia. One patient died due to profound myocardial poisoning; four survived to discharge. Complications included continuous renal replacement therapy filter clotting and catheter-associated thrombosis.</p><p><strong>Conclusions: </strong>A coordinated regional protocol enabling early access to ECMO and MARS is feasible in massive cardiotoxic ingestions.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1499"},"PeriodicalIF":2.9,"publicationDate":"2026-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13668303/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149186466","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":"Automated Versus Manual Occlusion Pressure at 100 ms With Hamilton C6 Using the Software Version 1.2.3: From Bedside to the Bench and Back to Bedside.","authors":"Flora Delamaire, Jérémy Caldonazzo, Arnaud Gacouin, Rémi Coudroy, Nicolas Terzi","doi":"10.1097/CCE.0000000000001493","DOIUrl":"10.1097/CCE.0000000000001493","url":null,"abstract":"<p><strong>Objectives: </strong>Occlusion pressure at 100 ms after the start of inspiratory effort (P0.1) is a marker of respiratory drive and a predictor of weaning outcomes in mechanically ventilated patients. Some ventilators, like the Hamilton C6 (Hamilton Medical AG, Bonaduz, Switzerland), estimate P0.1 automatically (P0.1vent) without performing an actual airway occlusion, potentially leading to inaccuracies.</p><p><strong>Setting: </strong>This prospective clinical and bench study aimed to assess the accuracy of P0.1vent compared with the manual occlusion method (P0.1occ) during spontaneous breathing trials (SBT) and following a reventilation period with varying ventilator settings.</p><p><strong>Design and patients: </strong>The clinical part of the study included patients undergoing SBT on Hamilton C6 (software version 1.2.3) with zero pressure support (PS) and zero end-expiratory pressure (PEEP) and reventilation (PS +8 cm H2O, PEEP +5 cm H2O). P0.1vent and P0.1occ were collected every 15 minutes. Bench part evaluated the P0.1vent and P0.1occ of the Hamilton C6 (software version 1.2.3) connected to a lung simulator (ASL 5000) creating different breathing efforts across different lung mechanics and varying PS and PEEP levels.</p><p><strong>Measurement and main results: </strong>In patients, P0.1vent values were significantly higher than P0.1occ (median, 11.0 vs. 1.0 cm H2O; p < 0.001), with a mean bias of 8.5 cm H2O. Similar overestimations were observed during the reventilation period (6.0 vs. 1.0 cm H2O; mean difference, 6.5 cm H2O; p < 0.001). Bench results confirmed the variable accuracy of P0.1vent found in the clinical part of the study, with biases ranging from nearly perfect (0.2 cm H2O) under high PS to 2.3 cm H2O under low PS.</p><p><strong>Conclusions: </strong>Automatic P0.1 estimation by the Hamilton C6 (software version 1.2.3) is inaccurate during SBTs. Manual occlusion remains essential for reliable P0.1 assessment at the bedside.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1493"},"PeriodicalIF":2.9,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13649338/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149139567","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":"Characteristics and Outcomes of Patients Referred but Declined for ICU Admission in a Resource-Limited Setting in South Africa.","authors":"George L Anesi, Nqobile Ndadane, Jonathan Invernizzi, Saajid Ally Alladeen, Arisha Ramkillawan, Stella M Savarimuthu, Robert D Wise, Michelle T D Smith, Zane Farina","doi":"10.1097/CCE.0000000000001498","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001498","url":null,"abstract":"<p><strong>Objectives: </strong>ICU beds are a limited resource and assessing net benefit from ICU admission remains incompletely understood. We sought to examine characteristics and outcomes of patients referred but declined for ICU admission, stratified by clinician-perceived likelihood of ICU benefit.</p><p><strong>Design: </strong>Descriptive, retrospective cohort study.</p><p><strong>Setting: </strong>Two public hospitals in the KwaZulu-Natal Department of Health, South Africa, from January 2022 to June 2022.</p><p><strong>Patients: </strong>Adult ICU-referred patients classified into four triage cohorts by clinician-assessed acuity and ICU triage status: ICU admissions; high-acuity capacity-declined ICU referrals; high-acuity prognosis-declined ICU referrals; and low-acuity prognosis-declined ICU referrals.