Critical Care最新文献

Background: Withdrawal of life-sustaining treatment (WLST) is common in clinical trials of patients with acute brain injuries (ABI), but current reporting practices and impact on trial-reported findings are unclear. We evaluated reporting practices of WLST in contemporary clinical trials of patients with ABI and quantified the magnitude of bias on treatment effect estimates in hypothetical trials.

Methods: We conducted a literature review of contemporary ABI randomized clinical trials and a simulation-based analysis. In the literature review, we included two-arm, randomized, superiority trials of adults with ABI (traumatic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, ischemic stroke, or post-cardiac arrest brain injury) published in 10 high-impact journals from January 1, 2015 to December 19, 2024. We extracted WLST characteristics including frequency, timing, reasons, and neuro-prognostication criteria. In the simulation-based analysis, we evaluated the impact of WLST misclassification-defined as WLST occurring in patients who could have survived with a good neurological outcome-on observed treatment effects. For each scenario, we estimated the observed treatment effect after misclassification and calculated bias as the difference between observed and true treatment effects. We assessed both blinded and unblinded trials and binary and ordinal neurologic outcomes.

Results: Among 69 trials included in the literature review, 17 trials (24.6%) reported WLST frequency, 9 (13.0%) timing, 10 (14.5%) reasons, and 7 (10.1%) standardized neuro-prognostication criteria. In simulations of blinded trials, WLST misclassification consistently attenuated observed treatment effects. Increasing the fraction of misclassified WLST events led to progressively greater bias, making beneficial treatments appear less effective and harmful treatments appear less harmful. In unblinded trial simulations, the direction of bias varied by the magnitude of the true treatment effect and degree of misclassification. Findings were similar for binary and ordinal neurologic outcomes. Across all simulations, WLST misclassification reversed statistical conclusions in a median of 22.1% (interquartile range 17.4-32.4%) of trials.

Conclusions: WLST is poorly reported in contemporary ABI trials. Misclassification of WLST-related deaths leads to important bias in trial-reported treatment effects, potentially yielding underpowered studies and erroneous trial conclusions. Standardized, transparent WLST reporting is essential to strengthen ABI trial design and interpretation.

Background: This study evaluated the effectiveness of replacing chlorhexidine-based oral care with toothbrushing and reinforcing head-of-bed elevation (HOBE) for the prevention of ventilator-associated pneumonia (VAP) in real-world practice using an interrupted time-series (ITS) analysis.

Methods: This quasi-experimental study was conducted in eight adult intensive care units (ICUs) of a 2,734-bed tertiary care hospital in Seoul, South Korea. The interventions, implemented in May 2023, included replacing chlorhexidine-based oral care with toothbrushing and strengthening HOBE adherence. ITS analysis was performed to assess the impact of the intervention on monthly VAP incidence rates from August 2022 through November 2024.

Results: Adherence to HOBE increased significantly from 84 to 95% after the intervention (P < 0.001). During the study period, 144 VAP cases occurred: 66 cases during 16,849 device-days in the pre-intervention period (3.9 per 1,000 device-days) and 78 cases during 32,185 device-days in the post-intervention period (2.4 per 1,000 device-days). ITS analysis demonstrated a significant decrease in both the level and trend of VAP incidence following the intervention (level change coefficient: -1.66, 95% confidence interval [CI]: -3.07 to -0.25, P = 0.029; trend change coefficient: -0.25, 95% CI: -0.45 to -0.06, P = 0.015). Sensitivity analyses using alternative transition windows and negative binomial models showed directionally consistent post-intervention declines, whereas estimates were attenuated and not statistically significant in the fully covariate-adjusted ITS model.

Conclusions: Implementation of toothbrushing-based oral care combined with reinforced HOBE was followed by lower VAP incidence in the primary ITS analysis, supporting the feasibility of these aspiration-prevention measures in routine ICU practice.

Background: Demographic aging is expected to substantially affect intensive care medicine, with a growing proportion of elderly patients and increasing clinical complexity, while resources remain limited. It is therefore critical for clinicians and health systems to understand, how intensive care unit (ICU) admissions, outcomes, and treatment intensity across patients of differing age have evolved in recent years. Longitudinal data on these parameters are scarce on the population level.

Methods: We conducted a retrospective population-based analysis of all German inpatient cases from 2011-2022. Hospitalizations with ICU treatment ≥ 24 h were included. Temporal trends in ICU admissions, in-hospital mortality, ICU-related deaths, and use of organ replacement therapies (ORT) were analyzed and stratified by age groups. ORTs comprised mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation.

Results: Overall, 8.4 million ICU admissions were analyzed. During the observation period, ICU admissions showed an overall decline of 12.6%, driven by reductions in patients aged 65-79 years (- 18.1%) and ≥ 80 years (- 24%), while remaining stable in younger patients. Despite fewer admissions, ICU-related mortality showed an overall increase from 14.4% to 18.9%, mainly in patients < 80 years. Overall, in-hospital deaths declined across all age groups, but the proportion of ICU-related deaths rose among patients < 80 years. ORT use increased across all age groups and was associated with persistently high mortality, particularly with combined ORTs (up to 79%). Patients aged 65-79 years received combined ORTs most frequently. Patients ≥ 80 years had the highest mortality.

Conclusions: ICU utilization and outcomes in Germany have shifted markedly over the past decade. Declining admissions among older patients, increasing ICU-related mortality in younger patients, and rising treatment intensity underscore age-specific differences in critical care delivery and outcomes, with important implications for ICU admission practices, treatment decisions and future resource planning.