Critical Care Medicine最新文献

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.

Objectives: A temperature control strategy is strongly recommended for comatose in-hospital cardiac arrest (IHCA) survivors. We aimed to investigate variation in adherence to this recommendation and associations with outcomes, which have not been comprehensively assessed for IHCA.

Design: Prospective observational cohort study with data collected from October 2023 to June 2024.

Setting: Multicenter, international (24 hospital systems, 46 enrolling hospitals).

Patients: Adults who suffered IHCA, survived initial resuscitation, and remained comatose and eligible for temperature control.

Interventions: None.

Measurements and main results: The main exposure was documentation of a temperature control strategy in the first 24 hours after arrest. Outcomes were survival to hospital discharge (primary), use of temperature control therapy, fever (temperature ≥ 38°C), favorable functional outcome (modified Rankin Scale ≤ 3), and favorable neurologic outcome (Cerebral Performance Category score ≤ 2). Among 1006 enrolled patients, 615 (61.1%) remained comatose and were eligible for temperature control; of those, 273 (44.4%) had a documented temperature control strategy. A documented strategy was associated with higher adjusted odds of receiving a temperature control therapy (adjusted odds ratio [aOR], 21.3; 95% CI, 12.3-36.7; p < 0.01), and lower adjusted odds of fever in the first 24 hours after resuscitation (aOR, 0.63; 95% CI, 0.43-0.92; p = 0.02). Having a strategy, compared with not, had no statistically significant association with survival (32.6% vs. 28.1%; aOR, 1.19; 95% CI, 0.79-1.80; p = 0.42), favorable functional outcome (9.9% vs. 10.5%; aOR, 1.14; 95% CI, 0.53-2.42; p = 0.74), or favorable neurologic outcome (12.8% vs. 12.3%; aOR, 1.15; 95% CI, 0.63-2.12; p = 0.65). Hospital system specific proportions of temperature control strategy ranged from 0% to 100%.

Conclusions: Among comatose IHCA survivors, more than half received no documented temperature control strategy. Those with a strategy were less likely to have a fever and more likely to receive temperature control directed therapy, but showed no difference in survival, functional, or neurologic outcomes.

Objectives: To evaluate temporal trends in clinical outcomes among nontraumatic out-of-hospital cardiac arrest (OHCA) patients transported to critical care medical centers (CCMCs) in Japan.

Design: Retrospective cohort study.

Setting: Nationwide multicenter registry involving CCMCs in Japan, which are government-designated advanced emergency care institutions specializing in intensive resuscitation and post-cardiac arrest management. Data were obtained from the Japanese Association for Acute Medicine OHCA (JAAM-OHCA) registry from June 1, 2014, to December 31, 2022.

Patients: Adult patients (≥ 18 yr old) with nontraumatic OHCA who were transported to CCMCs and had Utstein-style prehospital data available. Patients were categorized into three calendar periods (2014-2016, 2017-2019, and 2020-2022) for temporal comparison.

Interventions: None.

Measurements and main results: Among 61,725 eligible patients, the proportion with favorable neurologic outcomes decreased from 3.6% (2014-2016) to 3.3% (2017-2019) and further to 2.5% (2020-2022). Using multivariable logistic regression, the adjusted odds ratios (aORs) for favorable neurologic outcome were 1.01 (95% CI, 0.89-1.15) in 2017-2019 and 0.83 (95% CI, 0.72-0.94) in 2020-2022, compared with 2014-2016. Similarly, 30-day survival declined during the same period, from 6.9% to 6.8% and 5.4%. In most predefined subgroups, similar trends were observed. In contrast, neurologic outcomes improved among candidates for extracorporeal cardiopulmonary resuscitation (ECPR), with an aOR of 1.43 (95% CI, 1.06-1.93) in 2020-2022 compared with 2014-2016.

Conclusions: Outcomes among OHCA patients transported to CCMCs remained stable until 2019 but declined during the COVID-19 pandemic period. However, improved outcomes among patients eligible for ECPR suggest that timely and targeted post-arrest interventions may improve outcomes in selected populations.

