Critical Care最新文献

{"title":"The effects of blood cell salvage on transfusion requirements after decannulation from veno-venous extracorporeal membrane oxygenation: an emulated trial analysis","authors":"Valentina Camarda, Barnaby Sanderson, Nicholas A. Barrett, Patrick Duncan Collins, Benjamin Garfield, Luciano Gattinoni, Lorenzo Giosa, Teddy Tun Win Hla, Ruth H. Keogh, Claire Laidlaw, Francesca Momigliano, Brijesh V. Patel, Andrew Retter, Emilia Tomarchio, Daniel McAuley, Louise Rose, Luigi Camporota","doi":"10.1186/s13054-024-05177-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05177-7","url":null,"abstract":"Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a supportive therapy for acute respiratory failure with increased risk of packed red blood cells (PRBC) transfusion. Blood cell salvage (BCS) aims to reduce blood transfusion, but its efficacy is unclear. This study aimed to estimate the effect of BCS at the time of removal of the ECMO circuit (ECMO decannulation) on PRBC transfused. To compare BCS to non-blood cell salvage (n-BCS), we conducted an emulated trial of patients at two ECMO centres in the United Kingdom. We used inverse propensity of treatment weighting to control for confounding and estimated the average treatment effect of BCS on PRBC transfused within two days of decannulation, and on changes in haemoglobin (Hb). We included 841 patients who underwent VV-ECMO decannulation. The estimated marginal mean number of PRBC transfused when using BCS was 0·2 (95%CI: 0·16, 0·25) units compared to 0·51 (95%CI: 0·44, 0·59) units with n-BCS; an average treatment effect of −0·31 (95%CI: −0·40, −0·22) units. BCS reduced the risk of receiving any PRBC transfusion by 17·1% (95%CI: 11·1%, 22·9%) equating to a number needed to treat for any PRBC transfusion of 6 (95%CI: 5, 9). The difference in expected Hb levels after decannulation between BCS and n-BCS was 5·0 (95%CI: 4·2, 5·8) g/L. The use of BCS during VV-ECMO decannulation may be an effective strategy to augment haemoglobin levels and reduce PRBC transfusions.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"58 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142776553","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Roadmap for the evolution of monitoring: developing and evaluating waveform-based variability-derived artificial intelligence-powered predictive clinical decision support software tools","authors":"Andrew J. E. Seely, Kimberley Newman, Rashi Ramchandani, Christophe Herry, Nathan Scales, Natasha Hudek, Jamie Brehaut, Daniel Jones, Tim Ramsay, Doug Barnaby, Shannon Fernando, Jeffrey Perry, Sonny Dhanani, Karen E. A. Burns","doi":"10.1186/s13054-024-05140-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05140-6","url":null,"abstract":"Continuous waveform monitoring is standard-of-care for patients at risk for or with critically illness. Derived from waveforms, heart rate, respiratory rate and blood pressure variability contain useful diagnostic and prognostic information; and when combined with machine learning, can provide predictive indices relating to severity of illness and/or reduced physiologic reserve. Integration of predictive models into clinical decision support software (CDSS) tools represents a potential evolution of monitoring. We perform a review and analysis of the multidisciplinary steps required to develop and rigorously evaluate predictive clinical decision support tools based on monitoring. Development and evaluation of waveform-based variability-derived predictive models involves a multistep, multidisciplinary approach. The stepwise processes involves data science (data collection, waveform processing, variability analysis, statistical analysis, machine learning, predictive modelling), CDSS development (iterative research prototype evolution to commercial tool), and clinical research (observational and interventional implementation studies, followed by feasibility then definitive randomized controlled trials), and poses unique challenges (including technical, analytical, psychological, regulatory and commercial). The proposed roadmap provides guidance for the development and evaluation of novel predictive CDSS tools with potential to help transform monitoring and improve care.