Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05247-w
Tài Pham, Miklos Lipcsey
<p>Dear Editor,</p><p>The Rolling Stones say “<i>Time is on my side, yes it is!—Now you always say, that you want to be free…</i>”, indeed time is not always on patients' and clinicians’ side in the ICU, and being free, especially from ventilation is of benefit if it can be avoided. However, it is the clinician who imposes ventilator treatment on the patient and chooses the time to do this.</p><p>The ever-recurring decision for every clinician is to act or not to act and when to act. The balance of benefit or harm of an intervention and the optimal timing of treatment is not always clear. Intervening or not and the timing are different questions but related especially in studies of the latter. In intensive care, the issue of timing of life-sustaining treatments such as renal replacement therapy (RRT) [1] and vasopressors in sepsis [2] have been investigated. There is also an ongoing debate regarding ventilation strategy, as early tracheal intubation exposes patients to procedural complications, ventilator-induced lung injury, or ventilator-acquired pneumonia, on the other hand, delayed intubation exposes them to self-induced lung injury [3] or the emergency procedure in the context of more respiratory or hemodynamic instability that is associated with major adverse peri-intubation events can lead to more complications [4]. The timing of intubation has been studied in the general ICU population and COVID-19 patients in observational studies [5,6,7] and varies widely across countries and according to the physician in charge [8]. In sepsis, mechanical ventilation affects not only the lung but also other organs, making early intubation a double-edged sword: it may contribute to sustained oxygen delivery, but it may also contribute to circulatory instability due to sedatives and the effects of positive pressure ventilation.</p><p>In a paper recently published in this <i>Journal</i>, Kim et al<i>.</i> reported a cohort of 2440 patients with sepsis who received invasive mechanical ventilation in one of the 20 hospitals participating in the Korean Sepsis Alliance [9]. They found that the 2119 (87%) patients intubated on the first day of ICU admission had better outcomes, including lower ICU and hospital mortality, than those who received invasive ventilation later during their ICU stay. So, based on these results, should we intubate all patients admitted with sepsis upon arrival in the ICU? We argue that this study does not resolve the uncertainty. Although a valuable contribution to our knowledge on the timing of intubation in sepsis patients, there are some issues to mention that put these data into context.</p><p>To answer the question of timing of intubation Kim et al<i>.</i> used propensity score matching to minimize bias and render the two groups as similar as possible. This is not the first study exploring the timing of intubation using this method. For example, Mellado-Artigas et al. also using propensity score matching have reported that intubat
作者和工作单位法国比歇特尔医院、DMU CORREVE、重症监护室、FHU SEPSIS、Groupe de recherche clinique CARMAS、巴黎萨克雷大学、AP-HP、Le Kremlin-BicêtreTài Pham巴黎南大学、Inserm U1018、Epidémiologie respiratoire intégrative Equipe d'Epidémiologie、Centre de Recherche en Epidémiologie et Santé des Populations。巴黎南大学，Inserm U1018，Epidémiologie respiratoire intégrative，Centre de Recherche en Epidémiologie et Santé des Populations，Université Paris-Saclay，UVSQ，Villejuif，FranceTài PhamAnaesthesiology and Intensive Care，Department of Surgical Sciences，Uppsala University，Uppsala，SwedenMiklos LipcseyHedenstierna Laboratory，Department of Surgical Sciences、Uppsala University, 751 85, Uppsala, SwedenMiklos LipcseyAuthorsTài PhamView author publications您也可以在PubMed Google Scholar中搜索该作者Miklos LipcseyView author publications您也可以在PubMed Google Scholar中搜索该作者ContributionsTP and ML co-wrote the manuscript, reviewed modifications and approved the final version.通讯作者Miklos Lipcsey.Competing interests作者未声明任何利益冲突.Publisher's Note施普林格-自然对出版地图中的管辖权主张和机构隶属关系保持中立.Open Access本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议，该协议允许以任何媒介或格式进行非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出了许可使用范围，则您需要直接获得版权所有者的许可。如需查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articlePham, T., Lipcsey, M. Intubate patients with sepsis before midnight or do it when the time comes?.Crit Care 29, 10 (2025). https://doi.org/10.1186/s13054-024-05247-wDownload citationReceived：2024 年 12 月 23 日接受：31 December 2024Published: 07 January 2025DOI: https://doi.org/10.1186/s13054-024-05247-wShare this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
{"title":"Intubate patients with sepsis before midnight or do it when the time comes?","authors":"Tài Pham, Miklos Lipcsey","doi":"10.1186/s13054-024-05247-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05247-w","url":null,"abstract":"<p>Dear Editor,</p><p>The Rolling Stones say “<i>Time is on my side, yes it is!—Now you always say, that you want to be free…</i>”, indeed time is not always on patients' and clinicians’ side in the ICU, and being free, especially from ventilation is of benefit if it can be avoided. However, it is the clinician who imposes ventilator treatment on the patient and chooses the time to do this.</p><p>The ever-recurring decision for every clinician is to act or not to act and when to act. The balance of benefit or harm of an intervention and the optimal timing of treatment is not always clear. Intervening or not and the timing are different questions but related especially in studies of the latter. In intensive care, the issue of timing of life-sustaining treatments such as renal replacement therapy (RRT) [1] and vasopressors in sepsis [2] have been investigated. There is also an ongoing debate regarding ventilation strategy, as early tracheal intubation exposes patients to procedural complications, ventilator-induced lung injury, or ventilator-acquired pneumonia, on the other hand, delayed intubation exposes them to self-induced lung injury [3] or the emergency procedure in the context of more respiratory or hemodynamic instability that is associated with major adverse peri-intubation events can lead to more complications [4]. The timing of intubation has been studied in the general ICU population and COVID-19 patients in observational studies [5,6,7] and varies widely across countries and according to the physician in charge [8]. In sepsis, mechanical ventilation affects not only the lung but also other organs, making early intubation a double-edged sword: it may contribute to sustained oxygen delivery, but it may also contribute to circulatory instability due to sedatives and the effects of positive pressure ventilation.</p><p>In a paper recently published in this <i>Journal</i>, Kim et al<i>.</i> reported a cohort of 2440 patients with sepsis who received invasive mechanical ventilation in one of the 20 hospitals participating in the Korean Sepsis Alliance [9]. They found that the 2119 (87%) patients intubated on the first day of ICU admission had better outcomes, including lower ICU and hospital mortality, than those who received invasive ventilation later during their ICU stay. So, based on these results, should we intubate all patients admitted with sepsis upon arrival in the ICU? We argue that this study does not resolve the uncertainty. Although a valuable contribution to our knowledge on the timing of intubation in sepsis patients, there are some issues to mention that put these data into context.</p><p>To answer the question of timing of intubation Kim et al<i>.</i> used propensity score matching to minimize bias and render the two groups as similar as possible. This is not the first study exploring the timing of intubation using this method. For example, Mellado-Artigas et al. also using propensity score matching have reported that intubat","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"20 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142934906","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}
Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05234-1
Xiaoyang Zhou, Bixin Chen, Caibao Hu
