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The uncertainty principle: a novel approach to optimizing trials in critical care. 不确定性原则:优化重症监护试验的新方法。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-11-07 DOI: 10.1097/MCC.0000000000001220
Jacob Vine, Ari Moskowitz, Michael W Donnino
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引用次数: 0
Acute kidney injury subphenotyping and personalized medicine. 急性肾损伤亚表型和个性化医疗。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-13 DOI: 10.1097/MCC.0000000000001212
Melanie Meersch, Timo Mayerhöfer, Michael Joannidis

Purpose of review: This review discusses novel concepts of acute kidney injury (AKI), including subphenotyping, which may facilitate the development of target treatment strategies for specific subgroups of patients to achieve precision medicine.

Recent findings: AKI is a multifaceted syndrome with a major impact on morbidity and mortality. As efforts to identify treatment strategies have largely failed, it is becoming increasingly apparent that there are different subphenotypes that require different treatment strategies. Various ways of subphenotyping AKI have been investigated, including the use of novel renal biomarkers, machine learning and artificial intelligence, some of which have already been implemented in the clinical setting. Thus, novel renal biomarkers have been recommended for inclusion in new definition criteria for AKI and for the use of biomarker bundled strategies for the prevention of AKI. Computational models have been explored and require future research.

Summary: Subphenotyping of AKI may provide a new understanding of this syndrome and guide targeted treatment strategies in order to improve patient outcomes.

综述的目的:本综述讨论了急性肾损伤(AKI)的新概念,包括亚表型,这可能有助于为特定亚组患者制定目标治疗策略,从而实现精准医疗:急性肾损伤是一种多方面的综合征,对发病率和死亡率有重大影响。由于确定治疗策略的努力大多以失败告终,人们越来越清楚地认识到,不同的亚型需要不同的治疗策略。目前已研究出多种对 AKI 进行亚型分型的方法,包括使用新型肾脏生物标志物、机器学习和人工智能,其中一些方法已在临床环境中实施。因此,已建议将新型肾脏生物标志物纳入新的 AKI 定义标准,并使用生物标志物捆绑策略来预防 AKI。小结:对 AKI 进行亚表型分析可使人们对这一综合征有新的认识,并指导有针对性的治疗策略,从而改善患者的预后。
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引用次数: 0
Identifying the high-risk surgical patient. 识别高风险手术病人。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-11-07 DOI: 10.1097/MCC.0000000000001209
Javier Ripollés-Melchor, César Aldecoa
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引用次数: 0
Fluid management of acute kidney injury. 急性肾损伤的输液治疗。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-19 DOI: 10.1097/MCC.0000000000001211
Alison Fahey, Patrick J Neligan, Bairbre McNicholas

Purpose of review: Acute kidney injury (AKI) is commonly encountered in critical care medicine as is intravenous fluid therapy. It is accepted that there is interplay between fluid use and AKI, both potentially positive and negative. An understanding of the physiological rationale for fluid is important to help clinicians when considering fluid therapy in patients with, or at risk for AKI; this includes understanding choice of fluid, method of monitoring, administration and clinical sequelae.

Recent findings: There is increasing interest in combining both static and dynamic measures to assess fluid balance, fluid responsiveness effects of fluid therapy, which are areas requiring ongoing study to translate this theory into clinically useful practice at the bedside. Whilst the debate of choice of crystalloid in ICU practice continues, further evidence for benefits for balanced solutions emerges in the form of international guidelines and patient data meta-analysis of previously performed trials.

Summary: This review assesses the physiological rationale for fluid use in ICU cohorts with AKI of various types, as well as a systematic approach for choice of fluid therapy using a number of different variables, which aims to help guide clinicians in managing fluid use and fluid balance in critically ill patients with AKI.

