Critical Care Medicine最新文献

Objective: Acute pancreatitis (AP) complicated by disseminated intravascular coagulation (DIC) is associated with high mortality. Although recombinant human soluble thrombomodulin (rTM) is commonly used in clinical practice, its association with outcomes in AP has not been established.

Design: A nationwide, propensity score-matched, retrospective cohort study.

Setting: The Japanese Diagnosis Procedure Combination national inpatient database.

Patients: Adult patients hospitalized with AP and DIC between July 2010 and March 2022, who survived at least 3 days. Patients were divided into those receiving rTM within three days of admission and those who did not. Propensity score matching compared in-hospital mortality.

Interventions: None.

Measurements and main results: The analysis included 10,238 patients with AP and DIC, of whom 2,001 (19.5%) received rTM and 8,237 (80.5%) did not. Propensity score matching yielded 1,868 well-balanced pairs. In-hospital mortality was lower in the rTM group (15.5% [290/1,868]) compared with the non-rTM group (19.7% [368/1,868]; risk difference: -4.2%, 95% CI, -6.6% to -1.7%; risk ratio: 0.79, 95% CI, 0.69 to 0.91).

Conclusions: Administration of rTM in patients with AP complicated by DIC was associated with lower in-hospital mortality.

Objectives: To identify factors associated with short-term mortality among patients receiving microaxial flow pump (mAFP) therapy for acute myocardial infarction-related cardiogenic shock (AMI-CS).

Data sources: We searched four databases (MEDLINE, Embase, CENTRAL, and Scopus) from January 1, 2004, to January 1, 2025.

Study selection: We selected English-language studies that included adults with AMI-CS receiving mAFP and evaluated factors associated with short-term mortality. We excluded patients receiving concurrent venoarterial extracorporeal membrane oxygenation, as well as studies that solely included patients presenting with out-of-hospital cardiac arrest.

Data extraction: Two authors performed citation screening and data extraction. For each factor evaluated in at least two studies, we performed meta-analyses of adjusted odds ratios (aORs) using a random-effects model. Risk of bias was evaluated using the Quality in Prognosis Studies tool, and the certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations methodology.

Data synthesis: Our primary analysis included 18 studies, encompassing 20,617 patients. Median short-term mortality across studies was 50.7% (interquartile range 38.4-55.3%). Factors associated with short-term mortality based on high-certainty evidence included: increased age (aOR, 1.04 per year [95% CI, 1.03-1.05 per year] or ≥ 65 yr (aOR, 2.42 yr [95% CI, 0.77-7.64 yr]), female sex (aOR, 1.26 [95% CI, 1.09-1.45]), higher body mass index (aOR, 1.05 per point [95% CI, 1.04-1.07 per point]), higher heart rate (aOR, 1.02 per beats/min [95% CI, 1.01-1.02 per beats/min]), higher serum creatinine (aOR, 1.35 per mg/dL [95% CI, 1.08-1.70 per mg/dL]), mechanical ventilation (aOR, 2.53 [95% CI, 1.82-3.53]), vasopressors (aOR, 1.52 [95% CI, 1.11-2.08] for any vasopressors and aOR, 1.37 [95% CI, 1.18-1.58] per each vasopressor), presentation with ST-elevation myocardial infarction (aOR, 1.59 [95% CI, 1.11-2.26]), cardiac arrest (aOR, 2.85 [95% CI, 2.22-3.64]), and hypoxic-ischemic brain injury (aOR, 5.36 [95% CI, 3.03-9.47]).

Conclusions: We identified several prognostic factors associated with short-term mortality in AMI-CS patients receiving mAFP support. This work may help inform clinicians, patients, and families regarding utilization of mAFP in AMI-CS.

Rationale: Efficient distribution of scarce critical care resources is essential to save the most lives in times of crisis. Evidence-based practices and processes enhance clinical decision-making.

Objectives: The objective of these guidelines was to develop evidence-based, rather than expert-based, recommendations for triaging critically ill patients eligible for ICU admission during times of crisis-level shortages in ICU capacity.