<p>Dear Editor,</p><p>In a recent release in the journal Intensive Care Medicine, Saura et al. presented a systematic echo checklist for managing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) [1]. They proposed nine key challenges requiring ultrasound assessment throughout the entire VA-ECMO course. We have read this article with great interest and found the comprehensive insights highly beneficial. However, we would like to add a general comment regarding the assessment of blood flow in a distal perfusion catheter (DPC) during VA-ECMO using ultrasound.</p><p>In the last decades, V-A ECMO has been increasingly used to provide temporary cardiopulmonary support for potentially reversible cardiac diseases or as a bridge therapy to transplantation or ventricular assist device for unrecoverable cardiac illnesses. Peripheral cannulation represents the primary catheterization approach of VA-ECMO, usually accompanied by a high incidence of vascular complications [2]. Lower limb ischemia is a common and clinically important complication of VA-ECMO, often attributed to femoral arterial cannulation and vasospasm. Implanting a DPC into the superficial femoral artery effectively alleviates lower limb ischemia and is increasingly used for prophylactic purposes. According to the Extracorporeal Life Support Organization guidelines, maintaining a blood flow of at least 100 mL/min in the DPC is necessary to ensure adequate limb perfusion [3]. However, monitoring the blood flow in a DPC remains a challenge in the clinical management of VA-ECMO. While ultrasonic flowmeters offer continuous DPC flow assessment, it is typically limited to ¼-inch connecting tubes and is unavailable in many ECMO centers, particularly in resource-limited settings [4]. To address these limitations, we propose a method for quantitatively estimating the DPC flow using conventional ultrasound, without relying on flowmeters or specific tube diameters.</p><p>In our ECMO center, a 6-Fr introducer sheath is routinely used as a DPC to prevent limb ischemia in VA-ECMO patients, with dialysis tubing commonly serving as the connecting tube between the DPC and the arterial return cannula (Fig. 1A). First, a linear array probe (4–12 MHz) is placed on the connecting tube to obtain a long-axis view (Fig. 1B), allowing measurement of the internal diameter of the connecting tube (D<sub>CT</sub>) (Fig. 1C), while tilting the probe to form a certain angle with the connecting tube to reduce the angle between the ultrasound beam and the blood flow (≤ 60°). Next, pulsed-wave Doppler ultrasound is used to measure the blood flow velocity. To accurately measure the time-averaged mean velocity (TAMEAN), the sampling volume size is adjusted to cover the diameter of the tube and a conventional angle correction line is regulated (Fig. 1D). Given the non-pulsatile and laminar nature of ECMO blood flow, the DPC flow can be calculated as: π × (D<sub>CT</sub>/2)<sup>2</sup> × TAMEAN × 60 (mL/min). For examp
VA-ECMO:Veno-arterial extraorporeal membrane oxygenation DPC:Distal perfusion catheterDCT :The internal diameter of the connecting tubeTAMEAN:Time-averaged mean velocitySaura O, Combes A, Hekimian G. My echo checklist in venoarterial ECMO patients.Intensive Care Med.2024; 50(12):2158-61.Article PubMed Google Scholar Bonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Lo Coco V, et al. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment.Crit Care.2019;23(1):266.Article PubMed PubMed Central Google Scholar Lorusso R, Shekar K, MacLaren G, Schmidt M, Pellegrino V, Meyns B, et al. ELSO 关于成人心脏病患者静脉体外膜氧合的临时指南。ASAIO J. 2021; 67(8):827-44.Article PubMed Google Scholar Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, et al. 股动脉插管成人外周静脉体外膜肺氧合远端肢体灌注管理的演变。灌注。2024; 39(1):23S-38S.Article PubMed Google Scholar Holland CK, Brown JM, Scoutt LM, Taylor KJ.正常人的下肢容积动脉血流。1998; 24(8):1079-86.Article PubMed Google Scholar Walker RD, Smith RE, Sherriff SB, Wood RF.容积血流测量的时间平均平均速度：使用生理股动脉血流波形的体外模型验证研究。本文由浙江省医药卫生科技项目（编号：2023KY1084）资助。作者和单位宁波市第二医院重症医学科，宁波，315000周晓阳 &；浙江大学医学院附属浙江医院重症医学科，浙江杭州，310000、中国Caibao Hu作者Xiaoyang Zhou查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者Bixin Chen查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者Caibao Hu查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者ContributionsXZ提出了意见并起草了手稿。BC和CH提出了意见并修改了手稿。伦理批准和参与同意书不适用。同意发表不适用。利益冲突作者声明无利益冲突。出版者注释Springer Nature对已出版地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出了许可使用范围，则您需要直接获得版权所有者的许可。要查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleZhou, X., Chen, B. & Hu, C. A tip for assessing blood flow in distal perfusion catheter during veno-arterial extracorporeal membrane oxygenation.https://doi.org/10.1186/s13054-024-05234-1Download citationReceived：11 December 2024Accepted: 22 December 2024Published: 07 January 2025DOI: https://doi.org/10.1186/s13054-024-05234-1Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
{"title":"A tip for assessing blood flow in distal perfusion catheter during veno-arterial extracorporeal membrane oxygenation","authors":"Xiaoyang Zhou, Bixin Chen, Caibao Hu","doi":"10.1186/s13054-024-05234-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05234-1","url":null,"abstract":"<p>Dear Editor,</p><p>In a recent release in the journal Intensive Care Medicine, Saura et al. presented a systematic echo checklist for managing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) [1]. They proposed nine key challenges requiring ultrasound assessment throughout the entire VA-ECMO course. We have read this article with great interest and found the comprehensive insights highly beneficial. However, we would like to add a general comment regarding the assessment of blood flow in a distal perfusion catheter (DPC) during VA-ECMO using ultrasound.</p><p>In the last decades, V-A ECMO has been increasingly used to provide temporary cardiopulmonary support for potentially reversible cardiac diseases or as a bridge therapy to transplantation or ventricular assist device for unrecoverable cardiac illnesses. Peripheral cannulation represents the primary catheterization approach of VA-ECMO, usually accompanied by a high incidence of vascular complications [2]. Lower limb ischemia is a common and clinically important complication of VA-ECMO, often attributed to femoral arterial cannulation and vasospasm. Implanting a DPC into the superficial femoral artery effectively alleviates lower limb ischemia and is increasingly used for prophylactic purposes. According to the Extracorporeal Life Support Organization guidelines, maintaining a blood flow of at least 100 mL/min in the DPC is necessary to ensure adequate limb perfusion [3]. However, monitoring the blood flow in a DPC remains a challenge in the clinical management of VA-ECMO. While ultrasonic flowmeters offer continuous DPC flow assessment, it is typically limited to ¼-inch connecting tubes and is unavailable in many ECMO centers, particularly in resource-limited settings [4]. To address these limitations, we propose a method for quantitatively estimating the DPC flow using conventional ultrasound, without relying on flowmeters or specific tube diameters.</p><p>In our ECMO center, a 6-Fr introducer sheath is routinely used as a DPC to prevent limb ischemia in VA-ECMO patients, with dialysis tubing commonly serving as the connecting tube between the DPC and the arterial return cannula (Fig. 1A). First, a linear array probe (4–12 MHz) is placed on the connecting tube to obtain a long-axis view (Fig. 1B), allowing measurement of the internal diameter of the connecting tube (D<sub>CT</sub>) (Fig. 1C), while tilting the probe to form a certain angle with the connecting tube to reduce the angle between the ultrasound beam and the blood flow (≤ 60°). Next, pulsed-wave Doppler ultrasound is used to measure the blood flow velocity. To accurately measure the time-averaged mean velocity (TAMEAN), the sampling volume size is adjusted to cover the diameter of the tube and a conventional angle correction line is regulated (Fig. 1D). Given the non-pulsatile and laminar nature of ECMO blood flow, the DPC flow can be calculated as: π × (D<sub>CT</sub>/2)<sup>2</sup> × TAMEAN × 60 (mL/min). For examp","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"117 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142934876","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}
Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05218-1
Shahin Isha, Pablo Moreno Franco, Devang K. Sanghavi
