Critical Care Medicine最新文献

Objectives: To develop a practical consensus-based framework for ten steps to improve sepsis care in low-resource settings (LRSs), aligned with the sepsis chain of survival and informed by global expertise.

Data sources: We reviewed peer-reviewed literature on sepsis epidemiology, prevention, recognition, and management in LRS; international guidelines, including the Surviving Sepsis Campaign; and prior "ten-step" consensus frameworks for resuscitation and emergency care.

Study selection: A Task Force representing adult and pediatric sepsis care, emergency care, critical care, infectious diseases, public health, and implementation science identified key domains from the above data sources.

Data extraction: With guidance from methodologists and implementation science experts, we employed an iterative, consensus-based process-literature review, Delphi survey, Utstein-style conference, stakeholder input, and public comment-to first define and then refine steps and implementation strategies.

Data synthesis: The process resulted in ten nonsequential, actionable steps covering governance and commodities, provider and caregiver education, community and facility prevention, early recognition and rapid response, timely guideline-based interventions, structured post-sepsis care, data systems, quality improvement, a culture of excellence and respect, and holistic well-being of patients, caregivers, and providers. Each step includes a rationale and potential implementation strategies adaptable to local resources and needs. Collectively, the ten steps emphasize integration across the continuum of care, equitable access to essential interventions, and the role of emerging technologies to prevent, recognize, monitor, and follow-up sepsis.

Conclusions: The ten steps provide a consensus-driven roadmap for health leaders, clinicians, and policymakers to improve sepsis care, strengthen the sepsis chain of survival, reduce preventable morbidity and mortality, and address global inequities in sepsis outcomes.

Objectives: Sepsis is a time-sensitive cause of preventable death worldwide, with disproportionate mortality in low-resource settings (LRS). Many recommendations in international sepsis guidance presume resources unavailable in many facilities and communities. We sought to develop a practical framework that helps health systems embed feasible sepsis actions within broader emergency and essential critical care systems, while highlighting where evidence is limited and where local learning systems are needed.

Data sources: A targeted scoping review of peer-reviewed and grey literature on sepsis epidemiology, emergency care systems, essential emergency and critical care, implementation strategies, and quality improvement (QI) in LRS; and key guideline and policy documents relevant to sepsis and emergency care.

Study selection: We prioritized publications and guidance relevant to LRS, including observational studies, pragmatic implementation reports, consensus statements, and policies addressing emergency care organization, workforce, supply chains, diagnostics, and QI.

Data extraction: Task force members abstracted actionable strategies, implementation barriers/enablers, and feasibility considerations across the care continuum (community, transport/prehospital, facility-based acute care, and referral). We also identified domains where guideline certainty is low or indirect for LRS.

Data synthesis: A Society of Critical Care Medicine-convened multidisciplinary task force iteratively developed the "Sepsis Frame of Survival" using a structured process that included 1) scoping evidence review, 2) a Delphi-style prioritization of candidate framework elements by importance and feasibility, and 3) a structured consensus meeting ("Utstein-style" conference format) to finalize the model and its priority actions. We produced a concise implementation roadmap and a feasible measurement set aligned with resource constraints.

Conclusions: The Sepsis Frame of Survival is a pragmatic model to organize sepsis improvement as part of emergency and essential critical care strengthening. It emphasizes high-impact actions that can be implemented with limited resources (triage and early recognition, timely antimicrobials, oxygen and basic supportive care, cautious fluid resuscitation with reassessment, source control and referral, diagnostics/microbiology where feasible, and QI). The framework explicitly distinguishes near-term, feasible changes from longer-term system investments and highlights the need for locally generated evidence to guide quality indicators and resuscitation strategies in LRS.

Rationale: Older adults (those 65 years old or greater) compose a substantial proportion of the ICU population. As older adults with critical illness possess unique factors and considerations relevant to their care and outcomes, there is a need for evidence-based recommendations to guide critical care clinicians in the care of older ICU patients.

Objective: The objective of this guideline is to develop evidence-based recommendations addressing the care of older adults during and after critical illness.

Design: The American College of Critical Care Medicine Board convened a 22-member interprofessional panel, comprising physicians, advanced practice providers, nurses, a pharmacist, physical therapist, occupational therapist, and a patient representative. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting.

Methods: The panel members prioritized five Population, Intervention, Comparator, and Outcomes questions. A systematic review was conducted for each question to identify the best available evidence, synthesize the evidence and assess the certainty of evidence using GRADE. The evidence-to-decision framework was used to formulate recommendations.

Results: The panel generated two conditional recommendations and three "no recommendation" statements. The conditional recommendations are: 1) We suggest a geriatric model of care for all older adults admitted to the ICU and 2) We suggest not using antipsychotic medications for the prevention of delirium in older adults with critical illness. The three "no recommendation" statements are: 1) We make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness, 2) For older adults (age 65 and over) admitted to the ICU with vasodilatory shock, we make no recommendation with regard to targeting a mean arterial pressure (MAP) of 60-65 mm Hg as compared with usual care (MAP target > 65 mm Hg), and 3) We make no recommendation regarding the use of antipsychotic medication in the treatment of delirium in older adults with critical illness.

