Critical Care最新文献

{"title":"Application and safety of speaking valves in tracheostomy patients","authors":"Hao Wang, Hongying Jiang, Zhanqi Zhao, Jia Liu, Chenxi Zhang","doi":"10.1186/s13054-024-05217-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05217-2","url":null,"abstract":"<p><b>To the Editor</b></p><p>Tracheostomy is a surgical procedure commonly performed in the intensive care unit (ICU) [1]. It creates an artificial opening in the trachea for prolonged ventilation or airway obstruction. It offers benefits like improved airway protection and decreased respiratory effort but also brings physiological and psychological challenges, including speech loss and anxiety [2]. A speaking valve, attached to the tracheostomy tube, allows speech and improves swallowing, reduces aspiration risk, and enhances lung mechanics [3]. Early use improves patient activity and mobility, alleviating anxiety, depression, and social isolation [4, 5].</p><p>Despite many clinical benefits of speaking valves, their widespread use in clinical practice is still limited in many countries, including China [6]. The safety of speaking valve was not fully studied. This study aimed to determine the utility and safety of speaking valves in tracheostomy patients, facilitating evidence-based clinical use of speaking valves.</p><p>This study was approved by the Ethics Committee of Beijing Rehabilitation Hospital, Capital Medical University (approval number: 2017bkky066), and all participants provided written informed consents. Patients with tracheostomy receiving speaking valves at the Department of Respiratory and Critical Care Medicine, Beijing Rehabilitation Hospital, between September 2017 and September 2021 were included. The inclusion criteria were: (1) patients who had been successfully weaned off mechanical ventilation, (2) first-time use of a speaking valve, and (3) Glasgow Coma Scale (GCS) score ≥ 9. Patients were excluded from the study if: (1) altered mental status, (2) severe cognitive impairment, (3) unstable clinical condition, (4) severe upper airway obstruction, (5) excessive and thick airway secretions, (6) incompatibility between the speaking valve and tracheostomy tube.</p><p>Before placement, suctioning of airway and oral secretions was performed. The cuff was deflated and the valve secured. Vital signs and respiratory status were monitored, and the valve removed if distress occurred. We assessed patients’ vital signs, breath sounds, and secretions before, during, and after placement, recording tolerance, duration of use, reasons for discontinuation, and other variables. Descriptive statistics summarized patient characteristics and outcomes.</p><p>A total of 120 patients met the inclusion and exclusion criteria (male:female, 85:35). The age of the patients ranged from 14 to 93 years, with a mean age of 64.3 years. The average APACHE II score at admission was 12.1 ± 6, and the duration of tracheostomy ranged from 0 to 455 days, with an average of 66.0 days.</p><p>The interval between tracheostomy and the first placement of the speaking valve ranged from 7 to 455 days, with an average of 69.8 days. Among the patients, 37 (36.3%) tolerated the first-time use of the speaking valve well, However, 65 patients (63.7%) experienced poor toler","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"58 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142849093","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}

{"title":"Are crystalloid-based fluid expansion strategies still relevant in the first hours of trauma induced hemorrhagic shock?","authors":"Perrine Tubert, Alexandre Kalimouttou, Pierre Bouzat, Jean-Stéphane David, Tobias Gauss","doi":"10.1186/s13054-024-05185-7","DOIUrl":"https://doi.org/10.1186/s13054-024-05185-7","url":null,"abstract":"Crystalloid-based fluid resuscitation has long been a cornerstone in the initial management of trauma-induced hemorrhagic shock. However, its benefit is increasingly questioned as it is suspected to increase bleeding and worsen coagulopathy. The emergence of alternative strategies like permissive hypotension and vasopressor use lead to a shift in early trauma care practices. Critical appraisal of current evidence is necessary to guide clinicians and outline research perspectives. Current guidelines for managing trauma-induced hemorrhagic shock suggest titrating fluids and using vasopressors to achieve minimal blood pressure targets until hemorrhage is controlled. In case of traumatic brain injury with severe hemorrhage, blood pressure target increases. The scientific literature supporting these recommendations is limited, and several aspects remain the subject of ongoing scientific debate. The aim of this review is to evaluate the existing evidence on low-volume fluid resuscitation during the first hours