<p>Dear Editor,</p><p>We would like to thank Zhong et al. for the thoughtful comments regarding our manuscript “Impact of low-dose inhaled nitric oxide treatment in spontaneously breathing and intubated COVID-19 patients: a retrospective propensity-matched study” and welcome the opportunity to provide clarifications [1, 2]. While we acknowledge some of their points, others require further explanation to provide a clearer interpretation of our study findings.</p><p>First, Zhong et al. recommended that we use the initiation of inhaled nitric oxide (iNO) as the starting point for our survival analysis. As we can understand from the study design this was not a comparison between two interventions being provided but was rather a comparison between the intervention group (iNO) and standard of care group (HFNC/ intubation). Moreover, as Zhong et al. rightly pointed out, many times iNO was not started right away after HFNC initiation/ intubation. To establish a common timestamp for time-dependent survival analysis, we used the HFNC initiation time as the starting point for both the iNO and non-iNO groups. As the authors correctly pointed out, this approach can lead to immortal time bias. Therefore, we examined the exact dates of iNO initiation. We noted a median interval of 1 (IQR 0–4) days between HFNC initiation and the iNO start date. As suggested by the authors, we decided to perform additional analyses while considering iNO initiation and HFNC initiation as starting points for survival analyses for the iNO group and non-iNO group, respectively. Upon performing IPTW-weighted univariate Cox regression analysis, iNO use was found to have a lower risk of in-hospital mortality (HR: 0.48, 95% CI: 0.31–0.75, <i>p</i> = 0.001) as well as lower 28-day mortality risk (HR: 0.50, 95% CI: 0.31–0.79, <i>p</i> = 0.003).</p><p>The authors also inquired whether any adjustments for covariates were made in the Cox regression model. We would like to clarify that, since we used the propensity-matching and inverse propensity of treatment weighting (IPTW) approaches for our statistical analyses, we employed a weighted Cox univariate regression model for survival analysis. This method incorporates weights from multiple confounding variables, allowing us to estimate marginal hazard ratios and survival curves. This approach contrasts with traditional multivariate Cox models, which estimate conditional hazard ratios. These methodological choices are supported by prior published literature as well [3, 4]. Propensity weight was also taken into account to plot weighted Kaplan–Meier survival curves for visual representation (Figs. 3 and 4 in the original manuscript) [2].</p><p>We would also like to clarify that the mortality rates reported in Tables 1 and 4 of the original manuscript are in-hospital mortality and not 28-day mortality [2]. However, the Kaplan–Meier survival curves as demonstrated in Figs. 3 and 4 signify 30-day mortality risk. The discrepancy between crude in-hosp
{"title":"Response to: “Inhalation NO in the HFNC group may result in a meaningless extension of survival time”","authors":"Shahin Isha, Pablo Moreno Franco, Devang K. Sanghavi","doi":"10.1186/s13054-024-05218-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05218-1","url":null,"abstract":"<p>Dear Editor,</p><p>We would like to thank Zhong et al. for the thoughtful comments regarding our manuscript “Impact of low-dose inhaled nitric oxide treatment in spontaneously breathing and intubated COVID-19 patients: a retrospective propensity-matched study” and welcome the opportunity to provide clarifications [1, 2]. While we acknowledge some of their points, others require further explanation to provide a clearer interpretation of our study findings.</p><p>First, Zhong et al. recommended that we use the initiation of inhaled nitric oxide (iNO) as the starting point for our survival analysis. As we can understand from the study design this was not a comparison between two interventions being provided but was rather a comparison between the intervention group (iNO) and standard of care group (HFNC/ intubation). Moreover, as Zhong et al. rightly pointed out, many times iNO was not started right away after HFNC initiation/ intubation. To establish a common timestamp for time-dependent survival analysis, we used the HFNC initiation time as the starting point for both the iNO and non-iNO groups. As the authors correctly pointed out, this approach can lead to immortal time bias. Therefore, we examined the exact dates of iNO initiation. We noted a median interval of 1 (IQR 0–4) days between HFNC initiation and the iNO start date. As suggested by the authors, we decided to perform additional analyses while considering iNO initiation and HFNC initiation as starting points for survival analyses for the iNO group and non-iNO group, respectively. Upon performing IPTW-weighted univariate Cox regression analysis, iNO use was found to have a lower risk of in-hospital mortality (HR: 0.48, 95% CI: 0.31–0.75, <i>p</i> = 0.001) as well as lower 28-day mortality risk (HR: 0.50, 95% CI: 0.31–0.79, <i>p</i> = 0.003).</p><p>The authors also inquired whether any adjustments for covariates were made in the Cox regression model. We would like to clarify that, since we used the propensity-matching and inverse propensity of treatment weighting (IPTW) approaches for our statistical analyses, we employed a weighted Cox univariate regression model for survival analysis. This method incorporates weights from multiple confounding variables, allowing us to estimate marginal hazard ratios and survival curves. This approach contrasts with traditional multivariate Cox models, which estimate conditional hazard ratios. These methodological choices are supported by prior published literature as well [3, 4]. Propensity weight was also taken into account to plot weighted Kaplan–Meier survival curves for visual representation (Figs. 3 and 4 in the original manuscript) [2].</p><p>We would also like to clarify that the mortality rates reported in Tables 1 and 4 of the original manuscript are in-hospital mortality and not 28-day mortality [2]. However, the Kaplan–Meier survival curves as demonstrated in Figs. 3 and 4 signify 30-day mortality risk. The discrepancy between crude in-hosp","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"28 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142934880","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}
Pub Date : 2025-01-07DOI: 10.1186/s13054-024-05243-0
Vorakamol Phoophiboon, Antenor Rodrigues, Fernando Vieira, Matthew Ko, Fabiana Madotto, Annia Schreiber, Nannan Sun, Mayson L. A. Sousa, Mattia Docci, Clement Brault, Luca S. Menga, Irene Telias, Thomas Piraino, Ewan C. Goligher, Laurent Brochard
Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information. Research question. Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV. Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort. Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort. During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.
{"title":"Ventilation distribution during spontaneous breathing trials predicts liberation from mechanical ventilation: the VISION study","authors":"Vorakamol Phoophiboon, Antenor Rodrigues, Fernando Vieira, Matthew Ko, Fabiana Madotto, Annia Schreiber, Nannan Sun, Mayson L. A. Sousa, Mattia Docci, Clement Brault, Luca S. Menga, Irene Telias, Thomas Piraino, Ewan C. Goligher, Laurent Brochard","doi":"10.1186/s13054-024-05243-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05243-0","url":null,"abstract":"Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information. Research question. Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV. Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort. Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort. During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"14 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142934877","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}
Continuous electroencephalography (cEEG) has been recommended in critically ill patients although its efficacy for improving patients’ functional status remains unclear. This study aimed to compare the efficacy of Tele-cEEG with Tele-routine EEG (Tele-rEEG), in terms of seizure detection rate, mortality and functional outcomes. This study is a 3-year randomized, controlled, parallel, multicenter trial, conducted in eight regional hospitals across Thailand. Eligible participants were critically ill patients aged ≥ 15 years and at-risk for developing nonconvulsive seizure (NCS)/nonconvulsive status epilepticus (NCSE). Study interventions were 24–72 h Tele-cEEG versus 30-min Tele-rEEG. Study outcomes were seizure detection rate, mortality and functional outcomes (mRS), assessed at hospital discharge, ≤ 7 days, 3-, 6-, 9-months and 1 year. Two hundred and fifty-four patients were randomized, 128 and 126 patients received Tele-cEEG and Tele-rEEG, respectively. NCS/NCSE were detected more commonly in the Tele-cEEG (21.88%) than Tele-rEEG arm (14.29%) but this was not statistically significant (p = 0.116). Intention-to-treat, per-protocol and as-treated analysis showed non-significant differences in mortality at all assessment periods, with corresponding mortality rates of 10.03% (Tele-cEEG) versus 10.10% (Tele-rEEG) (p = 0.894), 9.67% versus 9.06% (p = 0.833) and 10.34% versus 9.06% (p = 0.600), respectively. Functional outcome was also not significantly different in all analyses. Both Tele-cEEG and Tele-rEEG are feasible, although Tele-EEG requires additional EEG specialists, budget, and computational resources. While Tele-cEEG may help detect NCS/NCSE, this study had limited power to detect its efficacy in reducing mortality or improving functional outcomes. In limited-resource settings, Tele-rEEG approximating 30 min or longer offers a feasible and potentially valuable initial screening tool for critically ill patients at-risk of seizures. However, where Tele-cEEG is readily available, it remains the recommended approach. Trial registration Thai Clinical Trials Registry (TTCTR20181022002); Registered 22 October 2018.