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"222 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142776550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Longitudinal assessment of immunoglobulin response and disease progression in critically ill patients with community acquired pneumonia","authors":"Emma Rademaker, Lisette M. Vernooij, Tom van der Poll, Marc J. M. Bonten, Helen Leavis, Olaf L. Cremer, Lennie P. G. Derde","doi":"10.1186/s13054-024-05197-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05197-3","url":null,"abstract":"Low endogenous immunoglobulin(Ig)-levels are common in critically ill patients with sepsis, but it is unknown whether low Ig-levels are associated with poor outcome, and in which patients Ig-replacement therapy (IgRT) improves outcome. Given the crucial role of immunoglobulins in eliminating certain encapsulated pathogens, we examined the relationship between serial Ig-levels and disease course in critically ill patients with community acquired pneumonia (sCAP) caused by encapsulated or other pathogens. We included a cohort of consecutive critically ill patients with CAP, and PaO2/FiO2-ratio < 200 with or without septic shock, from an existing biorepository where microbiological causes of infection had been adjudicated in a protocolized manner. We used generalized linear mixed models to assess the association between IgG and IgM (measured on admission days 1, 3 and 7) and disease course (Sequential Organ Failure Assessment (SOFA)-score on day 2, 4, and 8) for all-cause sCAP and for episodes caused by Streptococcus (S.) pneumoniae or Haemophilus (H.) influenzae. We included 255 eligible patients admitted with CAP, of which 82 (32%) episodes were caused by S. pneumoniae or H. influenzae. 151 (59%) patients had low IgG (< 7.0 g/L), 77 (30%) had low IgM (< 0.4 g/L), and 56 (22%) had both. A lower IgG-level was related to a slightly higher SOFA-score at admission (β = − 0.07 per 1 g/L IgG, p = 0.029), but an IgG-level decline over time was not associated with a SOFA-score increase (β = − 0.04, p = 0.564). IgM-levels were not associated with changes in SOFA-score over time. Neither association was affected by the presence or absence of S. pneumoniae and H. influenzae. In critically ill patients with CAP, IgG and IgM dynamics in the first week of ICU stay are not associated with clinically relevant changes in disease course, regardless of the causative pathogen.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"82 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142782705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epidemiology and outcomes of septic shock in Thai children: a nationwide retrospective study from 2015 to 2022","authors":"Sirapoom Niamsanit, Phanthila Sitthikarnkha, Leelawadee Techasatian, Suchaorn Saengnipanthkul, Rattapon Uppala","doi":"10.1186/s13054-024-05193-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05193-7","url":null,"abstract":"Paediatric septic shock is a formidable challenge worldwide that significantly impacts health care systems. This nationwide retrospective study analyses the prevalence and mortality rates of paediatric septic shock across Thailand from 2015 to 2022, focusing on hospital burdens, including mechanical ventilation and renal replacement therapy. The study included paediatric patients ranging from infants to individuals under 18 years of age who were admitted to hospitals due to septic shock across Thailand. Data were retrospectively gathered from the Thai National Health Security Office for the years 2015–2022. The data included demographic data, clinical outcomes, and hospital burden indicators such as mechanical ventilation and renal replacement therapy. From 2015 to 2022, there were 30,718 paediatric admissions for septic shock, with a peak in 2019. The highest incidence was observed in infants, accounting for 44.7% of the cases. The prevalence rate increased from 190 per 100,000 population in 2015 to a peak of 280 per 100,000 population in 2020. Mortality rates decreased from 30.7% in 2015 to 20.2% in 2022, with a peak of 40.5% observed in the central region in 2015. The study highlighted a substantial health care burden, with 34.9% of patients requiring prolonged mechanical ventilation and 23.4% needing renal replacement therapy. Despite a decrease in mortality, paediatric septic shock remains a significant burden on the health care system in Thailand. Urgent improvements in resources and adherence to clinical guidelines, especially in under-resourced areas, are necessary. Addressing disparities in mortality and resource usage across hospital levels is vital for improving outcomes and reducing the health care burden of paediatric patients with septic shock.