Critical Care最新文献

Background: Noninvasive evaluation of partial pressure of carbon dioxide (PCO₂) is clinically important for screening and monitoring of hypercapnia, especially in patients with chronic obstructive pulmonary disease (COPD). However, the comparative accuracy of end-tidal PCO₂ (PetCO₂) and transcutaneous PCO₂ (PtcCO₂) monitoring in COPD remains uncertain. This study aimed to evaluate the agreement between PetCO₂ obtained by using modified method of prolonged expiration with an integrated calculation algorithm (PetCO₂-PA) and PtcCO₂ with arterial PCO₂ (PaCO₂) in patients with COPD.

Methods: In this single-center study, 83 patients with COPD (48 at stable phase and 35 during acute exacerbation) underwent arterial blood gas (ABG) analysis followed with simultaneous measurement of PetCO₂-PA and PtcCO₂. Agreement between different measurements was assessed using Bland-Altman analysis (bias and limits of agreement (LOA)), and intraclass correlation coefficients. The receiver operating characteristic curve was used for evaluation of ability to detect hypercapnia, defined as PaCO₂ ≥ 45 mmHg and ≥ 50 mmHg.

Results: Bland-Altman analysis revealed a small bias of - 1.7 mmHg but a relatively wide LOA of - 8.6 to 5.1 for PtcCO₂ and - 2.4 mmHg (LOA: - 9.9 to 5.1) for PetCO₂-PA. The similar results were observed across disease states (stable vs. exacerbation) and degrees of hypercapnia. PetCO₂-PA and PtcCO₂ exhibited comparably diagnostic accuracy for hypercapnia (PaCO₂ ≥ 45 or 50 mmHg), each achieving an area under the curve (AUC) greater than 0.94, with no statistically significant inter-method differences. The proportions of measurements exceeding the clinical acceptability thresholds of ± 4 mmHg and ± 7 mmHg did not differ significantly between techniques.

Conclusion: PetCO₂-PA demonstrated a small bias but a relatively wide LOA with PaCO₂, non-inferior to PtcCO₂, in patients with COPD. Owing to its cost-effectiveness, rapid operation, and portability, PetCO₂-PA represented a practical alternative for screening and monitoring of hypercapnia in COPD patients.

Clinical trial registration: The trial was registered at ClinicalTrials.gov (identifier: NCT04051931).

Background: Intensive Care Unit-acquired weakness (ICUAW) is a common and debilitating complication in critically ill patients, resulting in substantial functional impairment and reduced quality of life. Although early mobilization is widely recommended, the most effective rehabilitation strategy remains unclear. This study aimed to evaluate the short-term clinical efficacy of a suspension-based lower-limb rehabilitation device (SS) combined with conventional rehabilitation in prompt improvement of lower-limb function in patients with ICUAW after diagnosis.

Method: A prospective, within-patient randomized controlled trial with a two-year study period. Sixty patients with ICUAW were enrolled, with one lower limb designated as the intervention side, receiving SS-assisted training plus standard physical therapy, and the opposite limb serving as the control, receiving standard physical therapy alone. Both limbs received 40 min of therapy daily, 5 days per week, for 2 consecutive weeks. Assessments were conducted at baseline (study enrolment), 1 week, and 2 weeks. The primary outcome was the change in lower-limb muscle thickness involving the rectus femoris, vastus intermedius, vastus medialis, vastus lateralis, and tibialis anterior, assessed by musculoskeletal ultrasound. Secondary outcomes included the Medical Research Council (MRC) score, active range of motion (AROM), and limb circumference.

Results: Mixed-effects model analysis of muscle thickness showed a significant interaction between group and time (p < 0.001) and a significant main effect of group (p = 0.001). Post-hoc analysis revealed that at two weeks, muscle thickness in the control limb was significantly lower than in the intervention limb (p < 0.01). In the control limb, muscle thickness was significantly reduced at both 1 week and 2 weeks compared with baseline (p < 0.01), with no significant difference between the two time points (p = 0.06). Notably, no significant within-group changes over time were observed in the intervention limb. Similarly, the control limb showed significantly lower MRC scores than the intervention limb at 1 week (p = 0.05) and 2 weeks (p = 0.003). AROM was also lower in the control limb at 1 week (p = 0.003) and 2 weeks (p < 0.001). No significant interaction or main effect was observed for lower-limb circumference (p = 0.18).