Design: The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel, comprising doctors in medicine, nursing, and law; advanced practice providers; respiratory therapists; ethicists; and patient/family representatives. 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 guidelines development including task force selection and voting.

Methods: The panel members identified and formulated five fundamental Patient, Intervention, Comparator, and Outcomes questions. The panel conducted a systematic review for each question to identify the best available evidence, analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional guidance.

Results: The panel generated one conditional recommendation and five no recommendation statements.

Conclusions: Crisis-level shortages significantly disrupt patient care. Despite the role of triage in minimizing adverse outcomes, there is a lack of evidence, as opposed to expert opinion, to guide practice recommendations in the critical clinical scenarios considered by the panel.

Objectives: To compare the effectiveness of histamine-2 receptor antagonists (H2RAs) vs. proton pump inhibitors (PPIs) for stress ulcer prophylaxis on the occurrence of upper gastrointestinal bleeding (UGIB) and other clinical outcomes in hospitalized patients with septic shock.

Design: Retrospective, multicenter, propensity-weighted cohort study.

Setting: Conducted across 220 geographically diverse community and teaching hospitals in the United States.

Patients: Adult patients (age ≥ 18 yr) with septic shock who were initiated on either H2RAs or PPIs on the day of hospital admission.

Interventions: H2RAs (famotidine) or PPIs (pantoprazole, omeprazole, esomeprazole, or lansoprazole).

Measurements and main results: The primary outcome was the occurrence of UGIB during hospitalization. Secondary outcomes included in-hospital mortality, ventilator-associated pneumonia, Clostridioides difficile infection, and hospital length of stay. Propensity scores with inverse probability of treatment weighting (IPTW) were used to control for confounding. Among 15,102 patients (5,492 H2RA, 9,610 PPI), the mean age was 65.8 ± 14.9 years, 47.8% were female, and 58.1% received invasive mechanical ventilation during hospitalization. After IPTW adjustment, PPI use was associated with a lower occurrence of UGIB compared with H2RA (odds ratio [OR], 0.78; 95% CI, 0.64-0.96; p = 0.016). A sensitivity analysis comparing famotidine to pantoprazole confirmed this finding (OR, 0.80; 95% CI, 0.65-0.97; p = 0.025). No significant differences were observed in in-hospital mortality (OR, 0.98; 95% CI, 0.91-1.06; p = 0.691), ventilator-associated pneumonia (OR, 0.93; 95% CI, 0.83-1.04; p = 0.188), C. difficile infection (OR, 1.32; 95% CI, 0.82-2.13; p = 0.246), or hospital length of stay (incidence rate ratio, 1.01; 95% CI, 0.98-1.05; p = 0.417).

Conclusions: In this large, diverse cohort of U.S. hospitalized adults with septic shock, PPI use for stress ulcer prophylaxis was associated with a significantly lower occurrence of UGIB compared with H2RA, with no significant differences in mortality, ventilator-associated pneumonia, C. difficile infection, or hospital length of stay.

Objectives: To summarize knowledge and identify gaps in evidence regarding the effects of vasoactive medications on microvascular perfusion in septic shock.

Data sources: We conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials.

Study selection: Studies included adult patients with septic shock who received vasoactive therapy with corresponding microcirculatory measurements between 1946 and May 7, 2025.

Data extraction: Data extraction was performed in Covidence by two independent reviewers. Data items included study design, patient population, vasoactive medication, macrohemodynamics, and microcirculation measurements and techniques.

Data synthesis: Thirty-three studies were included evaluating several vasoactive medications and microvascular measurement techniques. Despite heterogeneous study design, studies that recruited patients within 24 hours tended to report more significant microcirculatory changes. Microcirculatory changes and cardiac index only aligned in 39% of cases, highlighting a disconnect between global hemodynamics and microvascular perfusion. Several vasoactives, including norepinephrine, vasopressin, terlipressin, and levosimendan demonstrated context-dependent improvements in peripheral/sublingual microcirculation. Despite limitations in directly monitoring gastric microcirculation, dobutamine may enhance perfusion; however, further studies are needed to support dobutamine and other vasoactive agents' impacts on clinical outcomes.

