Critical Care最新文献

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.

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.