Conclusion: Prompt intervention with SS-assisted rehabilitation combined with conventional therapy may help attenuate muscle atrophy, improve muscle strength, and enhance hip and knee AROM in patients with ICUAW, potentially offering a novel rehabilitation strategy for this population.

Mechanical power has emerged as a unifying metric to quantify the risk of ventilator-induced lung injury (VILI), integrating multiple ventilatory parameters-such as tidal volume, airway pressures, respiratory rate, and inspiratory airflow-into a single measure of the mechanical energy delivered to the lungs. However, total mechanical power alone cannot fully predict the likelihood of injury, as the development of VILI depends not only on delivered energy but also on how this energy interacts with the lung's regional mechanical properties and its intrinsic vulnerability to stress. Critically, only externally measured inflation energy that exceeds one or more local alveolar stress thresholds-termed hazardous elastic power-is likely to contribute to lung damage. In this context, we propose a conceptual method to quantify this damaging component of mechanical power in relation to regional stress thresholds for injury. Once refined and validated, incorporating this approach into clinical practice could enhance individualized, lung-protective ventilation strategies by recognizing that VILI arises from the convergence of mechanical energy, regional stress, and structural vulnerability.

Background: Renal replacement therapy (RRT) is frequently used in critically ill patients with acute kidney injury (AKI). Here, we provide guidelines for the management of RRT in critically ill patients on the intensive care unit (ICU).

Methods: We convened a systemic literature research and a Delphi process with a bi-national multidisciplinary consensus panel including 22 clinicians of 12 different German-speaking societies (Germany and Austria) with expertise in RRT. This structured guideline process was the basis for the evidence-based statements and recommendations.

Results: We identified seven clinical areas needing guidance: (1) start, (2) modality (diffusion and convection), (3) continuous/ intermittent, (4) anticoagulation, (5) dose (6) pharmacotherapy, (7) stopping criteria. The consensus produced 73 statements and recommendations regarding key clinical areas, the most important 47 statements and recommendations are summarized in this overview.

Conclusions: This evidence-based bi-national guideline should provide physicians with guidance for delivering best practice to critically ill patients with a dialysis-dependent AKI.

Background: Ventilator-associated pneumonia (VAP) caused by multidrug-resistant Klebsiella pneumoniae (MDR-Kp) remains a major clinical challenge in critically ill patients. While bacteriophage therapy shows promise, clinical data on inhaled formulations are limited.

Methods: In this prospective, single-center, open-label, non-randomized interventional pilot study, we evaluated the efficacy and safety of a hospital-adapted phage cocktail in patients with MDR-Kp VAP. The cocktail was designed based on retrospective genomic and phenotypic analysis of local isolates. All patients received standard antibiotics and were assigned to three groups (n = 7 each): targeted phage therapy (cocktail active in vitro), non-targeted phage control (cocktail inactive in vitro), or control (no phage). A non-target phage control group was included to evaluate possible non-specific or immunomodulatory effects of phage presence in the respiratory tract. Phages were administered via nebulization twice daily for 14 days. The primary endpoint was microbiological eradication of any K. pneumoniae at day 14; secondary endpoints included clinical response and safety, assessed through clinical and laboratory parameters.

Results: By day 14, microbiological eradication of K. pneumoniae from respiratory samples was documented in 86% (6/7) of patients receiving targeted phage therapy, compared to 57% (4/7) with antibiotics alone and 0% (0/7) with non-targeted phages. Distinct patterns of infection dynamics were observed, with targeted therapy associated with more rapid and consistent clearance. Co-colonization with other nosocomial pathogens (primarily A. baumannii and S. marcescens) was common but showed no evidence of competitive interference with K. pneumoniae eradication. No significant between-group differences were observed in vital signs or laboratory indices; however, the PT group exhibited a significant within-group improvement in oxygenation (p = 0.0247), alongside earlier de-escalation of ventilatory support and discontinuation of antibiotics. Inhaled phage administration was well tolerated, with no therapy-related adverse events.

Conclusions: This comparative pilot study outlines a translational approach from local K. pneumoniae epidemiology to hospital-adapted phage cocktails. Although preliminary, our findings illustrate how this pragmatic approach could be evaluated into intensive care unit workflows, positioning hospital-adapted cocktails as a potential middle ground between broad-spectrum and personalized phage therapy.