Conclusions: Despite growing interest in perfusion-guided care, significant challenges remain in understanding how vasoactive agents affect the microcirculation. Clarifying these effects through standardized research and point-of-care perfusion monitoring remains a challenge in advancing outcome-driven resuscitation strategies.

Objectives: To evaluate whether remimazolam besylate could provide noninferior sedation to dexmedetomidine in patients under mechanical ventilation (MV) in the ICU.

Design: A multicenter, single-blind, randomized, noninferiority trial.

Setting: Fifteen ICUs across China between October 2021 and November 2023.

Patients: Adults under endotracheal intubation MV who were expected to require sedation for 8-48 hours.

Interventions: Three hundred fourteen patients were randomly assigned at a 1:1 ratio to the remimazolam besylate or dexmedetomidine group. Analgesia was provided via a continuous IV infusion of remifentanil at 1.2-9.0 µg/kg/hr. Remimazolam besylate or dexmedetomidine was administered IV at an initial loading dose of 0.1 mg/kg followed by a maintenance dose of 0.10-0.30 mg/kg/hr or at an initial loading dose of 0.20 µg/kg followed by a maintenance dose of 0.2-0.70 µg/kg/hr to achieve the targeted sedation range on the Richmond Agitation-Sedation Scale of -2 to +1.

Measurements and main results: Of the 314 patients enrolled, 299 completed the study. The sedation efficacy rates, as the primary endpoint, were 82.6% and 83.2% in remimazolam besylate and dexmedetomidine groups, respectively, in the per-protocol set (PPS), whereas the rate was 72.9% in both groups in the intention-to-treat (ITT) set. The noninferiority margin was set as 10%, and the lower limits of the two-sided 95% CI for the intergroup difference were -3.0% and -2.6% in the PPS and ITT sets, respectively. The dexmedetomidine group had a higher incidence of bradycardia than the remimazolam besylate group (4.7% vs. 0.7%; p = 0.029), whereas no intergroup differences were noted for the remaining secondary endpoints and adverse events.

Conclusions: Remimazolam besylate could provide noninferior sedation as dexmedetomidine with a lower risk of bradycardia for 48 hours in mechanically ventilated patients in the ICU.

Objectives: Venovenous extracorporeal membrane oxygenation (ECMO) represents a standard and well-accepted modality of treating patients with refractory respiratory failure. Nevertheless, some patients might develop refractory hypoxemia, hemodynamic compromise or end-organ perfusion requiring a change. This study analyzed characteristics and outcomes of patients requiring a change from venovenous to a different ECMO configuration.

Design: Multicenter, retrospective, observational analysis of the Extracorporeal Life Support Organization Registry (2010-2020) in adult patients (≥ 18 yr old) underwent venovenous ECMO as initial cannulation strategy.

Setting and patients: Comparison of patients who remained on venovenous ECMO vs. those who underwent configuration conversion and multivariable analysis to assess variables associated with configuration change.

Interventions: None.

Measurements and main results: Among 28,888 eligible venovenous ECMO runs, 702 (2.4%) received a change from the original configuration, including 399 (56.8%) conversions to venoarterial and 303 (43.2%) to hybrid ECMO configurations. Variables associated with conversion included: pre-ECMO cardiac conditions, bridge to lung transplant as indication, use of milrinone, epinephrine, sildenafil, bicarbonate, and 24-hour Pa o2 value. Conversion occurred at a median of 56 hours (interquartile range, 11.5-210 hr) after ECMO initiation, with earlier conversion to hybrid configuration. Increased rates of cardiovascular, hemorrhagic, vascular, renal, metabolic, infective, and circuit-related complications were reported in converted patients. In-hospital mortality was higher in converted patients (60.8%) overall, and highest for venovenous to venoarterial patients (63.2%).

Conclusions: The venovenous patients converted to other ECMO configurations were 2.4% and experienced higher complication and mortality rates. Variables associated with conversion highlight the importance of initial configuration selection and should be considered as part of the risk stratification framework when evaluating a patient for individualized ECMO support mode/configuration.