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We report descriptive statistics of ICU-referred patient characteristics stratified by triage cohorts and mortal status. Among 866 ICU referrals, 469 patients (54.2%) were admitted, and 397 patients (45.8%) were declined for ICU admission. ICU admissions had an observed all-cause 30-day hospital mortality of 27.7%. Among declined ICU referrals with nonmissing triage priority scores (<i>n</i> = 327), 250 patients (76.5%) were declined ICU admission for prognosis reasons, and 77 patients (23.5%) were declined for capacity reasons. Seventy-seven (9.7% of ICU referrals) high-acuity capacity-declined ICU referrals (\"appropriate patient; no bed capacity; not admitted\") had a 26.0% mortality (74.0% survival), 111 (13.9%) high-acuity prognosis-declined ICU referrals (\"too sick; not admitted\") had a 53.2% mortality (46.8% survival), and 139 (17.5%) low-acuity prognosis-declined ICU referrals (\"too well; not admitted\") had a 7.2% mortality. Declined ICU referrals were less likely surgical/trauma patients and more likely medical patients coming from wards and emergency departments.</p><p><strong>Conclusions: </strong>In one sampling in the South African public healthcare system, many patients are referred but declined for ICU admission due to perceptions of being both \"too well\" or \"too sick\" to benefit and due to bed capacity, with a proportion of such patients experiencing potential clinical deviations from triage-expected trajectories.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1498"},"PeriodicalIF":2.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629843/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149120175","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":"Palliative Care Involvement in Relation to Rapid Response Events: A Focus on Care Intensity at the End of Life.","authors":"Jason M Arnold, Chuanfen Ni, Kayla Thompson, Mary Clare Lipa, Deepa Daryani, Megan Christenson, Nandita R Nadig, Susan R Russell","doi":"10.1097/CCE.0000000000001489","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001489","url":null,"abstract":"<p><strong>Objectives: </strong>To examine current practice patterns of palliative care involvement in relation to rapid response (RR) events and to evaluate its association with ICU utilization and intensity of care received before death.</p><p><strong>Design: </strong>Retrospective cohort study of patients who underwent a RR event.</p><p><strong>Setting: </strong>General medical, cardiology, oncology, and observation patients admitted to a tertiary care academic medical center in the United States.</p><p><strong>Patients: </strong>Adults (≥ 18 yr) with an RR event.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>A total of 903 RR events occurred in 616 unique patients. The palliative care team was involved in 110 of 616 (17.9%) patients. Palliative care (PC) involvement was not associated with differences in repeat RR events or ICU transfer rates following an event. In-hospital mortality or hospice discharge occurred in 32.0% (197/616). Palliative care was involved in 36.5% (72/197) of these patients. PC involvement was associated with lower intensity of care within 24 hours before death after adjustment for age, sex, Charlson Comorbidity Index, pre-RR code status, and RR trigger (adjusted odds ratio [aOR], 0.26; 95% CI, 0.14-0.47; p < 0.001; Brant test, p = 0.44). This finding remained across sensitivity analyses for oncology status, primary service line, ICU transfer, and advanced directive documentation. PC consultation occurred only before RR in 16 of 110 (14.5%), only after RR in 63 of 110 (57.3%), and both before and after in 31 of 110 (28.2%). In timing-stratified ordinal regression, PC consultation only after RR (aOR, 0.19; 95% CI, 0.10-0.38; p < 0.001) or both before and after RR (aOR, 0.22; 95% CI, 0.09-0.56; p = 0.002) was associated with less-intense care, while pre-RR PC alone was not (aOR, 1.06; 95% CI, 0.33-3.35; p = 0.93).</p><p><strong>Conclusions: </strong>Palliative services may be underutilized in the RR patient population, a group with a high in-hospital mortality rate; when palliative care is consulted, it may be associated with a reduction in the intensity of interventions at the end of life.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1489"},"PeriodicalIF":2.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629844/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149120286","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":"From Formula Composition to Precision Nutrition: Who Benefits, From What, and When?","authors":"Sue Brierley-Hobson, Ashley DePriest","doi":"10.1097/CCE.0000000000001497","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001497","url":null,"abstract":"<p><p>Morowitz et al argue that the composition of enteral nutrition formulas deserves to be studied as an intervention in its own right. Building on this perspective, we consider how critical care nutrition research has progressively refined its questions from whether to feed to when and how much. We argue that enteral formula composition represents the next logical frontier in critical care nutrition research, while emphasizing the need for biologically informed, clinically meaningful, and practical interventions. We also highlight the importance of learning from previous translational challenges to ensure that future research identifies formulations that improve patient outcomes while remaining feasible for routine critical care practice.