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"45 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142760724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nailfold videocapillaroscopy – a novel method for the assessment of hemodynamic incoherence on the ICU","authors":"Sebastian Kintrup, Lukasz Listkiewicz, Philip-Helge Arnemann, Nana-Maria Wagner","doi":"10.1186/s13054-024-05194-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05194-6","url":null,"abstract":"Loss of hemodynamic coherence is a phenomenon in critically ill patients. Due to inflammatory events and endothelial remodeling, macro- and microhemodynamics are decoupled from each other, resulting in microcirculatory disturbances and end organ ischemia despite adequate vital parameters. So far, quantification of perfusion of vessels with < 100 μm diameter on the intensive care unit (ICU) was regularly performed with incident darkfield (IDF) microscopy. Nailfold videocapillaroscopy (NVC), however, is an established and easy method for visualization of the microcirculation in chronic diseases. We here evaluated NVC in critically ill patients and compared its use with consensus microcirculatory assessment of IDF-microscopy. A new score, the capillary microcirculation (CapMic) score summarizing the microcirculation of the nail fold at four regions of digitus III, IV and V in a number between 0 (= no microcirculation) and 1 (= completely preserved microcirculation) was first established in 10 healthy volunteers and compared to the Microangiopathy Evolution Score (MES) standardized for NVC in chronic diseases. Then, n = 60 critically ill patients were recruited from a surgical ICU. Consensus-defined IDF scores and NCV data were compared at a single time point. Evaluation of the CapMic score in 10 healthy volunteers at rest and under iatrogenic limb ischemia showed robust changes (0.80 ± 0.03 vs. 0.51 ± 0.12, p < 0.001). In critically ill patients, the IDF microscopy parameters “proportion of perfused vessels” (PPV) and “microvascular flow index” (MFI) inversely correlated with the MES (Spearman’s R = -0.590, p < 0.001; Spearman’s R = −0.585, p < 0.001). There was a positive correlation between PPV and the CapMic score (Spearman’s R = 0.714, p < 0.001) and between MFI and the CapMic score (Spearman’s R = 0.711, p < 0.001) and an inverse correlation between MES and the CapMic score (Spearman’s R = −0.610, p < 0.001). Both sublingual and nailfold microcirculation deteriorated under rising norepinephrine- and crystalloid volume-requirements. NVC-imaging provides comparable information on the microcirculation in critically ill patients compared to sublingual IDF microscopy. NCV could represent a new, additional method for diagnosing microcirculatory parameters on the ICU.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"46 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142760360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lymphocyte count trajectories are associated with the prognosis of sepsis patients","authors":"Jiale Yang, Binli Ma, Huasheng Tong","doi":"10.1186/s13054-024-05186-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05186-6","url":null,"abstract":"&lt;p&gt;Sepsis causes multiorgan dysfunction from immune dysregulation, resulting in high ICU admissions and mortality [1]. Lymphocytes are essential in the immune response during sepsis, with lymphopenia linked to increased vulnerability to secondary infections, higher sepsis severity, and mortality [2]. However, prior studies primarily analyzed lymphocyte counts at fixed time points, overlooking their dynamic nature and association with sepsis prognosis. Furthermore, unlike other complex immune biomarkers such as HLA-DR, lymphocyte count is easily accessible, making it a valuable marker for continuous monitoring of immune status. This study aims to identify heterogeneous lymphocyte count trajectories in sepsis patients by leveraging the group-based trajectory modeling (GBTM) [3], which accommodates unbalanced panels and missing values.&lt;/p&gt;&lt;p&gt;This is a retrospective study based on data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) v3.1 database (certification number: 64590357). We extracted data on 24,792 adult sepsis patients admitted to the ICU, diagnosed using Sepsis-3.0 criteria (suspected infection and a SOFA score increase of ≥ 2). After excluding patients with conditions such as long-term steroid use, transplant status, malignancy, rheumatic disease, or hematologic disease (detailed information provided in Table S1), 12,078 cases were retained. Among these, 3152 sepsis patients who had at least two lymphocyte count measurements within 7 days of ICU admission were included, with a hospital mortality rate of 24.6%.