{"title":"Efficacy of delivery of care with Tele-continuous EEG in critically ill patients: a multicenter randomized controlled trial (Tele-cRCT study) study","authors":"Chusak Limotai, Suda Jirasakuldej, Sattawut Wongwiangiunt, Tipakorn Tumnark, Piradee Suwanpakdee, Kwuanrat Wangponpattanasiri, Piyanuch Rakchue, Chaiwiwat Tungkasereerak, Polchai Pleumpanupatand, Phopsuk Tansuhaj, Phattarawin Ekkachon, Songchai Kittipanprayoon, Apiwoot Kerddonfag, Thippamas Pobsuk, Anuchate Pattanateepapon, Kammant Phanthumchinda, Nijasri C. Suwanwela, Iyavut Thaipisuttikul, Kanokwan Boonyapisit, Atiporn Ingsathit, Oraluck Pattanaprateep, John Attia, Gareth J. McKay, Andrea O. Rossetti, Ammarin Thakkinstian, Chutima Rukrung, Patcharapun Kangsananont, Jeerawan Mokkaew, Nittaya Phayaph, Supak Pukpraman, Warangkana Ritrhathon, Youwarat Jarungjitapinan, Jintana Pinpradab, Netphit Khamhoi, Mayuree Nookaew, Patchareeporn Chauywang, Pichai Rojdmapitayakorn, Paworamon Sribussara, Wasunon Tinroongroj, Wisan Teeratantikanon, Tabtim Chongsuvivatwong, Watchara Viratyaporn, Witoon Jantararotai, Komkrit Panyawattanakit, Nopparat Rujirarongrueng, Pornnapat Damthong, Pattama..","doi":"10.1186/s13054-024-05246-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05246-x","url":null,"abstract":"Continuous electroencephalography (cEEG) has been recommended in critically ill patients although its efficacy for improving patients’ functional status remains unclear. This study aimed to compare the efficacy of Tele-cEEG with Tele-routine EEG (Tele-rEEG), in terms of seizure detection rate, mortality and functional outcomes. This study is a 3-year randomized, controlled, parallel, multicenter trial, conducted in eight regional hospitals across Thailand. Eligible participants were critically ill patients aged ≥ 15 years and at-risk for developing nonconvulsive seizure (NCS)/nonconvulsive status epilepticus (NCSE). Study interventions were 24–72 h Tele-cEEG versus 30-min Tele-rEEG. Study outcomes were seizure detection rate, mortality and functional outcomes (mRS), assessed at hospital discharge, ≤ 7 days, 3-, 6-, 9-months and 1 year. Two hundred and fifty-four patients were randomized, 128 and 126 patients received Tele-cEEG and Tele-rEEG, respectively. NCS/NCSE were detected more commonly in the Tele-cEEG (21.88%) than Tele-rEEG arm (14.29%) but this was not statistically significant (p = 0.116). Intention-to-treat, per-protocol and as-treated analysis showed non-significant differences in mortality at all assessment periods, with corresponding mortality rates of 10.03% (Tele-cEEG) versus 10.10% (Tele-rEEG) (p = 0.894), 9.67% versus 9.06% (p = 0.833) and 10.34% versus 9.06% (p = 0.600), respectively. Functional outcome was also not significantly different in all analyses. Both Tele-cEEG and Tele-rEEG are feasible, although Tele-EEG requires additional EEG specialists, budget, and computational resources. While Tele-cEEG may help detect NCS/NCSE, this study had limited power to detect its efficacy in reducing mortality or improving functional outcomes. In limited-resource settings, Tele-rEEG approximating 30 min or longer offers a feasible and potentially valuable initial screening tool for critically ill patients at-risk of seizures. However, where Tele-cEEG is readily available, it remains the recommended approach. Trial registration Thai Clinical Trials Registry (TTCTR20181022002); Registered 22 October 2018.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"35 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142935869","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}
Pub Date : 2025-01-06DOI: 10.1186/s13054-024-05189-3
Emma J. Ridley, Michael Bailey, Marianne J. Chapman, Lee-anne S. Chapple, Adam M. Deane, Marlene Gojanovic, Alisa M. Higgins, Carol L. Hodgson, Victoria L. King, Andrea P. Marshall, Eliza G. Miller, Shay P. McGuinness, Rachael L. Parke, Eldho Paul, Andrew A. Udy
Nutrition interventions commenced in ICU and continued through to hospital discharge have not been definitively tested in critical care to date. To commence a program of research, we aimed to determine if a tailored nutrition intervention delivered for the duration of hospitalisation delivers more energy than usual care to patients initially admitted to the Intensive Care Unit (ICU). A multicentre, unblinded, parallel-group, phase II trial was conducted in twenty-two hospitals in Australia and New Zealand. Adult patients, requiring invasive mechanical ventilation (MV) for 72–120 h within ICU, and receiving < 80% estimated energy requirements from enteral nutrition (EN) were included. The intervention (tailored nutrition) commenced in ICU and included EN and supplemental parenteral nutrition (PN), and EN, PN, and/or oral nutrition after liberation from MV, and was continued until hospital discharge or study day 28. The primary outcome was daily energy delivery from nutrition (kcal). Secondary outcomes included duration of hospital stay, ventilator free days at day 28 and total blood stream infection rate. The modified intention to treat analysis included 237 patients (n = 119 intervention and n = 118 usual care). Baseline characteristics were balanced; the median [interquartile range] intervention period was 19 [14–35] and 19 [13–32] days in the tailored nutrition and usual care groups respectively. Energy delivery was 1796 ± 31 kcal/day (tailored nutrition) versus 1482 ± 32 kcal/day (usual care)—adjusted mean difference 271 kcal/day, 95% CI 189–354 kcal. No differences were observed in any secondary outcomes. A tailored nutrition intervention commenced in the ICU and continued until hospital discharge achieved a significant increase in energy delivery over the duration of hospitalisation for patients initially admitted to the ICU. Trial registration ClinicalTrials.gov Identifier NCT03292237 . First registered 25th September 2017. Last updated 10th Feb 2023.
营养干预从ICU开始，一直持续到出院，迄今为止还没有在重症监护中得到明确的检验。为了启动一个研究项目，我们的目的是确定在住院期间提供量身定制的营养干预是否比最初入住重症监护室（ICU）的患者提供更多的能量。在澳大利亚和新西兰的22家医院进行了一项多中心、非盲、平行组的II期试验。纳入了在ICU内需要有创机械通气（MV） 72-120 h、肠内营养（EN）能量需求< 80%的成年患者。干预（定制营养）在ICU开始，包括EN和补充肠外营养（PN），以及从MV解放后的EN、PN和/或口服营养，并持续到出院或研究第28天。主要指标为每日营养能量输送（千卡）。次要结局包括住院时间、第28天无呼吸机天数和总血流感染率。修改意向治疗分析包括237例患者（n = 119干预和n = 118常规护理）。基线特征平衡；定制营养组和常规护理组的干预期中位数（四分位数间距）分别为19[14-35]天和19[13-32]天。能量供给为1796±31千卡/天（量身定制的营养）与1482±32千卡/天（常规护理）-调整后的平均差271千卡/天，95% CI 189-354千卡。任何次要结局均无差异。量身定制的营养干预从ICU开始，一直持续到出院，在最初入住ICU的患者住院期间，能量输送显著增加。临床试验注册ClinicalTrials.gov标识符NCT03292237。首次注册于2017年9月25日。最后更新2023年2月10日。
{"title":"The impact of a tailored nutrition intervention delivered for the duration of hospitalisation on daily energy delivery for patients with critical illness (INTENT): a phase II randomised controlled trial","authors":"Emma J. Ridley, Michael Bailey, Marianne J. Chapman, Lee-anne S. Chapple, Adam M. Deane, Marlene Gojanovic, Alisa M. Higgins, Carol L. Hodgson, Victoria L. King, Andrea P. Marshall, Eliza G. Miller, Shay P. McGuinness, Rachael L. Parke, Eldho Paul, Andrew A. Udy","doi":"10.1186/s13054-024-05189-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05189-3","url":null,"abstract":"Nutrition interventions commenced in ICU and continued through to hospital discharge have not been definitively tested in critical care to date. To commence a program of research, we aimed to determine if a tailored nutrition intervention delivered for the duration of hospitalisation delivers more energy than usual care to patients initially admitted to the Intensive Care Unit (ICU). A multicentre, unblinded, parallel-group, phase II trial was conducted in twenty-two hospitals in Australia and New Zealand. Adult patients, requiring invasive mechanical ventilation (MV) for 72–120 h within ICU, and receiving < 80% estimated energy requirements from enteral nutrition (EN) were included. The intervention (tailored nutrition) commenced in ICU and included EN and supplemental parenteral nutrition (PN), and EN, PN, and/or oral nutrition after liberation from MV, and was continued until hospital discharge or study day 28. The primary outcome was daily energy delivery from nutrition (kcal). Secondary outcomes included duration of hospital stay, ventilator free days at day 28 and total blood stream infection rate. The modified intention to treat analysis included 237 patients (n = 119 intervention and n = 118 usual care). Baseline characteristics were balanced; the median [interquartile range] intervention period was 19 [14–35] and 19 [13–32] days in the tailored nutrition and usual care groups respectively. Energy delivery was 1796 ± 31 kcal/day (tailored nutrition) versus 1482 ± 32 kcal/day (usual care)—adjusted mean difference 271 kcal/day, 95% CI 189–354 kcal. No differences were observed in any secondary outcomes. A tailored nutrition intervention commenced in the ICU and continued until hospital discharge achieved a significant increase in energy delivery over the duration of hospitalisation for patients initially admitted to the ICU. Trial registration ClinicalTrials.gov Identifier NCT03292237 . First registered 25th September 2017. Last updated 10th Feb 2023.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"5 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142929109","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}
Targeted temperature management (TTM) is considered a beneficial treatment for improving outcomes in patients with OHCA due to acute coronary syndrome (ACS). The comparative benefits of hypothermic TTM (32–34°C) versus normothermic TTM (35–36°C) are unclear. This study compares these TTM strategies in improving neurological outcomes and survival rates in OHCA patients with ACS. We conducted a retrospective analysis using data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) registry, encompassing 68,110 OHCA patients between June 2014 and December 2020. After applying inclusion and exclusion criteria, 1,217 adult patients with ACS who received TTM were eligible for the study. Patients were categorized into two groups based on their TTM strategy: hypothermic TTM (32–34°C) and normothermic TTM (35–36°C). The primary outcome was 30-day favorable neurological outcome, defined by the Cerebral Performance Category (CPC) scale (CPC 1–2). Secondary outcomes included 30-day survival and adverse event incidence. Statistical analysis involved multivariable logistic regression and propensity score adjustments with inverse probability weighting (IPW) to account for potential confounders. Of the 1,217 patients, 369 received normothermic TTM and 848 received hypothermic TTM. In both groups, most patients were male, with a median age in the 60s. Approximately 70% had a shockable rhythm at the scene, one-third had a shockable rhythm in-hospital, around 70% had ST segment elevation, and about half received extracorporeal membrane oxygenation. The proportions of patients with 30-day favorable neurological outcomes were 36.6% (135) in the normothermic group and 36.6% (310) in the hypothermic group. No difference in neurological outcomes was observed in the multivariable regression analysis (adjusted OR 1.14, 95% CI 0.84–1.54), and the result was consistent in the IPW analysis (OR 1.11, 95% CI 0.84–1.47). Other outcomes also showed no significant differences. In this nationwide, retrospective study using the JAAM-OHCA registry, we found no significant differences in 30-day favorable neurological outcome, 30-day survival, and adverse event incidences between hypothermic TTM (32–34°C) and normothermic TTM (35–36°C) in adult patients with OHCA due to ACS.
