Critical Care Medicine最新文献

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.

Background: Sex-related discrepancies concerning the treatment of patients in intensive care are increasingly described. However, information about management and outcome of critically ill patients undergoing electroencephalography is scarce.

Objectives: This study explores sex-related disparities in management and clinical outcomes in critically ill patients needing electroencephalography for clinical purposes.

Design, setting, patients, and interventions: In this post hoc analysis of the multicenter Continuous Electroencephalography Randomized Trial in Adults (CERTA), which included patients with impaired consciousness requiring electroencephalography, we explored correlations between sex and the timing of electroencephalography, detection of electroencephalography abnormalities, mechanical ventilation, sedation, antiseizure therapy, mortality, and favorable functional outcome (Cerebral Performance Category [CPC] 1-2) at 6 months, using univariable and multivariable analyses.

Measurements and main results: Among 364 patients (33.8% women), women showed a higher prevalence of intracranial hemorrhage (women 30.9%, men 19.5%; p = 0.015) and epileptiform electroencephalography discharges (women 27.6%, men 21.2%; p = 0.008), but use of sedation, antiseizure medication and mechanical ventilation was similar between sexes. Although mortality was similar (adjusted odds ratio [OR], 0.70; 95% CI, 0.39-1.28), women were less likely to reach CPC 1-2 (adjusted OR, 0.50; 95% CI, 0.28-0.90).

Conclusions: Critically ill women and men requiring electroencephalography appear to receive similar clinical management and have comparable mortality, although long-term functional outcome in surviving women is worse. These findings warrant further investigation to identify modifiable factors contributing to sex-related outcome differences.

Objectives: Blood electrolyte panels, especially sodium ion (Na+) and potassium ion (K+), are fundamental and routine tests. In critical care settings, these measurements are typically performed by central laboratories using indirect potentiometry (IP) or via point-of-care blood gas analyzers using direct potentiometry (DP). Discrepancies between the two methods exist, and clinicians often have limited knowledge regarding the strengths and weaknesses of each technique. We wanted to quantify these observations.

Design: We compared prospectively Na+ and K+ measurements obtained from the same blood draw using both IP and DP (including analyses of correlation, agreement, and discrepancies). We also conducted a brief survey among physicians to assess their knowledge regarding IP and DP.

Settings: A tertiary hospital.

Patients: A total of 501 paired measurements were prospectively collected from an ICU population.

Interventions: None.

Measurements and main results: We assessed the degree of agreement between the two methods. We also examined the impact of proteinemia and hemolysis on Na+ and K+ values, respectively. Only 31.1% of the 103 responding physicians were aware of the analytical bias in Na+ measurements obtained by IP, and 45.6% considered K+ measurements from DP to be as reliable or more reliable than those obtained by IP. The agreement between the two methods was moderate (Lin's concordance correlation coefficient: 0.90 for Na+ and 0.93 for K+). The 95% limit of agreement for Na+ was particularly large (10.48 mmol/L). The divergence between the two methods, defined as a discrepancy in classification (within, below, or above the normal range), occurred in approximately 10% of cases, for both Na+ and K+.

Conclusions: IP and DP were not interchangeable, each exhibiting distinct strengths and limitations. Enhancing physician awareness of the differences between these methods could improve the quality of care.