Critical Care最新文献

Objectives: Influenza- and COVID-19-associated pulmonary aspergillosis (IAPA and CAPA respectively) are associated with increased mortality in critically ill patients. We evaluated whether longitudinal bronchoalveolar lavage (BAL) galactomannan (GM) dynamics predict clinical outcomes in these patients.

Methods: In a retrospective cohort (2009-2024) at a tertiary care ICU in Belgium, 180 adult patients with probable/proven IAPA (n = 68) or CAPA (n = 112) requiring mechanical ventilation were included. A total of 698 BAL samples were analysed. GM optical density values were modelled using linear mixed-effects models (10- and 30-day follow-up windows), with outcome measures at 30 and 90 days. Bayesian joint models linked longitudinal GM trends with time-to-death, adjusting for age, Charlson Comorbidity Index (CCI) and immunosuppression. Associations between Aspergillus culture results dynamics and mortality were also assessed.

Results: In general, BAL GM values declined significantly over days after diagnosis of aspergillosis, with steeper reductions in survivors (interaction p < 0.05). Joint models revealed each unit increase in GM over time corresponded to a 19% higher hazard of death at both 30 (aHR 1.19, p = 0.02) and 90 days (aHR 1.19, p = 0.007) after ICU admission. Persistent BAL culture positivity also correlated with worse outcomes.

Conclusions: In this large virus-associated pulmonary aspergillosis cohort, BAL GM kinetics emerged as a potential prognostic biomarker. Early and sustained increases in BAL GM values identify patients at increased risk of mortality.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and disability. However, post-discharge functional trajectories within the first year after the bleed remain poorly characterized. Understanding recovery patterns is essential for guiding clinical decisions, counseling families, and optimizing rehabilitation strategies.

Methods: We retrospectively analyzed consecutive adults with imaging-confirmed aSAH admitted to the neurocritical care unit (NCCU) of the University Hospital Zurich between January 2016 and June 2024. Patients who survived hospitalization and had standardized follow-up assessments at 3 and 12 months were included. Functional outcome was evaluated using the Glasgow Outcome Scale-Extended (GOSE). Improvement was defined as an increase in GOSE between 3 and 12 months. Predictors of functional improvement were identified using multivariable logistic regression and ordinal shift analysis.

Results: Among 342 hospital survivors, 301 were eligible for trajectory analysis. Overall, 58.5% of the 301 eligible survivors improved on the GOSE between 3 and 12 months, while functional decline was infrequent (≈ 6%). Excluding patients at the extremes of the scale (GOSE3 = 1 or 8, who by definition could not improve on GOSE), improvement rates ranged from 38% to 71% and were the highest in patients with moderate disability (GOSE at three months = 4). A higher Charlson Comorbidity Index (CCI) showed a consistent association with a lower likelihood of functional improvement: this effect did not reach the multiplicity-adjusted significance threshold in the primary multivariable logistic regression model but was directionally similar and nominally significant in the ordinal shift sensitivity analysis.

Conclusions: Post-discharge recovery after aSAH is heterogeneous but often continues beyond three months. Pre-existing medical conditions seem to play an important role in outcome trajectories. Patients with moderate disability demonstrate the greatest potential for improvement, highlighting the importance of individualized rehabilitation and extended follow-up strategies after aSAH.

Citrate accumulation is a relevant complication of continuous kidney replacement therapy (CKRT). In response to the commentary by Wang and Li, we reassessed findings from a cohort of 911 critically ill patients, in whom bilirubin levels, technical parameters, and CKRT modality were independently associated with citrate accumulation. Continuous venovenous haemodiafiltration (CVVHDF) was associated with a lower risk compared with continuous venovenous haemodialysis (CVVHD). While this difference was initially hypothesised to reflect transmembrane flux and membrane patency, Wang and Li highlighted potential confounding by device-specific citrate concentrations. We acknowledge this limitation, as CVVHDF was delivered exclusively using the Prismaflex system, whereas CVVHD was performed with the multiFiltrate device that both use different citrate regimens. Although multiFiltrate was associated with a higher citrate load, total citrate load was not independently associated with citrate accumulation at therapy initiation or at the time of accumulation. Importantly, treatment modality remained significantly associated with citrate accumulation after multivariable adjustment. These findings suggest that factors beyond citrate load contribute to citrate accumulation, warranting further investigation.

Background: To determine whether lung ultrasound (LUS) may early predict the failure of non-invasive respiratory support (high-flow nasal cannula-HFNC, continuous positive airway pressure-CPAP, non-invasive ventilation-NIV) in hypoxemic patients.