靶向温度管理（TTM）被认为是改善急性冠脉综合征（ACS）所致OHCA患者预后的有益治疗方法。低温TTM（32-34°C）与常温TTM（35-36°C）的比较效益尚不清楚。本研究比较了这些TTM策略在改善OHCA合并ACS患者的神经预后和生存率方面的作用。我们使用日本急性医学院外心脏骤停协会（JAAM-OHCA）登记处的数据进行了回顾性分析，其中包括2014年6月至2020年12月期间68,110名OHCA患者。在应用纳入和排除标准后，1217名接受TTM治疗的成年ACS患者符合研究条件。根据患者的TTM策略将患者分为两组：低温TTM（32-34°C）和常温TTM（35-36°C）。主要终点是30天的良好神经学预后，由脑功能分类（CPC）量表（CPC 1-2）定义。次要结局包括30天生存率和不良事件发生率。统计分析包括多变量逻辑回归和倾向评分调整与逆概率加权（IPW），以解释潜在的混杂因素。在1217例患者中，369例接受常温TTM， 848例接受低温TTM。在这两组中，大多数患者都是男性，平均年龄在60岁左右。约70%的患者在现场有震荡性心律，三分之一的患者在医院有震荡性心律，约70%的患者ST段抬高，约一半的患者接受了体外膜氧合。30天神经系统预后良好的患者比例，常温组为36.6%（135例），低温组为36.6%（310例）。在多变量回归分析中没有观察到神经系统预后的差异（校正OR 1.14, 95% CI 0.84-1.54），在IPW分析中结果一致（OR 1.11, 95% CI 0.84-1.47）。其他结果也无显著差异。在这项使用JAAM-OHCA登记的全国性回顾性研究中，我们发现，在ACS引起的成年OHCA患者中，低温TTM（32-34°C）和常温TTM（35-36°C）在30天有利神经预后、30天生存率和不良事件发生率方面没有显著差异。
{"title":"Comparison of hypothermic and normothermic targeted temperature management in out-of-hospital cardiac arrest patients with acute coronary syndrome: a nationwide retrospective study","authors":"Tasuku Matsuyama, Bon Ohta, Makoto Watanabe, Tetsuhisa Kitamura","doi":"10.1186/s13054-024-05235-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05235-0","url":null,"abstract":"Targeted temperature management (TTM) is considered a beneficial treatment for improving outcomes in patients with OHCA due to acute coronary syndrome (ACS). The comparative benefits of hypothermic TTM (32–34°C) versus normothermic TTM (35–36°C) are unclear. This study compares these TTM strategies in improving neurological outcomes and survival rates in OHCA patients with ACS. We conducted a retrospective analysis using data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) registry, encompassing 68,110 OHCA patients between June 2014 and December 2020. After applying inclusion and exclusion criteria, 1,217 adult patients with ACS who received TTM were eligible for the study. Patients were categorized into two groups based on their TTM strategy: hypothermic TTM (32–34°C) and normothermic TTM (35–36°C). The primary outcome was 30-day favorable neurological outcome, defined by the Cerebral Performance Category (CPC) scale (CPC 1–2). Secondary outcomes included 30-day survival and adverse event incidence. Statistical analysis involved multivariable logistic regression and propensity score adjustments with inverse probability weighting (IPW) to account for potential confounders. Of the 1,217 patients, 369 received normothermic TTM and 848 received hypothermic TTM. In both groups, most patients were male, with a median age in the 60s. Approximately 70% had a shockable rhythm at the scene, one-third had a shockable rhythm in-hospital, around 70% had ST segment elevation, and about half received extracorporeal membrane oxygenation. The proportions of patients with 30-day favorable neurological outcomes were 36.6% (135) in the normothermic group and 36.6% (310) in the hypothermic group. No difference in neurological outcomes was observed in the multivariable regression analysis (adjusted OR 1.14, 95% CI 0.84–1.54), and the result was consistent in the IPW analysis (OR 1.11, 95% CI 0.84–1.47). Other outcomes also showed no significant differences. In this nationwide, retrospective study using the JAAM-OHCA registry, we found no significant differences in 30-day favorable neurological outcome, 30-day survival, and adverse event incidences between hypothermic TTM (32–34°C) and normothermic TTM (35–36°C) in adult patients with OHCA due to ACS.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"25 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142929112","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}
<p>Dear Editor,</p><p>In a recent study [1], Chang et al. highlighted a critical challenge in the management of sepsis: the lack of etiological data in culture-negative cases, complicating the concept of therapeutic appropriateness. Their large multicentre cohort study demonstrated that, while empirical antibiotic therapy was deemed more “appropriate” in culture-negative cases (based on adherence to guidelines) than in culture-positive ones (based on susceptibility profile of causative organisms), patients in the former group faced worse mortality outcomes.</p><p>We propose reframing the understanding of “appropriateness” in antibiotic therapy to address the unique challenges of culture-negative sepsis.</p><p>Several points should be considered when interpreting these apparently contradictory findings, which question the adequacy of the defining “appropriate treatment” relying on empirical benchmarks derived from culture-positive cases to guide decisions for culture-negative patients. Moreover, the inclusion/exclusion criteria of the study imply a not negligible risk of misclassification bias, particularly differential misclassification, where the probability of being misclassified differs between groups [2].</p><p>Addressing this requires careful evaluation of diagnostic protocols to minimize bias and to ensure accurate stratification of sepsis cases.</p><p>First, the study focused on bacterial sepsis identified via standard culture methods, and not by other techniques, also excluding newer options such as molecular testing. This approach appears outdated given the current availability of “fast microbiology” tools designed to reduce the time to effective therapy in septic patients [3], as well as to lower the rates of so-called “culture negative sepsis”. Furthermore, the authors do not report whether blood culture volumes were sufficient, a critical factor as under-inoculated bottles correlate with lower diagnostic yields and higher rates of negative blood cultures [4]. Without this information, comparison between study groups is less reliable. At any rate, molecular diagnostics, including metagenomic sequencing, represent promising advancements for identifying pathogens in culture-negative cases, also overcoming limitations of standard techniques, such as the issue of blood inoculum.</p><p>Certain bacterial pathogens inherently elude identification via traditional culture-based methods: a textbook example is <i>Legionella pneumophila</i>, which causes community-acquired pneumonia (CAP) or systemic disease often fulfilling criteria for sepsis [5]. Diagnosis typically relies on urinary antigen detection or polymerase chain reaction (PCR) in respiratory specimens [5]. Following the inclusion/exclusion criteria of Chang et al., a case of severe Legionnaires’ disease wherein extrapulmonary manifestations predominate could be considered in the category of “appropriate treatment” if an empirical guideline-directed medical therapy for suspected central