Conclusions: The guideline panel developed recommendations on caring for older adults during and after critical illness. Areas for future research were also identified during the guideline process.

Objectives: The practice of limiting life-sustaining therapy (LST) at end-of-life is widespread globally. The goal of this study was to evaluate whether patient's age influences end-of-life limitations overall and of various LST in ICUs worldwide.

Design: Multinational, multicenter, prospective observational study.

Setting: One hundred ninety-nine ICUs in 36 countries worldwide.

Patients: Consecutive adult patients admitted to ICUs who died and/or had LST limitations (withholding, withdrawing, or active shortening of the dying process) were included during a 6-month period between September 2015 and September 2016.

Interventions: None.

Measurements and main results: Patients were grouped: younger than 65 years, 65-79 years old, and 80 years old or older. A total of 12,200 patients were included. In multivariate logistic regression analysis, odds ratio (OR) for any LST limitation in the 80 years old or older group was higher than in younger than the 65 years old group (OR 1.47 [95% CI, 1.22-1.76], p < 0.001). When stratified by region, this association was significant in Central and Southern Europe (OR 1.56 [95% CI, 1.11-2.20], p = 0.037 and OR 2.23 [95% CI, 1.58-3.17], p < 0.001, respectively), but not in the other regions. The proportion of withholding therapy of each LST was highest in the group of individuals 80 years or older, whereas the proportion of withdrawing therapy was highest in the group younger than 65 years. The 80-year-old or older group also had a shorter time from ICU admission to first limitation. The predominant reason for any LST limitation in all age groups was unresponsiveness to maximal therapy, followed by neurologic and chronic diseases. Patient age was rarely the primary reason for limitations for all groups.

Conclusions: End-of-life limitations were higher in patients 80 years or older compared to those 65 years old or younger, with regional variations. The main reasons for limitations were comparable across age groups, with age not being the primary reason.

Objectives: Almost 80% of sepsis cases occur in low-resource settings (LRS), where limited resources impede the effective implementation of international guidelines for sepsis management. In addition, existing sepsis guidelines have not fully addressed specific issues relevant to LRS. Therefore, an international panel of 20 multiprofessional sepsis experts was convened to generate consensus on the gaps in and strategies for sepsis care in LRS. The recently developed "sepsis chain of survival" was used as a framework.

Data sources: MEDLINE, Embase.

Study selection: Studies selected included human studies (clinical trials, cohort, case-control, and case series) reporting clinical outcomes in patients with sepsis from LRS between January 1, 2000, and July 4, 2024. Search terms included "developing countries," "LMIC," "resource-poor settings," and regional terms such as Africa, Southeast Asia, and Latin America. The Delphi process involved iterative, anonymous voting by the expert panel to achieve consensus to draft clinical practice statements.

Data extraction: A detailed literature review was conducted using the "sepsis chain of survival" as a basis, with an emphasis on sepsis prevention, detection, therapy, post-sepsis care, education, and future research priorities. A total of 8865 studies were identified and screened, with 155 included in the review.

Data synthesis: Based on literature review, the Delphi process achieved a stable consensus for 58 of 62 (94%) of the proposed clinical practice statements after eight survey rounds. These statements offer guidance on measures to improve the prevention, early recognition and time-sensitive, comprehensive management of sepsis in LRS through the continuum of care from first response to post-sepsis care and follow-up.

Conclusions: There remains a significant lack of high-quality evidence to support improvements in sepsis care for patients in LRS. Pending new data, the clinical practice statements identified here complement the existing international guidelines for sepsis management by serving as a basis for immediate care and future research in LRS.

Objectives: To evaluate the association between socioeconomic position (SEP) and mortality in patients with sepsis or septic shock.

Data sources: We searched MEDLINE, Embase, and Cochrane CENTRAL from inception to August 11, 2025.

Study selection: We included English-language observational studies that evaluated the association between SEP indicators and mortality in adults with sepsis and/or septic shock.

Data extraction: Two reviewers independently and in duplicate performed data extraction and risk-of-bias assessment using the Quality in Prognosis Studies tool. We pooled adjusted odds ratios (aORs) or adjusted hazard ratios (aHRs) using random-effects models and assessed certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Data synthesis: We included 13 observational studies involving 3,951,677 patients. Lack of private insurance (aOR, 1.34; 95% CI, 1.19-1.51; high certainty) was associated with increased mortality while lower neighborhood socioeconomic status (aOR, 1.35; 95% CI, 1.29-1.41; moderate certainty) and lower income (aOR, 1.06; 95% CI, 1.01-1.11; aHR, 1.51; 95% CI, 1.01-2.25; moderate certainty) were probably associated with increased mortality. Less education (aOR, 1.33; 95% CI, 1.14-1.55; low certainty) and unemployment (aOR, 1.91; 95% CI, 1.00-3.63; low certainty) may be associated with increased mortality.

Conclusions: We found that several indicators of SEP were associated with increased short-term mortality in patients with sepsis and septic shock. These findings underscore the need for routine collection of equity-relevant variables in sepsis research to inform health policy and support equitable care delivery. Given that some of these variables are potentially modifiable, targeted interventions may help improve outcomes and reduce disparities in disadvantaged populations.