of trauma management, with an emphasis on its integration with permissive hypotension, vasopressor use and cerebral perfusion pressure in traumatic brain injury. The review also highlights the limitations of current guidelines, particularly the lack of robust evidence supporting specific type of fluid, volumes and administration protocols tailored to specific trauma scenarios and populations. Emerging technologies such as point-of-care diagnostics, integrated monitoring systems, and machine learning hold promise for enhancing clinical decision-making in trauma care. These innovations could play a crucial role, ultimately helping clinicians address critical unanswered questions in trauma management and improve patient survival. Crystalloid-based resuscitation remains relevant in early trauma care, but its application must be reassessed considering recent evidence and evolving practices. Further research is essential to refine fluid resuscitation guidelines, particularly in defining safe fluid volumes and the role of vasopressors. The integration of advanced monitoring technologies may offer new opportunities to optimize trauma care and improve outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"122 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841130","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}

{"title":"Urinary proteomics identifies distinct immunological profiles of sepsis associated AKI sub-phenotypes","authors":"Ian B. Stanaway, Eric D. Morrell, F. Linzee Mabrey, Neha A. Sathe, Zoie Bailey, Sarah Speckmaier, Jordan Lo, Leila R. Zelnick, Jonathan Himmelfarb, Carmen Mikacenic, Laura Evans, Mark M. Wurfel, Pavan K. Bhatraju","doi":"10.1186/s13054-024-05202-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05202-9","url":null,"abstract":"Patients with sepsis-induced AKI can be classified into two distinct sub-phenotypes (AKI-SP1, AKI-SP2) that differ in clinical outcomes and response to treatment. The biologic mechanisms underlying these sub-phenotypes remains unknown. Our objective was to understand the underlying biology that differentiates AKI sub-phenotypes and associations with kidney outcomes. We prospectively enrolled 173 ICU patients with sepsis from a suspected respiratory infection (87 without AKI and 86 with AKI on enrollment). Among the AKI patients, 66 were classified as AKI-SP1 and 20 as AKI-SP2 using a three-plasma biomarker classifier. Aptamer-based proteomics assessed 5,212 proteins in urine collected on ICU admission. We compared urinary protein abundances between AKI sub-phenotypes, conducted pathway analyses, tested associations with risk of RRT and blood bacteremia, and predicted AKI-SP2 class membership using LASSO. In total, 117 urine proteins were higher in AKI-SP2, 195 were higher in AKI-SP1 (FDR < 0.05). Urinary proteins involved in inflammation and chemoattractant of neutrophils and monocytes (CXCL1 and REG3A) and oxidative stress (SOD2) were abundant in AKI-SP2, while proteins involved in collagen deposition (GP6), podocyte derived (SPOCK2), proliferation of mesenchymal cells (IL11RA), anti-inflammatory (IL10RB and TREM2) were abundant in AKI-SP1. Pathways related to immune response, complement activation and chemokine signaling were upregulated in AKI-SP2 and pathways of cell adhesion were upregulated in AKI-SP1. Overlap was present between urinary proteins that differentiated AKI sub-phenotypes and proteins that differentiated risk of RRT during hospitalization. Variable correlation was found between top aptamers and ELISA based protein assays. A LASSO derived urinary proteomic model to classify AKI-SP2 had a mean AUC of 0.86 (95% CI: 0.69–0.99). Our findings suggest AKI-SP1 is characterized by a reparative, regenerative phenotype and AKI-SP2 is characterized as an immune and inflammatory phenotype associated with blood bacteremia. We identified shared biology between AKI sub-phenotypes and eventual risk of RRT highlighting potential therapeutic targets. Urine proteomics may be used to non-invasively classify SP2 participants.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"24 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841128","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}