&lt;/p&gt;&lt;p&gt;We applied GBTM to identify lymphocyte count trajectories, selecting a three-class model (Fig. 1), based on the Akaike and Bayesian information criterion, and clinical rationality (Table S2). Trajectory 1, the “Rapid-slow decrease” class, included 525 (16.7%) patients and was characterized by a rapid decrease in lymphocyte counts in the first 3 days, followed by a slower decline. Trajectory 2, the “Stable” class, included 1453 (46.1%) patients with relatively stable lymphocyte counts. Trajectory 3, the “Rapid-slow increase” class, included 1174 (37.2%) patients who showed a rapid increase in lymphocyte counts in the first 3 days, followed by a slower rise at relatively low levels. Baseline characteristics varied significantly across these trajectories (Table 1). Patients in Trajectory 3 had the longest hospital stays, higher APSIII, OASIS, and MELD scores, and a greater prevalence of comorbidities, with the highest 28-day mortality (22.9%). In contrast, patients in Trajectory 1 had the shortest hospital stays but higher SIRS score and the highest 7-day mortality (12%).&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05186-6/MediaObjects/13054_2024_5186_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"360\" loading=\"lazy\" src=\"/","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142758344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Angiotensinogen: a new era beyond lactate as a biomarker?","authors":"Yanfei Shen, Xinyuan Ding","doi":"10.1186/s13054-024-05164-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05164-y","url":null,"abstract":"&lt;p&gt;Dear editor&lt;/p&gt;&lt;p&gt;In a recent brief report [1], Dr.Chappell and colleagues compared the predictive value of angiotensinogen, renin, and lactate for 30-day mortality in patients with sepsis or septic shock. The study included a total of 103 sepsis patients. The results showed that serum angiotensinogen concentration had a stronger association with mortality than either serum renin or lactate, suggesting that angiotensinogen may serve as a clinical predictor superior to lactate. We believe several points should be noted when interpreting these findings.&lt;/p&gt;&lt;p&gt;First, lactate is widely recognized as an important biomarker in critically ill patients, primarily reflecting an imbalance in tissue oxygen supply and consumption, which is commonly used to assess tissue perfusion and disease severity in septic shock. However, although this study included patients with sepsis or septic shock, we observed that the baseline systolic blood pressure in both the survival and non-survival groups was approximately 100 mmHg (survival group: 102.1 ± 23.5; non-survival group: 106.0 ± 21.9, &lt;i&gt;p&lt;/i&gt; = 0.464), indicating that these patients were not in a state of severe shock or, at the very least, retained a degree of hemodynamic stability. Additionally, the baseline lactate levels were also relatively low and similar between the two groups (survival group: 2.6 [1.8–3.8]; non-survival group: 2.2 [1.6–6.1], &lt;i&gt;p&lt;/i&gt; = 0.629). This raises the question of whether the study sample might skew toward a less severe sepsis population, which could influence the relative performance of angiotensinogen and lactate as predictive markers (as patients with relatively stable circulation tend to have normal lactate levels).&lt;/p&gt;&lt;p&gt;Moreover, this study found no significant difference in survival analysis between high and low lactate groups, which is inconsistent with previous findings in septic shock [2,3,4]. This lack of difference may be attributed to specific characteristics of the patient cohort or sample heterogeneity, which may limit the generalizability of this study’s findings to sepsis patients.&lt;/p&gt;&lt;p&gt;Future studies with larger, more diverse sepsis cohorts are needed to validate these findings and further explore the potential of angiotensinogen as a routine prognostic marker in sepsis or septic shock. Given lactate’s established role in assessing sepsis severity and predicting outcomes, future research should also investigate whether angiotensinogen can complement lactate or other established biomarkers to provide additional prognostic value. Also, longitudinal studies could help clarify the dynamic changes in angiotensinogen levels over time and their correlation with patient outcomes, offering a more comprehensive understanding of angiotensinogen’s role in the complex pathophysiology of sepsis.&lt;/p&gt;&lt;p&gt;Finally, we extend our gratitude to Dr. Chappell and colleagues for their valuable work, and we hope our perspectives contribute to a deeper understanding of these findings.