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1497"},"PeriodicalIF":2.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629841/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149120245","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":"Characteristics and Outcomes of Patients Referred but Declined for ICU Admission in a Resource-Limited Setting in South Africa.","authors":"George L Anesi, Nqobile Ndadane, Jonathan Invernizzi, Saajid Ally Alladeen, Arisha Ramkillawan, Stella M Savarimuthu, Robert D Wise, Michelle T D Smith, Zane Farina","doi":"10.1097/CCE.0000000000001498","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001498","url":null,"abstract":"<p><strong>Objectives: </strong>ICU beds are a limited resource and assessing net benefit from ICU admission remains incompletely understood. We sought to examine characteristics and outcomes of patients referred but declined for ICU admission, stratified by clinician-perceived likelihood of ICU benefit.</p><p><strong>Design: </strong>Descriptive, retrospective cohort study.</p><p><strong>Setting: </strong>Two public hospitals in the KwaZulu-Natal Department of Health, South Africa, from January 2022 to June 2022.</p><p><strong>Patients: </strong>Adult ICU-referred patients classified into four triage cohorts by clinician-assessed acuity and ICU triage status: ICU admissions; high-acuity capacity-declined ICU referrals; high-acuity prognosis-declined ICU referrals; and low-acuity prognosis-declined ICU referrals.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We report descriptive statistics of ICU-referred patient characteristics stratified by triage cohorts and mortal status. Among 866 ICU referrals, 469 patients (54.2%) were admitted, and 397 patients (45.8%) were declined for ICU admission. ICU admissions had an observed all-cause 30-day hospital mortality of 27.7%. Among declined ICU referrals with nonmissing triage priority scores (n = 327), 250 patients (76.5%) were declined ICU admission for prognosis reasons, and 77 patients (23.5%) were declined for capacity reasons. Seventy-seven (9.7% of ICU referrals) high-acuity capacity-declined ICU referrals (\"appropriate patient; no bed capacity; not admitted\") had a 26.0% mortality (74.0% survival), 111 (13.9%) high-acuity prognosis-declined ICU referrals (\"too sick; not admitted\") had a 53.2% mortality (46.8% survival), and 139 (17.5%) low-acuity prognosis-declined ICU referrals (\"too well; not admitted\") had a 7.2% mortality. Declined ICU referrals were less likely surgical/trauma patients and more likely medical patients coming from wards and emergency departments.</p><p><strong>Conclusions: </strong>In one sampling in the South African public healthcare system, many patients are referred but declined for ICU admission due to perceptions of being both \"too well\" or \"too sick\" to benefit and due to bed capacity, with a proportion of such patients experiencing potential clinical deviations from triage-expected trajectories.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1498"},"PeriodicalIF":2.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149120304","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Response to Dobutamine in Septic Shock With Myocardial Dysfunction: A Single-Center Retrospective Study.","authors":"Marwa Tarbaghia, Abdelrahman Nanah, Ryota Sato, Filippo Sanfilippo, Siddharth Dugar","doi":"10.1097/CCE.0000000000001487","DOIUrl":"10.1097/CCE.0000000000001487","url":null,"abstract":"<p><strong>Importance: </strong>Dobutamine is recommended for septic shock with myocardial dysfunction and persistent hypoperfusion despite preload and mean arterial pressure optimization; however, supporting evidence is limited, and predictors of response remain unclear.</p><p><strong>Objectives: </strong>To determine whether early hemodynamic responsiveness to dobutamine is associated with clinical outcomes and whether baseline echocardiographic parameters identify responders.</p><p><strong>Design, setting, and participants: </strong>Single-center retrospective cohort study at a quaternary academic medical center. Adults with septic shock who received concomitant dobutamine with vasopressor therapy and underwent transthoracic echocardiography within 12 hours before dobutamine initiation.</p><p><strong>Main outcomes and measures: </strong>Hemodynamic responsiveness was defined as the combination of an increase in central venous oxygen saturation (ScvO2) of at least five percentage points and a reduction in norepinephrine-equivalent (NEE) dose measured at 2 hours after dobutamine initiation. The primary outcome was 28-day ICU mortality. Secondary outcomes included ICU-free days and renal replacement therapy (RRT) requirement.