{"title":"Luciano Gattinoni: a tribute to a pioneer in intensive care medicine","authors":"Antonio Pesenti, Gaetano Iapichino, Jean Louis Vincent","doi":"10.1186/s13054-024-05210-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05210-9","url":null,"abstract":"&lt;p&gt;Luciano Gattinoni was a truly exceptional scientist and a unique personality. He was one of the rare individuals destined to be cited in medical textbooks for generations to come. He passed away at the end of an extraordinary, active, and impactful life, just shy of his 80th birthday.&lt;/p&gt;&lt;p&gt;Gattinoni studied in Milan, where he completed high school with a focus on classical humanities. This background profoundly shaped his thinking, leaving an indelible mark on his life and work. After graduating from medical school and fulfilling compulsory military service as a medical officer in the Alpine troops—a role he often recounted with characteristic humor—Gattinoni became captivated by a nascent discipline: Intensive Care Medicine.&lt;/p&gt;&lt;p&gt;At the time, intensive care medicine was virtually unknown in Italy. Gattinoni joined a group of intelligent, resourceful young physicians determined to establish this emerging specialty at the Ospedale Maggiore Ca’ Granda in Milan. Founded on April 1, 1456, this historic hospital housed the city’s medical school and fostered an inspiring environment of youthful energy and innovation. Under the farsighted direction of Professor Giorgio Damia, the ICU team developed a unique, friendly team spirit that persists to this day, even as many of its members have retired or passed away.&lt;/p&gt;&lt;p&gt;Luciano quickly stood out with his charm, quick wit, and insatiable curiosity—a trait that defined him throughout his life. Driven by an unrelenting desire to understand the mechanisms of disease, he and his colleagues placed physiology at the heart of their clinical reasoning, guided by a shared mantra: “Measure, measure, measure”.&lt;/p&gt;&lt;p&gt;To support himself during his early career, Gattinoni moonlighted in a clinical chemistry lab, performing blood tests and cell counts. There, he met Luigi Rossi Bernardi, a renowned biochemist whose research had brought him into contact with Dr. Theodor “Ted” Kolobow at the NIH. Kolobow, the inventor of the spiral coil membrane lung—the first such device commercialized for human use—was an extraordinary scientist and innovator passionate about artificial organs and respiratory pathophysiology. A WWII refugee from Estonia, Kolobow’s ethical trait was legendary; he famously sold his membrane lung patent to the U.S. government for just $1, saying, “It’s time to give back for all I’ve received”.&lt;/p&gt;&lt;p&gt;Gattinoni and Kolobow made a formidable partnership. When the disappointing results of the NIH ECMO study emerged, they identified the problem: the use of high tidal volumes and respiratory rates during ECMO. Together, they championed a groundbreaking concept—lung protection and rest—arguing that the focus should not solely be on gas exchange or machine performance but on using the right tool in the right way. Their idea that a membrane lung, by removing CO&lt;sub&gt;2&lt;/sub&gt; from blood, could provide complete freedom in ventilatory management laid the foundation for modern lung-protective ventilation strategies du","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"24 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142849091","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}

{"title":"Aggressive therapies for intracranial hypertension after aneurysmal subarachnoid hemorrhage: a single-center experience","authors":"Tommaso Zoerle, Elisa Zoe Battistelli, Valeria Conte, Silvia Pifferi, Alessandra Merrino, Anna Zanetti, Marco Locatelli, Fabrizio Ortolano, Nino Stocchetti","doi":"10.1186/s13054-024-05205-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05205-6","url":null,"abstract":"&lt;p&gt;&lt;b&gt;To the editor,&lt;/b&gt;&lt;/p&gt;&lt;p&gt;Intracranial hypertension (HICP) is a frequent cerebral insult after aneurysmal subarachnoid hemorrhage (SAH) and it is related to unfavorable outcome [1]. Its treatment is based on escalating-intensity approaches, translated from traumatic brain injury, including aggressive therapies such as barbiturate infusion, secondary surgical decompression and/or intracerebral hemorrhage (ICH) evacuation, hypothermia and hypocapnia [1, 2]. However, there is limited data about these therapies after SAH and their impact on the patient’s outcome [1, 3]. The aims of this study, based on a single-center experience, were: (1) to describe how frequently HICP requires aggressive therapies after SAH; (2) to explore clinical and radiological factors related to the need for these therapies; (3) to analyse the relationship between aggressive therapies and the patient’s outcome.&lt;/p&gt;&lt;p&gt;We examined a prospective observational database including aneurysmal SAH adult patients requiring ICP monitoring and admitted to the neuro-ICU of our hospital.&lt;/p&gt;&lt;p&gt;Patients were managed as previously described [4]. In our center, ICP after aneurysmal SAH is monitored in severe, comatose patients and/or cases with acute hydrocephalus requiring external ventricular drain placement. The mean ICP for 12-h intervals was calculated and indicated as “mean ICP”. The highest mean ICP and episodes of HICP (ICP &gt; 20 mm Hg for at least 5 min) were noted for each patient.