在最近的一项研究b[1]中，Chang等人强调了脓毒症管理中的一个关键挑战：缺乏培养阴性病例的病因学数据，使治疗适当性的概念复杂化。他们的大型多中心队列研究表明，虽然经验性抗生素治疗在培养阴性病例（基于对指南的遵守）中被认为比在培养阳性病例（基于病原体的易感性特征）中更“合适”，但前一组患者面临更糟糕的死亡率结果。我们建议在抗生素治疗中重新定义“适当性”的理解，以解决培养阴性败血症的独特挑战。在解释这些明显矛盾的发现时，应该考虑几点，这些发现质疑“适当治疗”的定义是否足够，依赖于从培养阳性病例中得出的经验基准来指导培养阴性患者的决策。此外，该研究的纳入/排除标准意味着不可忽视的误分类偏倚风险，特别是差异误分类，其中被错误分类的概率在各组之间不同[2]。解决这一问题需要仔细评估诊断方案，以尽量减少偏见，并确保败血症病例的准确分层。首先，这项研究的重点是通过标准培养方法鉴定的细菌性败血症，而不是通过其他技术，也排除了分子检测等新方法。鉴于目前“快速微生物学”工具的可用性，这种方法似乎过时了，这些工具旨在减少脓毒症患者获得有效治疗的时间，并降低所谓的“培养阴性脓毒症”的发生率。此外，作者没有报告血培养量是否足够，这是一个关键因素，因为接种不足的瓶子与较低的诊断率和较高的血培养阴性率相关。没有这些信息，研究小组之间的比较就不太可靠。无论如何，分子诊断，包括宏基因组测序，代表了在培养阴性病例中识别病原体的有希望的进步，也克服了标准技术的局限性，例如血液接种问题。某些细菌病原体本质上无法通过传统的基于培养的方法进行鉴定：教科书上的一个例子是嗜肺军团菌，它导致社区获得性肺炎（CAP）或全身性疾病，通常符合败血症的标准。诊断通常依赖于泌尿抗原检测或聚合酶链反应（PCR）在呼吸道标本[5]。根据Chang等人的纳入/排除标准，如果在发烧、意识不清和定向障碍的病例中开始了针对疑似中枢神经系统感染的经验指南指导的药物治疗，则可以将以肺外表现为主的严重军团病病例纳入“适当治疗”范畴，这意味着万古霉素加头孢曲松或头孢噻肟，可能还有氨苄西林bb0的治疗方案。这强调了将分子诊断和快速诊断纳入败血症管理的必要性。此外，在抗生素管理时代，应优先考虑针对分离病原体的窄谱治疗。这项研究将受益于描述两组使用的抗生素治疗的范围。其次，作者承认他们的发现在细菌性败血症之外具有有限的普遍性。然而，这并不排除一部分培养阴性病例具有非细菌性感染病因的可能性：病毒、真菌、寄生虫[7,8,9]。根据脓毒症-3共识，目前脓毒症或脓毒性休克的定义不是病原体敏感的[10]。这一限制强调了病原体不可知论诊断策略的必要性，以确保非细菌性病因得到准确识别和治疗。考虑到病毒性败血症，可能是最常见的非细菌情况，经验性抗生素过度使用的风险已经争论多年了。最典型的例子是CAP：指南建议对严重病例使用β -内酰胺加大环内酯类药物，如有需要，还可增加对假单胞菌或耐甲氧西林金黄色葡萄球菌的治疗。因此，虽然第三代头孢菌素与阿奇霉素之间的关联符合指南，但如果通过多重PCR鉴定出病毒病原体，则回顾性地认为不合适。这种情况可能发生在研究中，引起了对适当性定义和抗生素过度使用的担忧。第三，另一个可能被低估的风险是在一部分“培养阴性”病例中真正缺乏感染过程，这可能是由免疫介导的炎症状况模拟败血症来解释的。 作者承认，在他们的研究中，不充分的测试或技术问题可能影响了文化结果。对于许多没有微生物产率的病例，有一些合理的解释：也许最常见的是先前的抗生素暴露，这是血培养阴性心内膜炎（BCNE）的主要原因，可以说是传染病领域最公认的“培养阴性”实体。然而，BCNE根植于客观发现，如心脏瓣膜上的植被，较新的微生物学方法（如靶向或散弹枪宏基因组测序）以及组织病理学可以区分感染过程和非感染性实体，如非细菌性血栓性心内膜炎[13]。与此形成鲜明对比的是，即使在2016年达成共识之后，脓毒症的定义仍然存在争议，而且有些主观，因为它意味着任何器官功能障碍不明的患者都必须怀疑感染。不幸的是，既没有一种通用的生物标志物来诊断持续感染（无论是哪种原因），也没有一种病理生物学标志来区分败血症和感染；因此，即使确定了任何类型的感染，到目前为止，除了合理怀疑之外，还没有办法将感染过程与正在进行的器官功能障碍在因果途径中联系起来，而心肌梗死的特定发现（如st段抬高）可以依赖于[14]。事实上，目前脓毒症的定义是基于一种预后工具，即SOFA评分，该评分已转化为准诊断的1分。在发现“圣杯”，即能够快速诊断感染和败血症的生物标志物之前，每一项关于该主题的研究都将受到纳入与感染无关的病例的风险的影响。在一项严重依赖传统培养方法的研究中，被错误识别为脓毒症的病例负担很大，特别是在“培养阴性”患者群体中，从而进一步损害了“适当治疗”与临床结果之间的关联。总之，“培养阴性”脓毒症应该从字面上解释，描述标准培养技术没有结果的病例，而不是作为没有病原体的脓毒症的同义词。使用包括分子诊断在内的所有可用方法快速鉴定病原体至关重要。这些工具是现代微生物学不可或缺的一部分，尽管它们的结果应该总是被明智地解释，以避免过度诊断。事实上，关于治疗的适当性，基因型和表型之间的差异并不罕见，在基于检测一些抗性基因（例如[16]）决定经验性治疗时应考虑到这一点。在图1中，我们总结了“培养阴性”脓毒症管理的挑战和解决方案。我们提倡将先进的诊断方法整合到临床实践中，以提高脓毒症管理的准确性，减少对经验指南的依赖，这些指南可能无法充分解决培养阴性病例。最后，仅仅根据遵守指南来定义抗生素治疗是否“适当”，可能会忽视经验性抗生素治疗与实际病因之间的不匹配，从而导致抗生素滥用及其后果。没有生成或分析数据集来提供本评论。Chang Y, Oh JH, Oh DK, Lee SY, Hyun DG, Park MH, Lim CM，韩国败血症联盟（KSA）调查员。培养阴性脓毒症可能与培养阳性脓毒症是不同的实体：一项前瞻性全国多中心队列研究。危重症护理，2024;28(1):385。文章来自PubMed PubMed Central bbb学者Pham A， Cummings M, Lindeman C, Drummond N, Williamson T.认识研究和医疗实践中的错误分类偏差。农学通报，2019;36(6):804-7。学者Liborio MP， Harris PNA, Ravi C, Irwin AD。加快速度：败血症的快速病原体和抗微生物药物耐药性诊断。微生物。2024;12(9):1824。文章来自PubMed PubMed Central bbb学者Michael Miller J， Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gonzalez MD, Harrington A, Jerris RC, Kehl SC, Leal SM, Patel R, Pritt BS, Richter SS, Robinson-Dunn B, Snyder JW, Telford S, Theel ES, Thomson RB, Weinstein MP, Yao JD。传染病诊断微生物实验室使用指南：美
{"title":"The elusive concept of appropriate antibiotic for septic patients when a pathogen is not detected by standard culture methods","authors":"Alberto Enrico Maraolo, Rita Murri, Danilo Buonsenso, Massimo Fantoni, Maurizio Sanguinetti","doi":"10.1186/s13054-024-05240-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05240-3","url":null,"abstract":"<p>Dear Editor,</p><p>In a recent study [1], Chang et al. highlighted a critical challenge in the management of sepsis: the lack of etiological data in culture-negative cases, complicating the concept of therapeutic appropriateness. Their large multicentre cohort study demonstrated that, while empirical antibiotic therapy was deemed more “appropriate” in culture-negative cases (based on adherence to guidelines) than in culture-positive ones (based on susceptibility profile of causative organisms), patients in the former group faced worse mortality outcomes.</p><p>We propose reframing the understanding of “appropriateness” in antibiotic therapy to address the unique challenges of culture-negative sepsis.</p><p>Several points should be considered when interpreting these apparently contradictory findings, which question the adequacy of the defining “appropriate treatment” relying on empirical benchmarks derived from culture-positive cases to guide decisions for culture-negative patients. Moreover, the inclusion/exclusion criteria of the study imply a not negligible risk of misclassification bias, particularly differential misclassification, where the probability of being misclassified differs between groups [2].</p><p>Addressing this requires careful evaluation of diagnostic protocols to minimize bias and to ensure accurate stratification of sepsis cases.</p><p>First, the study focused on bacterial sepsis identified via standard culture methods, and not by other techniques, also excluding newer options such as molecular testing. This approach appears outdated given the current availability of “fast microbiology” tools designed to reduce the time to effective therapy in septic patients [3], as well as to lower the rates of so-called “culture negative sepsis”. Furthermore, the authors do not report whether blood culture volumes were sufficient, a critical factor as under-inoculated bottles correlate with lower diagnostic yields and higher rates of negative blood cultures [4]. Without this information, comparison between study groups is less reliable. At any rate, molecular diagnostics, including metagenomic sequencing, represent promising advancements for identifying pathogens in culture-negative cases, also overcoming limitations of standard techniques, such as the issue of blood inoculum.</p><p>Certain bacterial pathogens inherently elude identification via traditional culture-based methods: a textbook example is <i>Legionella pneumophila</i>, which causes community-acquired pneumonia (CAP) or systemic disease often fulfilling criteria for sepsis [5]. Diagnosis typically relies on urinary antigen detection or polymerase chain reaction (PCR) in respiratory specimens [5]. Following the inclusion/exclusion criteria of Chang et al., a case of severe Legionnaires’ disease wherein extrapulmonary manifestations predominate could be considered in the category of “appropriate treatment” if an empirical guideline-directed medical therapy for suspected central","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"16 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142929111","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}
Pub Date : 2025-01-06DOI: 10.1186/s13054-024-05241-2
Lowell Ling, Andrew Li, Jason Phua