审查目的:急性肾损伤(AKI)与静脉输液治疗一样,是重症监护医学中经常遇到的问题。输液与急性肾损伤之间存在相互作用,既可能是积极的,也可能是消极的。了解输液的生理原理非常重要,有助于临床医生在考虑对 AKI 患者或有 AKI 风险的患者进行输液治疗;这包括了解输液的选择、监测方法、给药和临床后遗症:人们越来越关注结合静态和动态测量方法来评估液体平衡、液体反应性和液体疗法的效果,这些都是需要持续研究的领域,以便将这一理论转化为床边临床实用实践。虽然在 ICU 实践中关于晶体液选择的争论仍在继续,但国际指南和对之前进行的试验进行的患者数据荟萃分析进一步证明了平衡溶液的益处。摘要:本综述评估了在患有各种类型 AKI 的 ICU 队列中使用液体的生理学原理,以及使用多种不同变量选择液体疗法的系统方法,旨在帮助指导临床医生管理 AKI 重症患者的液体使用和液体平衡。
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引用次数: 0
Developments in the epidemiology of calcium channel blocker poisoning and implications for management. 钙通道阻滞剂中毒流行病学的发展及其对管理的影响。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-25 DOI: 10.1097/MCC.0000000000001218
Michael D Simpson, Jon B Cole

Purpose of review: The aim of this study was to outline recent developments in calcium channel blocker (CCB) poisoning. The dihydropyridine CCB amlodipine is commonly prescribed in the United States, and amlodipine poisoning is increasing in frequency, presenting new challenges for clinicians because current paradigms of CCB poisoning management arose from literature on non-dihydropyridine agents.

Recent findings: Amlodipine is now the most common CCB involved in poisoning. High-dose insulin is a potent inotrope and vasodilator; as such, it should be used cautiously, and typically in conjunction with vasopressors, as it theoretically may worsen vasodilation in amlodipine poisoning. High-dose insulin is best used when some degree of cardiogenic shock is suspected. Venoarterial extracorporeal membrane oxygenation utilization in CCB poisoning appears to be increasing, but high flow rates may be needed to combat amlodipine-induced vasoplegia. Intravenous lipid emulsion cannot be routinely recommended but may have a role in peri-arrest situations. Adjunct treatments such as angiotensin II, methylene blue, and hydroxocobalamin offer theoretical benefit but warrant further study.

Summary: Amlodipine causes most cases of CCB poisoning and can induce both cardiogenic and distributive shock through multiple mechanisms. Clinicians should tailor treatment to suspected shock etiology, be aware of adjunct treatments for refractory shock, and consult an expert in poisoning.

综述目的:本研究旨在概述钙通道阻滞剂(CCB)中毒的最新进展。二氢吡啶类钙通道阻滞剂氨氯地平是美国的常用处方药,氨氯地平中毒的发生率越来越高,这给临床医生带来了新的挑战,因为目前的钙通道阻滞剂中毒处理范例来自于非二氢吡啶类药物的文献:氨氯地平是目前最常见的CCB中毒。大剂量胰岛素是一种强效肌力剂和血管扩张剂,因此应谨慎使用,通常应与血管加压药同时使用,因为理论上它可能会加重氨氯地平中毒患者的血管扩张。当怀疑出现某种程度的心源性休克时,最好使用大剂量胰岛素。静脉体外膜肺氧合在氯苯类药物中毒中的应用似乎正在增加,但可能需要高流速来对抗氨氯地平诱发的血管麻痹。静脉注射脂质乳剂不能作为常规推荐疗法,但可能会在围休克情况下发挥作用。血管紧张素 II、亚甲蓝和羟钴胺等辅助治疗在理论上可提供益处,但仍需进一步研究。总结:氨氯地平可导致大多数 CCB 中毒病例,并可通过多种机制诱发心源性休克和分布性休克。临床医生应根据疑似休克的病因进行治疗,了解难治性休克的辅助治疗方法,并咨询中毒专家。
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引用次数: 0
Advances in critical care nephrology through artificial intelligence. 通过人工智能推进重症肾病学的发展。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-08-30 DOI: 10.1097/MCC.0000000000001202
Wisit Cheungpasitporn, Charat Thongprayoon, Kianoush B Kashani

Purpose of review: This review explores the transformative advancement, potential application, and impact of artificial intelligence (AI), particularly machine learning (ML) and large language models (LLMs), on critical care nephrology.

Recent findings: AI algorithms have demonstrated the ability to enhance early detection, improve risk prediction, personalize treatment strategies, and support clinical decision-making processes in acute kidney injury (AKI) management. ML models can predict AKI up to 24-48 h before changes in serum creatinine levels, and AI has the potential to identify AKI sub-phenotypes with distinct clinical characteristics and outcomes for targeted interventions. LLMs and generative AI offer opportunities for automated clinical note generation and provide valuable patient education materials, empowering patients to understand their condition and treatment options better. To fully capitalize on its potential in critical care nephrology, it is essential to confront the limitations and challenges of AI implementation, including issues of data quality, ethical considerations, and the necessity for rigorous validation.