&lt;/p&gt;&lt;p&gt;Therapeutic intensity was assessed twice a day. Therapies for HICP were classified as:&lt;/p&gt;&lt;ol&gt;\u0000&lt;li&gt;\u0000&lt;span&gt;(1)&lt;/span&gt;\u0000&lt;p&gt;Preventive: normocapnia and sedation in ventilated patients, avoidance of pyrexia.&lt;/p&gt;\u0000&lt;/li&gt;\u0000&lt;li&gt;\u0000&lt;span&gt;(2)&lt;/span&gt;\u0000&lt;p&gt;Active: cerebrospinal fluid (CSF) withdrawal through an external ventricular catheter, mild hypocapnia (arterial pCO&lt;sub&gt;2&lt;/sub&gt; 30–35 mmHg), hyperosmolar fluid and muscle relaxants.&lt;/p&gt;\u0000&lt;/li&gt;\u0000&lt;li&gt;\u0000&lt;span&gt;(3)&lt;/span&gt;\u0000&lt;p&gt;Aggressive: reinforced hypocapnia (pCO&lt;sub&gt;2&lt;/sub&gt; less than 30 mmHg), barbiturates (continuous thiopentone infusion), hypothermia (endovascular or surface cooling to maintain temperature below 36 °C), secondary ICH evacuation and/or surgical decompression (done more than 24 h after ICU admission).&lt;/p&gt;\u0000&lt;/li&gt;\u0000&lt;/ol&gt;&lt;p&gt;Six-month Glasgow Outcome Scale (GOS) scores 1–3 were considered unfavorable, scores 4–5 as favorable.&lt;/p&gt;&lt;p&gt;Univariate analysis followed by a logistic regression model were used to identify clinical and radiological factors related to aggressive therapies using the stepwise method.&lt;/p&gt;&lt;p&gt;Six hundred eighty-two adult patients with aneurysmal SAH were consecutively admitted to the ICU between 2006 and 2020. Two hundred thirty-six patients were included in the analysis while 446 were excluded because ICP was not monitored. The main clinical and radiological findings are summarized in Table 1. Sixty patients out of 236 (25%) required at least one aggressive therapy. All these patients received ICP preventive treatments and at least one","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"11 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841132","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}

{"title":"Structural, physiological or clinical outcomes to define urine output threshold in acute kidney injury","authors":"Guido Dias Machado, Leticia Libório Santos, Alexandre Braga Libório","doi":"10.1186/s13054-024-05195-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05195-5","url":null,"abstract":"&lt;p&gt;To the editor:&lt;/p&gt;&lt;p&gt;We read with interest the comments by Zhu and Li [1] regarding our article on evaluating various urine output (UO) thresholds and timeframes for defining acute kidney injury (AKI) [2]. The authors rightly emphasize that the core principle of AKI diagnosis is to reflect impaired excretion of metabolic waste. However, the concept of AKI must evolve in parallel with advancements in our understanding and the development of interventions to alter its natural progression and clinical impact.&lt;/p&gt;&lt;p&gt;From a physiological perspective, the traditional definition of oliguria (&lt; 400 mL/24 h) is based on the assumption that a healthy adult excretes 600–800 mOsm of metabolic waste daily. At maximal urine concentration (1200 mOsm/L), at least 400 mL of urine is required for adequate waste excretion [3]. However, critically ill patients likely produce less metabolic waste and rarely achieve maximal urine concentration, making this physiological definition impractical in such contexts.&lt;/p&gt;&lt;p&gt;In our study, we also compared proposed UO thresholds to KDIGO standards for predicting progression to AKI stages 2/3, as measured by serum creatinine—a marker of metabolic waste. Our proposed criteria not only predicted hospital mortality but also outperformed KDIGO standards in predicting serum creatinine increases, a secondary outcome [2].&lt;/p&gt;&lt;p&gt;An accurate AKI definition is also essential to enable early interventions that can modify its course. Currently, these interventions are mostly preventive and include avoiding nephrotoxins, controlling hyperglycemia, monitoring serum creatinine and UO closely, and optimizing fluid balance and hemodynamics [4]. However, no studies have identified specific UO thresholds for initiating such measures. Future research should evaluate whether interventions targeting sensitive renal biomarkers—detectable before significant impairment in waste excretion—can effectively reduce AKI-related morbidity and mortality. If proven effective, we agree these biomarkers should be incorporated into AKI definitions.&lt;/p&gt;&lt;p&gt;As Zhu and Li pointed out [1], AKI stage 1—especially when based solely on UO—often does not correlate with increased mortality. Furthermore, there is limited evidence supporting the 0.5 mL/kg/h UO threshold as a definitive AKI marker for outcomes such as mortality, prolonged hospitalization, need for renal replacement therapy, or long-term morbidity. Additionally, no studies have demonstrated the efficacy of preventive or therapeutic interventions at this early stage.