</p><p><strong>Results: </strong>Of 104 patients, 37 (36%) met the composite definition of hemodynamic response. Baseline demographics, illness severity, lactate, and baseline vasopressor dose were similar between groups. Beyond the 2-hour window used to define response, separation persisted at 6 hours: responders showed a greater reduction in NEE dose (ΔNEE, -0.13 vs. 0.04 µg/kg/min; p < 0.001) and a higher MAP/NEE ratio (380 vs. 166; p = 0.003), and a greater increase in ScvO2 (+12% vs. +6%; p = 0.014). 28-day ICU mortality was 41% in responders and 58% in nonresponders (p = 0.13); after multivariable adjustment, hemodynamic response was associated with lower 28-day ICU mortality (odds ratio, 0.18; 95% CI, 0.04-0.68; p = 0.018). Responders had more ICU-free days (17 [0-22] vs. 0 [0-15]; p = 0.017); RRT requirement did not differ (43% vs. 37%; p = 0.7). No baseline echocardiographic parameter was associated with hemodynamic responsiveness.</p><p><strong>Conclusions and relevance: </strong>In septic shock with myocardial dysfunction, early hemodynamic responsiveness to dobutamine identified a subgroup with a more favorable clinical trajectory. Resting echocardiographic parameters did not identify responders. These findings are hypothesis-generating and require prospective confirmation.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1487"},"PeriodicalIF":2.9,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13619267/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149076998","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":"Sepsis Diagnostic Excellence: Development and Validation of a Theoretical Framework for Conceptualizing Accurate, Timely Sepsis Diagnosis.","authors":"Sarah A Birken, Sachita Shrestha, Laura S Clark, Cheyenne R Wagi, Kandice L Reilly, Marc A Kowalkowski, Jessica A Palakshappa, Jessie E King, Chadwick D Miller, Stefanie S Sebok-Syer, Stephanie P Taylor","doi":"10.1097/CCE.0000000000001490","DOIUrl":"10.1097/CCE.0000000000001490","url":null,"abstract":"<p><strong>Objectives: </strong>Develop and empirically validate the Sepsis Diagnostic Excellence (SepsisDx) Theoretical Framework of multilevel factors influencing accurate, timely sepsis diagnosis.</p><p><strong>Design: </strong>Observational qualitative semi-structured interviews.</p><p><strong>Setting and participants: </strong>Twenty hospitals spanning four states and two health systems within the United States were purposively selected to maximize location, system structure, and patient population representation.</p><p><strong>Analysis: </strong>We conducted 41 interviews with key informants from 13 hospitals, including top managers (e.g., system leaders), mid-level managers (e.g., emergency department (ED) heads; sepsis coordinators), and patient-facing clinicians and staff (e.g., unit nurses). We developed an interview guide by integrating three extant frameworks that collectively conceptualize sepsis diagnosis as a behavior among healthcare providers that is influenced by factors at micro-, meso-, and macroorganization levels. To develop SepsisDx, we used template analysis to identify constructs that influenced accurate, timely sepsis diagnosis and rapid analysis to identify relationships among the framework's constructs. We refined preliminary findings based on feedback from a study advisory board and interview participants.</p><p><strong>Results: </strong>Interviews validated the central premise of SepsisDx-that is, sepsis diagnosis is influenced by the interaction of factors at micro-, meso-, and macrolevels. The most salient individual-level factor influencing timely sepsis diagnosis was attention (i.e., noticing, encoding, interpreting, and focusing time and effort). Attention was reduced by ambiguous clinical presentations and environmental shocks (e.g., COVID-19). Various strategies increased organization-level attention while decreasing provider-level attention (e.g., audit and feedback). Strategies' effectiveness was moderated by hospital characteristics such as staffing.</p><p><strong>Conclusions: </strong>The SepsisDx framework clarifies which factors influence sepsis diagnosis and how these factors operate through specific mechanisms. Accurate, timely sepsis diagnosis depends on organizational attention that aligns with individual provider attention to potential sepsis diagnoses. Leaders may improve sepsis diagnosis by pursuing health system- and organization-level strategies that reflect individual-, team-, and emergency-department-level experiences.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":"8 10","pages":"e1490"},"PeriodicalIF":2.9,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13619180/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149066541","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}