Summary: The integration of AI in critical care nephrology has the potential to revolutionize the management of AKI and continuous renal replacement therapy. While AI holds immense promise for improving patient outcomes, its successful implementation requires ongoing training, education, and collaboration among nephrologists, intensivists, and AI experts.

综述的目的:这篇综述探讨了人工智能(AI),尤其是机器学习(ML)和大型语言模型(LLM)的变革性进步、潜在应用和对重症肾脏病学的影响:人工智能算法已证明有能力加强早期检测、改善风险预测、个性化治疗策略,并支持急性肾损伤(AKI)管理的临床决策过程。ML 模型可在血清肌酐水平变化前 24-48 小时预测 AKI,而人工智能则有可能识别出具有不同临床特征和结果的 AKI 亚型,从而进行有针对性的干预。LLM 和生成式人工智能为自动生成临床笔记提供了机会,并提供了宝贵的患者教育材料,使患者能够更好地了解自己的病情和治疗方案。要充分发挥人工智能在重症肾脏病学中的潜力,必须正视人工智能实施过程中的局限性和挑战,包括数据质量问题、伦理考虑以及严格验证的必要性。虽然人工智能在改善患者预后方面大有可为,但其成功实施需要持续的培训、教育以及肾脏病专家、重症监护专家和人工智能专家之间的合作。
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引用次数: 0
Cardiac arrest and microcirculatory dysfunction: a narrative review. 心脏骤停与微循环功能障碍:叙述性综述。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-27 DOI: 10.1097/MCC.0000000000001219
Max S Kravitz, John H Lee, Nathan I Shapiro

Purpose of review: This review provides an overview of the role of microcirculation in cardiac arrest and postcardiac arrest syndrome through handheld intravital microscopy and biomarkers. It highlights the importance of microcirculatory dysfunction in postcardiac arrest outcomes and explores potential therapeutic targets.

Recent findings: Sublingual microcirculation is impaired in the early stage of postarrest and is potentially associated with increased mortality. Recent work suggests that the proportion of perfused small vessels is predictive of mortality. Microcirculatory impairment is consistently found to be independent of macrohemodynamic parameters. Biomarkers of endothelial cell injury and endothelial glycocalyx degradation are elevated in postarrest settings and may predict mortality and clinical outcomes, warranting further studies. Recent studies of exploratory therapies targeting microcirculation have shown some promise in animal models but still require significant research.

Summary: Although research continues to suggest the important role that microcirculation may play in postcardiac arrest syndrome and cardiac arrest outcomes, the existing studies are still limited to draw any definitive conclusions. Further research is needed to better understand microcirculatory changes and their significance to improve cardiac arrest care and outcomes.

综述的目的:本综述通过手持式体内显微镜和生物标志物概述了微循环在心脏骤停和心脏骤停后综合征中的作用。它强调了微循环功能障碍在心脏骤停后结果中的重要性,并探讨了潜在的治疗目标:最近的研究结果:在心跳骤停后的早期阶段,舌下微循环受损,可能与死亡率增加有关。最近的研究表明,灌注小血管的比例可预测死亡率。微循环损伤一直与宏观血流动力学参数无关。内皮细胞损伤和内皮糖萼降解的生物标志物在心搏骤停后升高,可预测死亡率和临床结果,值得进一步研究。最近针对微循环的探索性疗法的研究在动物模型中显示出一定的前景,但仍需要大量的研究。总结:尽管研究继续表明微循环可能在心脏骤停后综合征和心脏骤停预后中扮演重要角色,但现有的研究仍然有限,无法得出任何明确的结论。要更好地了解微循环变化及其对改善心脏骤停护理和预后的意义,还需要进一步的研究。
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引用次数: 0
New drugs on the horizon for acute kidney injury. 治疗急性肾损伤的新药即将问世。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-20 DOI: 10.1097/MCC.0000000000001217
Louis Mourisse, Peter Pickkers

Purpose of review: Acute kidney injury (AKI) is a frequent and serious complication in critically ill patients. Currently, no effective therapy to prevent or treat AKI is available. This review highlights recently published developments on pharmacological treatments that aim to prevent AKI or to alleviate the severity of AKI in critical ill patients.