&lt;/p&gt;&lt;p&gt;Until higher UO thresholds are validated to guide AKI therapy or identify conditions associated with morbidity and mortality, overdiagnosing AKI poses risks of unnecessary costs and potential harm. This underscores the need for further research to define the optimal timing for AKI diagnosis, aiming to balance the benefits of early intervention with the financial, psychological, and clinical implications of the diagnosis.&lt;/p&gt;&lt;p&gt;Regarding t","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"201 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142840779","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}

{"title":"Associations between oxygenation status and prognosis in sepsis","authors":"Lihong Zhu, Juan Lin","doi":"10.1186/s13054-024-05201-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05201-w","url":null,"abstract":"&lt;p&gt;We read with great interest the recent study [1] which investigated whether a relatively high arterial oxygen tension (PaO&lt;sub&gt;2&lt;/sub&gt;) is associated with improved survival rate in sepsis compared to conservative oxygenation targets. After propensity score matching (PSM), 2422 patients evenly distributed between the liberal and conservative oxygen groups. The findings indicated that a higher PaO&lt;sub&gt;2&lt;/sub&gt; (≥ 80 mmHg) during the first three days in ICU was associated with lower 28-day mortality. While these results contribute significantly to the field of critical care medicine, several aspects require further clarification.&lt;/p&gt;&lt;p&gt;The study reported a significant reduction in 28-day mortality in the liberal group compared to the conservative group. However, according to the supplementary materials, we noted that the difference in mortality primarily occurred by day 7, with mortality rates of 14.3% in the liberal group compared to 6.9% in the conservative group—a reduction of approximately 7.4%. Interestingly, after day 7, the difference in mortality between the two groups appeared to stabilize, remaining at around 7% on day 14 (17.9% vs. 10.4%) and day 28 (22.5% vs. 14.8%), or even small on day 90 (31.3% vs. 27.0%). This pattern raises the question of whether the mortality benefit associated with higher oxygenation is predominantly a short-term effect or it still has more enduring implications. Also, it remains unclear whether this short-term mortality effect is directly attributable to differences in oxygenation status or whether it might be influenced by other confounding factors (e.g., patients who died within 7 days might be more likely due to disease severity), which highlighted the need for further analyses to better understand the reason for the observed mortality benefit and to explore its underlying mechanisms.&lt;/p&gt;&lt;p&gt;In addition, although PSM is a robust method for balancing measured covariates, it has its own limitations [2]. For instance, in this study, almost half of the patients were excluded during propensity score matching (PSM). By excluding a large proportion of study patients, PSM may reduce the representativeness of the sample and limit the generalizability of the findings. Moreover, while PSM adjusts for known confounders, it does not address potential unmeasured confounders, which may still significantly influence the observed outcomes [3]. For example, it remains unclear whether the observed differences in 7-day mortality rates between the liberal group and the conservative group are attributable to unmeasured confounders. Therefore, future analyses incorporating sensitivity analyses or analyses of the entire cohort may provide a more comprehensive evaluation of the robustness of these findings.&lt;/p&gt;&lt;p&gt;In the subgroup analysis, authors reported that higher oxygenation levels were associated with a reduced 28-day mortality risk in the following populations: males, hospital-acquired sepsis, vasopressors, mechanical ventilat","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"90 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841138","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}