Methods: In this prospective multicenter international observational study, we enrolled patients undergoing non-invasive treatments for hypoxemia (PaO₂/FiO₂ < 300 mmHg). LUS, PaO₂/FiO₂ and ROX index were assessed before (baseline) and 2 h after treatment start. Regional/global LUS aeration scores were computed (4 degrees of loss-of-aeration: 0-normal to 3-severe loss of aeration) in 6 regions per hemithorax (2 anterior, 2 lateral, 2 posterior). Failure was defined as need of respiratory support's escalation within 48 h (HFNC to CPAP to NIV, any support to intubation/ECMO).

Results: We studied 100 patients (age 70 [57-76] years; female sex 39%; supports: 13 HFNC, 68 CPAP, 19 NIV); the overall rate of treatment failure was 22%. At the baseline, clinical and ultrasound parameters were similar in failing and non-failing patients; after 2 h, failing patients had lower PaO₂/FiO₂. (149 mmHg [124-201] vs. 200 [171-243]; p = 0.001), lower ROX index (7.8 [4.9-9.2] vs. 10.9 [7.9-13.8]; p = 0.003) and higher lateral (3.0 [1.0-6.0] vs. 1.5 [0.0-3.0]; p = 0.047), antero-lateral (4.0 [1.0-9.0] vs. 2.0 [0.0-4.0]; p = 0.027) and global (13.0 [8.0-17.0] vs. 10.0 [7.0-13.0]; p = 0.036) LUS aeration scores. No improvement in lung aeration was observed in failing patients within the initial 2 h of treatment (global LUS score variations 0.0 [-2.0-1.0] vs. -3.0 [-5.0 - -2.0]; p < 0.001). ROX index and antero-lateral/global LUS scores' variations were independent predictors of failure. AUCs for treatment failure were: 2-hour ROX index 0.71 [0.58-0.84], 2-hour PaO₂/FiO₂ 0.73 [0.60-0.85], global LUS score variations 0.73 [0.62-0.89]. A combined clinical-ultrasound score (ROX-US) showed AUC of 0.82 [0.73-0.91]. A ROX-US≥1 identified the success of the treatment with sensitivity 95% and specificity 50%; a ROX-US≥2 identified the success of the treatment with sensitivity 45% and specificity 96%.

Conclusions: Changes in LUS aeration scores induced by 2 h of non-invasive respiratory support help early predict the risk of treatment failure. LUS score improved only in responders and was an independent predictor of failure.

Background: Extracorporeal carbon dioxide removal (ECCO₂R), when used as an adjunct to mechanical ventilation in patients with mild to moderate acute respiratory distress syndrome (ARDS), has been proposed as a strategy to control hypercapnic acidosis during ultra-lung-protective ventilation (ULPV). However, no multicenter study has systematically assessed ventilation improvement markers with a standardized protocol using ECCO₂R devices featuring a peristaltic pump design. This prospective, multicenter study conducted in France addresses these gaps by evaluating the performance and safety of PRISMALUNG+, a novel membrane lung specifically developed for ECCO₂R, either as a standalone therapy or combined with continuous renal replacement therapy (CRRT). A specific protocol for ULPV was used to minimize lung stress and mitigate the risk of hypoxemia.

Methods: Between April 2021 and December 2023, 58 patients were treated with ECCO₂R (16 in combination with CRRT). Tidal volume (V_T) was reduced stepwise from 6 mL/kg to 4 mL/kg. Once the partial pressure of carbon dioxide (PaCO₂) exceeded 50 mmHg, sweep gas (100% oxygen at 10 L/min) was initiated to provide ECCO₂R. Outcomes were measured at 8 and 24 h, while safety was monitored until discharge or day 28.

Results: During V_T reduction and before ECCO₂R initiation, peak hypercapnia and respiratory acidosis reached PaCO₂ of 53.0 [50.0-55.0] mmHg and pH of 7.30 [7.24-7.36]. After 24 h of treatment, V_T significantly decreased from 6.0 [6.0-6.1] to 4.0 [4.0-4.30] (p < 0.0001), driving pressure (∆P) from 12.0 [10.0-16.0] cmH₂O to 10.0 [8.0-13.0] cmH₂O (p < 0.0001), ventilatory ratio (VR) from 1.7 [1.5-2.1] to 1.3 [1.0-1.6] (p < 0.0001) and mechanical power from 18.8 [15.0-22.0] J/min to 11.8 [8.8-15.5] J/min (p < 0.0001). PaO₂/FiO₂ did not significantly change over time and respiratory acidosis resolved with treatment, as evidenced by normalization of pH and a reduction in PaCO₂. Importantly, no major bleeding events, intracranial hemorrhages, or hemolysis were reported during the study.

Conclusion: This study demonstrates that hypercapnic acidosis occurring during ultra-low V_T ventilation (ULPV) can be safely mitigated with ECCO₂R in mechanically ventilated patients with mild to moderate ARDS. Moreover, under ULPV, ∆P, VR and mechanical power were improved without inducing hypoxemia.

Trial registration: Clinicaltrials.gov: NCT04617093, Registration date: 30 October 2020.