&lt;/","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"260 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142758499","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Differential effects of thiamine and ascorbic acid in clusters of septic patients identified by latent variable analysis","authors":"David Legouis, Céline Monard, Aimad Ourahmoune, Sebastian Sgardello, Hervé Quintard, Gilles Criton, Frederic Sangla, Antoine Schneider","doi":"10.1186/s13054-024-05188-4","DOIUrl":"https://doi.org/10.1186/s13054-024-05188-4","url":null,"abstract":"Thiamine and ascorbic acid have been proposed to mitigate the devastating consequences of sepsis and septic shock. To date, randomized controlled trials have failed to demonstrate a benefit of these therapies and heterogeneity of treatment effect is suspected. In this study, we aimed at assessing the heterogeneity of treatment effect of thiamine (B1) and the combination of B1 plus ascorbic acid (AA + B1) in critically ill patients with sepsis. We conducted a bi-centric retrospective cohort study. All adult patients admitted to the ICU with sepsis or septic shock between January 2012 and August 2022 were included. Patient clusters were identified using latent variable analysis based on demographics and physiological variables obtained within 24 h of admission. Within each cluster and using inverse probability weighted Cox models, we compared in-hospital mortality between patients who received standard treatment (control), standard treatment plus B1 (B1 group), and standard treatment plus a combination of thiamine and ascorbic acid (AA + B1 group). A total of 3465 septic patients were included, 2183, 1054 and 228 in the standard, B1 and AA + B1 groups respectively. Five clusters of patients were identified in an unsupervised manner. The “Cluster Severe” included the most severely ill patients, the “Cluster Resp” patients presented with predominantly respiratory failure, the “Cluster Old” included elderly patients with multiple comorbidities, the “Cluster Fit” patients were young, healthy with low severity indices and “Cluster Liver” included patients with predominant liver failure. B1 treatment was associated with different outcomes across the five clusters. It was associated with a lower in-hospital mortality in the “Cluster Severe” and “Cluster Resp”. On the other hand, the combination of thiamine and ascorbic acid was not associated with reduced mortality in any cluster but an increased mortality in”Cluster Old”. These results reinforce the lack of efficacy of the combination of AA + B1 reported in recent trials and even raise concerns about potential harm in older patients with comorbidities. On the contrary, we reported improved ICU survival associated with B1 supplementation in the most severe patients and those with predominant respiratory failure, supporting the need for further trials in this specific population.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"486 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142753687","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intra-aortic balloon pump after VA-ECMO reduces mortality in patients with cardiogenic shock: an analysis of the Chinese extracorporeal life support registry","authors":"Kexin Wang, Liangshan Wang, Jiawang Ma, Haixiu Xie, Chenglong Li, Xing Hao, Zhongtao Du, Hong Wang, Xiaotong Hou","doi":"10.1186/s13054-024-05129-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05129-1","url":null,"abstract":"The role of intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock (CS) remains unclear. This study investigated the effect of applying IABP for left ventricle (LV) unloading after VA-ECMO on reducing mortality in patients with CS. Data from 5,492 consecutive patients with CS treated with VA-ECMO between January 2017 and July 2023 were collected from the CSECLS registry. The primary outcome was in-hospital mortality. The secondary outcomes included 30-day mortality, survival on VA-ECMO, and various complications. The association between the application of IABP after VA-ECMO and in-hospital outcomes was assessed. Among 5,492 patients undergoing VA-ECMO (mean age 54.7 ± 15.1 years, 3,917 [71.3%] male), 832 (15.1%) received IABP after VA-ECMO. Before VA-ECMO, a higher incidence of cardiac intervention (13.9% vs. 16.7%) and myocardial infarction (12.0% vs. 14.8%) (all P < 0.05) was seen in the IABP after VA-ECMO group. In this cohort, the IABP after VA-ECMO group had a lower in-hospital mortality (52.5% vs. 48.0%, P = 0.017) and a higher survival