<p>We thank Wang and Zhong for raising the important considerations on limitation or withdrawal of therapy in the MOSAICS II studies [1]. Although limitation or withdrawal of therapy was not part of the exclusion criteria for MOSACIS II, data on subsequent limitation of therapy or withdrawal of therapy during ICU stay was collected but not previously published [2, 3]. Amongst the 4826 patients included in the MOSACIS II secondary analysis on qSOFA prognostic value, only 5.9% (283/4826) had withdrawal of life-sustaining treatments and 5.9% (287/4826) had withholding of life-sustaining treatments [3]. Even amongst those who died within 28 days, only 11.2% (142/1271) and 10.8% (137/1271) had withdrawal or withholding of life-sustaining treatments prior to death. Overall, low rates of limitation of therapy suggest it may not have significantly biased the conclusions drawn about prognostic value of qSOFA in sepsis.</p><p>The Asian Critical Care Clinical Trials group have previously published multiple survey studies on end-of-life practices in Asian ICUs [4,5,6]. However, real-life observations on end-of-life practices in MOSAICS II seem discrepant to these survey results. The ACME study reported that 70.2% of Asian ICU physicians would almost always or often withhold life-sustaining treatments and 20.7% would withdraw such treatments for patients with no real chance of recovering meaningful life [4]. The low observed rates of limitation of therapy in MOSAICS II may reflect the perception that limitation of life-sustaining treatment may expose the physician to legal risks [5]. Furthermore, there is significant variations in practice across cultures and income settings. As Wang and Zhong highlighted, Chinese physicians are more likely to consider financial burden when considering limiting life-sustaining treatments [6].</p><p>We appreciate the suggestions made by Wang and Zhong and agree that variations in local end-of-life practices may impact clinical research and care of critically ill patients in Asian ICUs. More prospective data are needed to understand the cultural and religious, financial and contextual factors that shape end-of-life practices in ICUs.</p><p>The data that support the findings of this study are available from the corresponding author upon reasonable request.</p><ol data-track-component="outbound reference" data-track-context="references section"><li data-counter="1."><p>Wang M, Zhong L. Reflections on epidemiological investigations of sepsis in the Asian Region. Crit Care. 2024;28(1):59.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter="2."><p>Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, et al. Epidemiology, management, and outcomes of sepsis in ICUs among countries of differing national wealth across Asia. Am J Respir Crit Care Med. 2022;206(9):1107–16.</p><p>Article PubMed Google Scholar </p></li><li data-counter="3."><p>Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, et al. Prognostic evaluation
我们感谢Wang和Zhong在MOSAICS II研究中提出限制或停药的重要考虑[10]。虽然限制或停止治疗不是MOSACIS II的排除标准的一部分，但收集了ICU住院期间随后限制治疗或停止治疗的数据，但先前未发表[2,3]。在MOSACIS II二次分析qSOFA预后价值的4826例患者中，只有5.9%（283/4826）的患者停止了维持生命的治疗，5.9%（287/4826）的患者停止了维持生命的治疗。即使在28天内死亡的人中，也只有11.2%（142/1271）和10.8%（137/1271）在死前停止或停止了维持生命的治疗。总的来说，较低的治疗限制率表明，qSOFA在脓毒症中的预后价值的结论可能没有明显偏差。亚洲重症监护临床试验小组此前发表了多项关于亚洲icu临终实践的调查研究[4,5,6]。然而，现实生活中对MOSAICS II临终实践的观察似乎与这些调查结果不一致。ACME的研究报告称，70.2%的亚洲ICU医生几乎总是或经常停止维持生命的治疗，20.7%的医生会对没有真正机会恢复有意义的生活的患者停止这种治疗。在MOSAICS II中观察到的治疗限制率较低，这可能反映了一种观念，即生命维持治疗的限制可能使医生面临法律风险。此外，在不同的文化和收入背景下，实践也存在显著差异。正如Wang和钟所强调的那样，中国医生在考虑限制维持生命的治疗时更有可能考虑经济负担。我们赞赏Wang和Zhong提出的建议，并同意当地临终实践的差异可能会影响亚洲icu重症患者的临床研究和护理。需要更多的前瞻性数据来了解影响icu临终实践的文化和宗教、财务和环境因素。支持本研究结果的数据可根据通讯作者的合理要求提供。王敏，钟磊。亚洲地区脓毒症流行病学调查的思考。危重症护理，2024;28(1):59。[文章]李安，凌玲，秦海，Arabi YM, Myatra SN, Egi M，等。亚洲不同国家的icu脓毒症流行病学、管理和结局。[J] .呼吸与危重症杂志。2012;26(9):1107 - 1106。学者李安，凌玲，秦海，Arabi YM, Myatra SN, Egi M，等。不同收入环境下ICU脓毒症患者快速序贯器官衰竭评估评分的预后评价。危重症护理，2024;28(1):30。Phua J, joint GM, Nishimura M, Deng Y, Myatra SN, Chan YH，等。在亚洲的重症监护病房中停止和停止维持生命的治疗。中华医学杂志，2015;17(3):363-71。Phua J, joint GM, Nishimura M, Deng Y, Myatra SN, Chan YH，等。亚洲中低收入国家和地区与高收入国家和地区停止和停止维持生命治疗的情况。重症监护医学，2016;42(7):1118-27。[文章]学者Park SY， Phua J, Nishimura M, Deng Y, Kang Y, Tada K，等。东亚icu临终关怀：中国、韩国和日本的比较。危重病护理，2018;46(7):1114-24。mosaics II研究组：在附加文件1中列出了参与招募和数据收集的研究地点和研究者。这不是一项受资助的研究。作者及单位：香港中文大学麻醉及重症监护科（中国香港特别行政区）lingwell新加坡国立大学卫生系统国立大学附属医院医学部呼吸及重症监护医学系（新加坡）andrew Li &；新加坡国立大学卫生系统亚历山德拉医院的Jason phufast和Chronic Programmed，新加坡jason phuaauthorslowwell LingView作者出版物您也可以在PubMed谷歌ScholarAndrew LiView作者出版物中搜索该作者您也可以在PubMed谷歌ScholarJason PhuaView作者出版物中搜索该作者您也可以在PubMed谷歌ScholarConsortiathe MOSAICS II Study GroupUzzal Kumar Mallick， Motiul Islam, Tarequl Hamid, a.k. m Shirazul Islam, Rabiul Halim, Md Arifur Rahman Khan, Mohammad Asaduzzaman, Md Rezaul Karim， Nahim中搜索该作者Sarwar, Shamsul Hoque Milon, Rashed Mahmud, a.k. M。 Ostanin, Khamsay Detleuxay, Noryani Mohd Samat, Ismail Tan, Nahla Irtiza Ismail, Chew Har Lim, Wan Nasrudin Wan Ismail, Siti Rohayah Sulaiman, Anita Alias, Joanne Tiong Jia Wen, Azmin Huda Abdul Rahim, Asmah Zainudin, Nik Azman Nik Adib, Zihni Abdullah, Hafizah, Mohd Zulfakar Mazlan, Mohd Basri Mat Nor, munkasiakhan，Naranpurev,秋敏吞Thinzar胃,秋秋,汉盛,Myo颧骨赢,伦伦Hnin,曹曹伦,啊苏莫,易Sandar登,钦乐乐,Myo敏哥奈,νν,Lun奈,钦看到于昂,林莫邱,昂山苏姬,觉敏敏桶,素新钦钦Pyone咦,钦Waan, Moe Thidar,苏姬苏姬君,μμ耶,胜利赢得3月,奈奈林,Lalit Rajbanshi Trishant Limbu, Baburaja Shrestha, Ujma Shrestha,阿施施施Rosi Pradhan,拉维Ram Shrestha Sulav Acharya, PrameshSunder Shrestha, Puja Thapa Karki, Moosa Awladthani, Jacob Paul, Nadia Al Badi, Adil Al Kharusi, Khalil Al Kharousi, Sandeep Kantor, Yohannan John, Said Al Mandhari, Geetha Jacob, Amr Muhammad Esmat, b.m.j. Shetty, Ahmed Mostafa, Naveed Haroon Rashid, Muhammad Sohaib, Sonia Joseph, Safia Zafar, Ahmed Farooq, Muhammad Sheharyar Ashraf, Tanveer Hussain, Muhammad Hayat, Ataur Rehman, Syed Muneeb Ali, Saad ur Rehman, Ashok Kumar, Aaron Hernandez, Crystal Aperocho, Raymundo Resurreccion, DebbieNoblezada-Uy, Jose Emmanuel Palo,