{"title":"Timing of invasive mechanical ventilation in patients with sepsis: the impact of excluding non-intubated patients","authors":"Yun Ji, Libin Li","doi":"10.1186/s13054-024-05208-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05208-3","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;Early initiation of invasive mechanical ventilation (IMV) may represent a potentially beneficial approach for sepsis patients [1]. A recent study by Kim et al. [2], published in &lt;i&gt;Critical Care&lt;/i&gt;, provides evidence supporting this approach, reporting that earlier IMV initiation (on the first day of ICU admission) may be associated with lower mortality.&lt;/p&gt;&lt;p&gt;However, in their study, 2,363 patients who never required IMV during their ICU stay were excluded from the analysis. While this approach focuses on patients who received IMV, it may inadvertently select a population with more severe illness for comparison, potentially introducing bias into the results. In clinical practice, a subset of sepsis patients may benefit from a wait-and-see strategy, where intubation is avoided through the use of non-invasive ventilation or other supportive measures, potentially reducing the risks associated with IMV. Excluding these patients from the analysis may have influenced the reported outcomes and the perceived benefits of early IMV.&lt;/p&gt;&lt;p&gt;To better illustrate this issue, we conducted an analysis of sepsis patients using the Medical Information Mart for Intensive Care (MIMIC)-IV database [3] (refer to Additional file 1: Supplemental methods). Among 24,518 ICU patients with sepsis, 12,654 received IMV on the first day of ICU admission (early IMV group). Of the remaining 11,864 patients (non-early IMV group), 1,217 eventually required IMV later during their ICU stay (delayed IMV group), while the rest did not receive IMV during their ICU stay (Additional file 1: Fig. S1).&lt;/p&gt;&lt;p&gt;First, we compared the early IMV group and the non-early IMV group. Propensity score matching (PSM) improved the balance of baseline characteristics between the two groups, achieving an absolute standardized mean difference (SMD) &lt; 0.10 (Additional file 1: Table S1). After matching, the 90-day mortality rate was 23.3% (1,413/6,067) in the early IMV group and 28.5% (1,731/6,067) in the non-early IMV group. The Kaplan–Meier curve for 90-day mortality in the matched cohort is shown in Fig. 1A. Early IMV was associated with lower 90-day mortality in both univariable analysis (hazard ratio [HR], 0.79; 95% confidence interval (CI), 0.74–0.85; &lt;i&gt;P&lt;/i&gt; &lt; 0.001) and multivariable analysis (HR, 0.77; 95% CI, 0.72–0.83; &lt;i&gt;P&lt;/i&gt; &lt; 0.001).&lt;/p&gt;&lt;figure&gt;&lt;figcaption&gt;&lt;b data-test=\"figure-caption-text\"&gt;Fig. 1&lt;/b&gt;&lt;/figcaption&gt;&lt;picture&gt;&lt;source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05208-3/MediaObjects/13054_2024_5208_Fig1_HTML.png?as=webp\" type=\"image/webp\"/&gt;&lt;img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"1097\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05208-3/MediaObjects/13054_2024_5208_Fig1_HTML.png\" width=\"685\"/&gt;&lt;/picture&gt;&lt;p&gt;Kaplan–Meier curves for 90-day mortality based on the timing of IMV in the matched cohort. &lt;b&gt;A&lt;/b&gt; Comparison between the early IM","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"22 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841419","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}

{"title":"Reply to: angiotensinogen: a new era beyond lactate as a biomarker?","authors":"Mark C. Chappell, Christopher L. Schaich, Ashish K. Khanna","doi":"10.1186/s13054-024-05183-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05183-9","url":null,"abstract":"&lt;p&gt;Dear Editor,&lt;/p&gt;&lt;p&gt;We appreciate the comments from Drs. Shen and Ding [1] regarding our brief research report, “&lt;i&gt;Stronger association of intact angiotensinogen with mortality than lactate or renin in critical illness: post-hoc analysis from the VICTAS trial&lt;/i&gt; [2]. Their letter addresses several excellent points about the extent and severity of septic shock in the VICTAS cohort in relation to serum lactate. We agree that the serum levels of lactate were not excessively elevated in our patient population which likely reflects the fact that most of the VICTAS patients were not in severe septic shock. Nonetheless, there was significant mortality in this cohort of sepsis patients that was strongly associated with circulating levels of intact angiotensinogen, suggesting under these conditions that intact angiotensinogen as a biomarker outperformed both renin and lactate according to model performance metrics including area under the curve and the Youden index. Thus, we believe intact angiotensinogen may constitute an additional clinical tool in the care of patients in early sepsis or septic shock. We previously showed that active renin also associated with mortality in this cohort consistent with the recent literature that renin may be a predictor of disease severity that outperforms lactate, as well as a potential indicator for exogenous Ang II treatment to maintain blood pressure and tissue perfusion [3,4,5]. As renin converts angiotensinogen to Ang I and then Ang II through ACE, our results suggest that reduced levels of intact angiotensinogen through excessive