rate on VA-ECMO (75.4% vs. 79.4%, P = 0.014). On multivariate modeling, the use of IABP after VA-ECMO was associated with a lower risk of in-hospital mortality (adjusted odds ratio[aOR], 0.823 [95% confidence interval [CI], 0.686–0.987]; P = 0.035) and on-support mortality (aOR, 0.828 [95% CI, 0.688–0.995]; P = 0.044). However, the use of IABP after VA-ECMO was also associated with an increased incidence of complications, including mechanical (aOR: 1.905, [95% CI, 1.278–2.839]; P = 0.002), bleeding (aOR: 1.371, [95% CI, 1.092–1.721]; P = 0.007), renal (aOR: 1.252, [95% CI, 1.041–1.505]; P = 0.017), and pulmonary (aOR: 1.768, [95% CI, 1.446–2.163]; P < 0.001). In this multicenter retrospective study, the use of IABP after VA-ECMO was associated with lower in-hospital mortality in patients with CS. These findings suggest that IABP may offer advantages for LV unloading in patients with CS treated with VA-ECMO, but further validation through randomized controlled trials is warranted to better understand the balance of risks and benefits.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142753692","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Timing of mechanical ventilation in sepsis","authors":"Juqin Shao, Juan Lin","doi":"10.1186/s13054-024-05179-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05179-5","url":null,"abstract":"&lt;p&gt;To the editor,&lt;/p&gt;&lt;p&gt;A recent study [1] by Dr. Kim and colleagues examined the association between the timing of mechanical ventilation (MV) and clinical outcomes in ICU patients with sepsis. The study included 2440 adult sepsis patients from 20 hospitals in Korea. Results showed that the early MV group had lower in-hospital mortality, shorter ICU stays, and less tracheostomy rate compared to the delayed MV group, suggesting that early MV may benefit sepsis patients. However, certain considerations should be taken into account when interpreting these findings.&lt;/p&gt;&lt;p&gt;First, the reason for MV in sepsis patients may contribute to the differences observed between the early and delayed MV groups. Not all ICU-admitted sepsis patients require intubation, with respiratory failure or acute respiratory distress syndrome (ARDS) being common reasons for intubation in this population. Thus, baseline differences, particularly the higher prevalence of primary respiratory infections in the early MV group, may partly explain the observed mortality benefits. Compared to the delayed MV group, the early MV group had a significantly higher rate of respiratory infections (1256/2119 [59.3%] vs. 126/321 [39.3%], &lt;i&gt;p&lt;/i&gt; &lt; 0.01), which is a major cause of acute respiratory failure and possibly prompting early intubation. In contrast, patients in the delayed MV group may not initially have pulmonary involvement but developed complications such as ARDS or multiple organ dysfunction syndrome (MODS) as their disease progressed. In this case, the differences between the early and delayed MV groups are more likely due to differences in disease status rather than the timing of intubation itself.&lt;/p&gt;&lt;p&gt;Second, regarding clinical applicability, the study’s inclusion criteria limit its generalizability to other sepsis patients, as not all sepsis patients require intubation. For example, in the current study, 2363 of 4890 patients admitted with sepsis did not require MV during their ICU stay and were excluded from the analysis. Thus, while this study highlights the potential benefits of early MV, it does not clarify which sepsis patients require MV, and simply applying early MV protocol could lead to unnecessary intubation.&lt;/p&gt;&lt;p&gt;While early MV may be beneficial for sepsis patients with respiratory involvement, a one-size-fits-all approach could lead to suboptimal patient management. Future studies should explore more refined criteria for early versus late MV in sepsis. Stratifying patients by risk factors may help better elucidate the benefits of early MV and prevent unnecessary intubations. Additionally, assessing other respiratory support methods, such as high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV), as interim measures before invasive intubation could improve outcomes for patients who might avoid mechanical ventilation altogether.&lt;/p&gt;&lt;p&gt;In conclusion, while this study suggests an association between early MV and reduced mortality in sepsis, careful pa","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"19 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142753686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}