{"title":"Limitation of life-sustaining treatments in Asian ICUs: theory versus practice","authors":"Lowell Ling, Andrew Li, Jason Phua","doi":"10.1186/s13054-024-05241-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05241-2","url":null,"abstract":"<p>We thank Wang and Zhong for raising the important considerations on limitation or withdrawal of therapy in the MOSAICS II studies [1]. Although limitation or withdrawal of therapy was not part of the exclusion criteria for MOSACIS II, data on subsequent limitation of therapy or withdrawal of therapy during ICU stay was collected but not previously published [2, 3]. Amongst the 4826 patients included in the MOSACIS II secondary analysis on qSOFA prognostic value, only 5.9% (283/4826) had withdrawal of life-sustaining treatments and 5.9% (287/4826) had withholding of life-sustaining treatments [3]. Even amongst those who died within 28 days, only 11.2% (142/1271) and 10.8% (137/1271) had withdrawal or withholding of life-sustaining treatments prior to death. Overall, low rates of limitation of therapy suggest it may not have significantly biased the conclusions drawn about prognostic value of qSOFA in sepsis.</p><p>The Asian Critical Care Clinical Trials group have previously published multiple survey studies on end-of-life practices in Asian ICUs [4,5,6]. However, real-life observations on end-of-life practices in MOSAICS II seem discrepant to these survey results. The ACME study reported that 70.2% of Asian ICU physicians would almost always or often withhold life-sustaining treatments and 20.7% would withdraw such treatments for patients with no real chance of recovering meaningful life [4]. The low observed rates of limitation of therapy in MOSAICS II may reflect the perception that limitation of life-sustaining treatment may expose the physician to legal risks [5]. Furthermore, there is significant variations in practice across cultures and income settings. As Wang and Zhong highlighted, Chinese physicians are more likely to consider financial burden when considering limiting life-sustaining treatments [6].</p><p>We appreciate the suggestions made by Wang and Zhong and agree that variations in local end-of-life practices may impact clinical research and care of critically ill patients in Asian ICUs. More prospective data are needed to understand the cultural and religious, financial and contextual factors that shape end-of-life practices in ICUs.</p><p>The data that support the findings of this study are available from the corresponding author upon reasonable request.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Wang M, Zhong L. Reflections on epidemiological investigations of sepsis in the Asian Region. Crit Care. 2024;28(1):59.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"2.\"><p>Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, et al. Epidemiology, management, and outcomes of sepsis in ICUs among countries of differing national wealth across Asia. Am J Respir Crit Care Med. 2022;206(9):1107–16.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"3.\"><p>Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, et al. Prognostic evaluation","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"10881 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142929110","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}
Pub Date : 2025-01-03DOI: 10.1186/s13054-024-05239-w
Frederic Michard, Adrian Wong, Vanina Kanoore Edul
The advancements in cardiovascular imaging over the past two decades have been significant. The miniaturization of ultrasound devices has greatly contributed to their widespread adoption in operating rooms and intensive care units. The integration of AI-enabled tools has further transformed the field by simplifying echocardiographic evaluations and enhancing the reproducibility of hemodynamic measurements, even for less experienced operators. Speckle tracking echocardiography offers a direct, visual, and quantitative assessment of myocardial shortening, serving as a compelling alternative to traditional methods for evaluating right and left ventricular systolic function. In critically ill patients, sublingual microcirculation imaging has revealed a high prevalence of microvascular alterations, which are markers of disease severity. The use of handheld vital microscopes enables the quantification of several key parameters, including vessel density, perfusion, red blood cell velocity, and the perfused vascular density. Such metrics are useful for evaluating microcirculatory health. The development of automated software marks a significant advance toward real-time bedside microvascular assessment. These advancements could eventually allow shock resuscitation to be tailored based on microvascular responses. In parallel with imaging advances, cardiac output monitors have evolved significantly. Once cumbersome devices displaying basic numerical data in tabular form, they now feature sleek, touch-screen interfaces integrated with visual decision-support tools. These tools synthesize hemodynamic data into intuitive graphical formats, allowing clinicians to quickly grasp the determinants of circulatory shock. This visual clarity supports more efficient and accurate decision-making, which may ultimately lead to improved patient care and outcomes.
{"title":"Visualizing hemodynamics: innovative graphical displays and imaging techniques in anesthesia and critical care","authors":"Frederic Michard, Adrian Wong, Vanina Kanoore Edul","doi":"10.1186/s13054-024-05239-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05239-w","url":null,"abstract":"The advancements in cardiovascular imaging over the past two decades have been significant. The miniaturization of ultrasound devices has greatly contributed to their widespread adoption in operating rooms and intensive care units. The integration of AI-enabled tools has further transformed the field by simplifying echocardiographic evaluations and enhancing the reproducibility of hemodynamic measurements, even for less experienced operators. Speckle tracking echocardiography offers a direct, visual, and quantitative assessment of myocardial shortening, serving as a compelling alternative to traditional methods for evaluating right and left ventricular systolic function. In critically ill patients, sublingual microcirculation imaging has revealed a high prevalence of microvascular alterations, which are markers of disease severity. The use of handheld vital microscopes enables the quantification of several key parameters, including vessel density, perfusion, red blood cell velocity, and the perfused vascular density. Such metrics are useful for evaluating microcirculatory health. The development of automated software marks a significant advance toward real-time bedside microvascular assessment. These advancements could eventually allow shock resuscitation to be tailored based on microvascular responses. In parallel with imaging advances, cardiac output monitors have evolved significantly. Once cumbersome devices displaying basic numerical data in tabular form, they now feature sleek, touch-screen interfaces integrated with visual decision-support tools. These tools synthesize hemodynamic data into intuitive graphical formats, allowing clinicians to quickly grasp the determinants of circulatory shock. This visual clarity supports more efficient and accurate decision-making, which may ultimately lead to improved patient care and outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"34 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142917109","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}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：