renin activity and/or impaired synthesis may also be an indicator of disease severity and may further reveal the need for exogenous Ang II therapy in sepsis patients. The accurate and rapid assessment of plasma Ang II levels is not currently feasible, whereas assay of intact angiotensinogen and active renin or their combination may be a more suitable point-of-care test for critical care patients [2]. We also agree that additional time points in the course of disease are necessary in the assessment of angiotensinogen and other components of the renin–angiotensin–aldosterone system (RAAS) in the critically ill, as well as more detailed assessment of optimal clinical thresholds for each. Indeed, a clinical trial in septic shock patients that directly arose from our present study is currently under way at Wake Forest University School of Medicine that is designed to address several of the issues raised by Drs. Shen and Ding regarding the response of the circulating RAAS and serum lactate.&lt;/p&gt;&lt;p&gt;No datasets were generated or analysed during the current study.&lt;/p&gt;&lt;ol data-track-component=\"outbound reference\" data-track-context=\"references section\"&gt;&lt;li data-counter=\"1.\"&gt;&lt;p&gt;Shen Y, Ding X. Angiotensinogen: a new era beyond lactate as a biomarker? Crit Care. 2024. https://doi.org/10.1186/s13054-024-05164-y.&lt;/p&gt;&lt;p&gt;Article PubMed PubMed Central Google Scholar &lt;/p&gt;&lt;/li&gt;&lt;li data-counter=\"2.\"&gt;&lt;p&gt;Cha","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"36 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142825537","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}

{"title":"REmoval of cytokines during CArdiac surgery (RECCAS): a randomised controlled trial","authors":"Andreas Hohn, Nathalie M. Malewicz-Oeck, Dirk Buchwald, Thorsten Annecke, Peter K. Zahn, Andreas Baumann","doi":"10.1186/s13054-024-05175-9","DOIUrl":"https://doi.org/10.1186/s13054-024-05175-9","url":null,"abstract":"Cardiopulmonary bypass (CPB) triggers marked cytokine release often followed by a systemic inflammatory response syndrome, associated with adverse postoperative outcomes. This trial investigates the intraoperative use of haemoadsorption (HA) during cardiac surgery with CPB to assess its impact on postoperative systemic inflammatory response. In this prospective randomised controlled trial (ethics approval no. 5094-14DRKS00007928), patients (> 65 years) undergoing elective on-pump cardiac surgery were randomised to intraoperative HA (CytoSorb) during CPB or standard care without HA. Primary outcome was the difference in mean interleukin (IL)-6 serum concentrations between groups on intensive care unit (ICU) admission. The secondary outcomes included various clinical and biochemical endpoints. Statistical methods included paired and unpaired t-tests, Wilcoxon, Mann–Whitney U-tests, and chi-square tests. Thirty-eight patients were allocated to receive either intraoperative HA (n = 19) or standard care (n = 19). The primary outcome, IL-6 levels on ICU admission, did not differ between the study group and controls (214.4 ± 328.8 vs. 155.8 ± 159.6 pg/ml, p = 0.511). During surgery pre- versus post-adsorber IL-2, IL-6, IL-8, IL-10, heparan sulfate and myoglobin post- levels were reduced. Furthermore, IL-6 levels did not differ between the study groups on day 1 and 2 in the ICU. While sequential organ failure assessment scores, lactate levels, and C-reactive protein and procalcitonin (PCT) showed no statistically significant differences. Regarding haemodynamic stability in the treatment group the cardiac index (3.2 ± 0.7 vs. 2.47 ± 0.47 l/min/m2, p = 0.012) on ICU day 2 increased, and lower fluid requirements as well as decreased fibrinogen requirement were observed. Need for renal replacement therapy did not differ though a shorter duration was observed in the treatment group. Time on ventilator, respiratory parameters, infectious complications, delirium scores, ICU and hospital lengths of stay, and mortality did not differ between groups. HA did not reduce the IL-6 level on ICU admission or afterwards. Even though HA reduced cytokine load during cardiac surgery in the treatment group. There were no significant differences between groups in the postoperative course of other cytokine concentrations, organ dysfunction, ICU and hospital lengths of stay and mortality rates. Trial registration prospectively DRKS00007928 and published under: Baumann A, Buchwald D, Annecke T, Hellmich M, Zahn PK, Hohn A. RECCAS - REmoval of Cytokines during Cardiac Surgery: study protocol for a randomised controlled trial. Trials. 2016;17: 137. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"20 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142815700","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}