Central to managing critically ill patients is the identification of the etiology of cardiorespiratory insufficiency (i.e., shock), early appropriate targeted therapies to support the cardiorespiratory system to sustain adequate blood flow and oxygen to the tissues, plus specific treatments to reverse the cause of shock. Over the past 40 years, numerous advances in our understanding of shock, its severity, and its response to therapies, along with more specific and insightful monitoring approaches, have been developed. This perspective summarizes some aspects of that progress. We have come a long way, but we need to understand three things. First, that once organ injury has occurred all that our treatments can do is mitigate further injury, not reverse it. If initial aggressive resurrection efforts cannot restore organ function, then their actions often cause only iatrogenic injury. Second, existing advanced monitoring devices, no matter how insightful their data, will not improve patient outcomes unless coupled to a treatment that itself improves outcomes. Finally, all our advances over these years have underscored the fundamental need for having a thoughtful and observant bedside clinician cognizant of the pathophysiologic underpinnings of disease and its care who titrates care based on the patient's individual response.

Objectives: Evidence supporting the benefits of combined nutrition and exercise programs in ICU survivors is limited. We assessed the impact of a combined lifestyle intervention on perceived physical functioning (PF) and health-related quality of life (HRQoL) post-ICU.

Design: Single-center randomized control trial.

Setting: Teaching hospital in the Netherlands (Frisius Medical Centre Leeuwarden).

Patients: Adult long stay ICU survivors (≥ 48 hr) with a PF score of less than 67% on the Dutch translation of the RAND-36 item Health Survey.

Interventions: The 12-week intervention included twice-weekly group exercise, dietary advice, and protein supplementation as needed. The control group received standard aftercare according to local protocol.

Measurements and main results: Primary outcome (PF score at 12 wk) and secondary outcomes were assessed during a clinic visit at baseline and after a 12-week period. 39 patients completed the study (control, n = 20; intervention, n = 19): 26% female, median age 61 years (46-72), median ICU stay 7 days (4-14), and patients were severely ill (Acute Physiology and Chronic Health Evaluation III: 67 [50-89]). Although there were imbalances in ICU characteristics, baseline characteristics and PF scores were similar. At 12 weeks, the intervention group showed a significant improvement (p = 0.024) in PF-domain score. Daily protein intake in the intervention group increased from 82.3 (67.5-97.9) to 116.7 (107.3-138.7) g/kg (p = 0.003), with 68% meeting the minimal intake target of 1.2 g/kg/d.

Conclusions: The data of this small-sample size randomized controlled trial suggest that a combined lifestyle intervention program can significantly improve PF and protein intake in ICU survivors with a prolonged PF scores below reference.

Objectives: To assess the effects of adjunctive inhaled antibiotics in treating ventilator-associated pneumonia (VAP).

Data sources: We searched PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov through May 31, 2025.

Study selection: We included randomized controlled trials (RCTs) and nonrandomized studies comparing adjunctive inhaled antibiotics with placebo/blank or IV antibiotics for VAP treatment.

Data extraction: Two groups independently screened studies, extracted data, and assessed risk of bias. Analyses used random effects models. Subgroup analyses, meta-regression, trial sequential analysis, and the Grading of Recommendations Assessment, Development, and Evaluation were performed.

Data synthesis: We included 32 RCTs in the primary analysis and 41 non-RCTs in sensitivity analysis. Compared with placebo/blank, inhaled antibiotics significantly improved clinical cure (16 RCTs; n = 1425; risk ratio [RR], 1.24; 95% CI, 1.07-1.43) and reduced all-cause mortality (21 RCTs; n = 1855; RR, 0.84; 95% CI, 0.71-0.98), with consistent findings in sensitivity analyses including non-RCTs. These benefits were significant in VAP-only patients (clinical cure: 11 RCTs; n = 775; RR, 1.29; 95% CI, 1.10-1.52 and all-cause mortality: 15 RCTs; n = 1152; RR, 0.77; 95% CI, 0.65-0.90), but not in studies including mixed pneumonia populations. Meta-regression confirmed VAP-only population as a significant effect modifier. Inhaled antibiotics also improved microbiological eradication (20 RCTs; n = 1805; RR, 1.42; 95% CI, 1.27-1.58) and reduced emergence of new drug resistance (four RCTs; n = 182; RR, 0.20; 95% CI, 0.06-0.64). No differences were found in ICU length of stay, ventilator duration, or other adverse events. Compared with IV antibiotics, inhaled antibiotics shortened ventilator duration (three RCTs; n = 322; mean difference, -2.11 d; 95% CI, -3.73 to -0.49 d), and reduced nephrotoxicity (three RCTs; n = 292; RR, 0.42; 95% CI, 0.26-0.68).

Conclusions: Compared with placebo/blank, adjunctive inhaled antibiotics improve clinical cure and microbiological eradication, and may reduce mortality, particularly in VAP-only patients. Exploratory analyses based on limited data suggest potential advantages over IV therapy, including shorter ventilator duration and lower nephrotoxicity, warranting further high-quality trials.