Recent findings: Studies on pharmacological interventions aimed to improve hemodynamics, renal perfusion, to mediate inflammation-associated renal damage and to reduce oxidative stress are presented, including several observational studies and randomized trials focused on the potential renal protective effects in relevant patient populations. Different existing and novel compounds are being investigated for the effects on renal endpoints and several show potential to prevent or alleviate the occurrence of AKI. It is now acknowledged that different underlying pathophysiological processes are relevant in the development of AKI. Recognition of these sub-endotypes of AKI and knowledge of the therapeutic target of different compounds is of paramount importance to select the right patient for the right treatment at the right time.

Summary: The discovery of reno-protective therapies is hampered by the timely detection and recognition of the overriding mechanism of AKI. Nevertheless, several compounds are under investigation, which hold promise for a future treatment.

审查目的:急性肾损伤(AKI)是危重病人常见的严重并发症。目前,尚无预防或治疗急性肾损伤的有效疗法。本综述重点介绍了近期发表的旨在预防危重病人急性肾损伤或减轻其严重程度的药理治疗进展:本文介绍了旨在改善血液动力学、肾脏灌注、介导炎症相关性肾损伤和减少氧化应激的药理干预研究,其中包括几项观察性研究和随机试验,这些研究的重点是在相关患者群体中发挥潜在的肾脏保护作用。目前正在研究不同的现有化合物和新型化合物对肾脏终点的影响,其中一些化合物显示出预防或缓解 AKI 发生的潜力。现在人们已经认识到,不同的潜在病理生理过程与 AKI 的发生有关。识别 AKI 的这些亚内型并了解不同化合物的治疗靶点,对于在正确的时间选择正确的患者进行正确的治疗至关重要。摘要:及时发现和识别 AKI 的主要机制阻碍了肾脏保护疗法的发现。尽管如此,仍有几种化合物正在研究之中,有望成为未来的治疗方法。
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引用次数: 0
Editorial introductions. 编辑介绍。
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-11-07 DOI: 10.1097/MCC.0000000000001222
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引用次数: 0
Cerebral oximetry in high-risk surgical patients: where are we? 高危手术患者的脑氧饱和度:我们进展到哪里了?
IF 3.5 3区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-12-01 Epub Date: 2024-09-04 DOI: 10.1097/MCC.0000000000001204
Rosalia Navarro-Perez, Nekane Romero-García, Camilla Paolessi, Chiara Robba, Rafael Badenes

Purpose of review: This review aims to summarize the latest evidence on the role of near-infrared spectroscopy (NIRS) in monitoring cerebral oxygenation in high-risk surgical patients, including both cardiac and noncardiac surgeries, and to present a new algorithm for its application.

Recent findings: NIRS effectively measures brain oxygen saturation noninvasively, proving valuable in cardiac surgeries to reduce neurological complications, though its impact on nonneurological outcomes is less clear. In noncardiac surgeries, NIRS can help prevent complications like postoperative cognitive dysfunction, particularly in high-risk and major surgeries. Studies highlight the variability of cerebral oxygenation impacts based on surgical positions, with mixed results in positions like the beach chair and sitting positions. A structured algorithm for managing cerebral desaturation has been proposed to optimize outcomes by addressing multiple factors contributing to blood oxygen content and delivery.

Summary: Despite its limitations, including spatial resolution and interindividual variability, NIRS is a useful tool for intraoperative cerebral monitoring. Further studies are needed to confirm its broader applicability in noncardiac surgeries, but current evidence supports its role in reducing postoperative complications especially in cardiac surgeries.

综述目的:本综述旨在总结近红外光谱(NIRS)在高风险手术患者(包括心脏和非心脏手术)脑氧饱和度监测中的作用的最新证据,并提出一种新的应用算法:最近的研究结果:近红外成像技术能有效测量无创的脑氧饱和度,在心脏手术中对减少神经系统并发症很有价值,但对非神经系统结果的影响还不太清楚。在非心脏手术中,近红外成像技术有助于预防术后认知功能障碍等并发症,尤其是在高风险和重大手术中。研究强调了手术体位对脑氧饱和度影响的差异性,沙滩椅和坐姿等体位的结果不一。总结:尽管存在空间分辨率和个体间变异性等局限性,近红外成像仍不失为术中脑部监测的有用工具。需要进一步的研究来确认其在非心脏手术中的广泛适用性,但目前的证据支持其在减少术后并发症方面的作用,尤其是在心脏手术中。
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引用次数: 0
期刊
Current Opinion in Critical Care
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