Current Opinion in Critical Care最新文献

Purpose of review: The purpose of this review is to summarize the current evidence in the treatment of patients with cardiogenic shock focusing on the use of microaxial flow pump (mAFP) support.

Recent findings: In recent years, the use of mAFP for the treatment of patients with cardiogenic shock has increased. This review summarizes the most important studies on this topic from recent years with a focus on patients with ST-elevation myocardial infarction-related cardiogenic shock (STEMI-CS).

Summary: Based on the results of a recently published randomized trial (DanGer Shock study), it is essential for clinical practice to carry out a differentiated patient selection to achieve a survival benefit. Specifically, according to the current findings, patients with STEMI-CS, intact right ventricular function, and a low probability of hypoxic brain damage appear to benefit most from treatment with mAFP. A subgroup analysis also suggests a benefit to patients younger than 77 years old.

Purpose of review: The increasing use of prone position, in intubated patients with acute respiratory distress syndrome as well as in patients with acute hypoxemic respiratory failure receiving noninvasive respiratory support, mandates a better definition and monitoring of the response to the manoeuvre. This review will first discuss the definition of the response to prone positioning, which is still largely based on its effect on oxygenation. We will then address monitoring respiratory and hemodynamic responses to prone positioning in intubated patients. Finally, we will also discuss monitoring inspiratory effort in nonintubated patients with acute hypoxemic respiratory failure who breathe spontaneously and receive noninvasive respiratory support.

Recent findings: The response to prone positioning should be enriched by data pertaining to lung protection beyond oxygenation. These include trans-pulmonary pressure, driving pressure, mechanical power, distribution of aeration and ventilation and assessment of potential for lung recruitment before the pronation.

Summary: The implications of present findings are to: better select those patients who will benefit from proning in physiological terms, better indicate the timing of onset and end of the sessions, and strengthen the relationship between physiological response and patient outcome.

Purpose of review: Recognition of firearm injury as a public health challenge increasingly garners mainstream acceptance, accompanied by increased federal funding for firearm research and federal coordination for firearm injury prevention and response. This review summarizes recent developments relevant to firearm injury epidemiology, prevention, and outcomes.

Recent findings: Interpersonal firearm violence reached a 30-year peak during the COVID-19 pandemic, but the last 2 years have indicated some improvement. Here, we offer updates regarding firearm injury epidemiology, including disparities according to race, ethnicity, age, sex, and geography. This review summarizes recent literature on risk and protective factors for firearm injury, including aspects related to existing or emerging public policy. New data on the long-term costs and outcomes of firearm injury show pervasive effects, while studies on violence intervention programming, mental health interventions, and coordinated care for survivors of injury offer the potential to improve patient recovery. Lastly, enhanced firearm data infrastructure may yield higher quality research and enable more effective prevention and recovery interventions.

Summary: Recent findings underscore the multifactorial contributors to the far-reaching public health challenge of firearm injury. Clinicians, researchers, and policy makers must appreciate both the acute and long-term broad consequences of this epidemic to develop, deploy, and evaluate effective interventions to reduce firearm injury harm.

Purpose of review: This review explores advances in risk stratification tools and their applicability in identifying and managing high-risk emergency general surgery (EGS) patients.

Recent findings: Traditional risk assessment tools have several limitations when applied to complex EGS patients as comorbidities are generally treated in a binary, linear and sequential fashion. Additionally, some tools are only usable in the postoperative period, and some require multidisciplinary involvement and are not suitable in an emergency setting. Frailty in particular - for which there are multiple calculators-maladaptively influences outcomes. Artificial intelligence tools, such as the machine-learning-based POTTER calculator, demonstrate superior performance by addressing nonlinear interactions among patient factors, offering a dynamic and more accurate approach to risk prediction.

Summary: Integrating advanced, data-driven risk assessment tools into clinical practice can help identify and manage high-risk patients as well as forecast outcomes for EGS patients. Such tools are intended to trigger preoperative interventions as well as discussions that ensure goal-concordant care, align expectations with anticipated outcomes and support both facility and patient-relevant outcomes.

Purpose of review: This study aims to examine the ethical and legal discourse surrounding normothermic regional perfusion (NRP) for donation after circulatory death (DCD).

Recent findings: NRP is well established within Europe but faces challenges in the US and is not utilized in a variety of other countries. NRP compliance with the dead donor rule (DDR) and Uniform Declaration of Death Act (UDDA) is the most significant recently addressed US ethical and legal issue. Additionally, NRP procedures raise concerns regarding public education, informed consent, public engagement, and trust. Inconsistent NRP regulation - such as in the US- is a cause for concern with the anticipated increase in NRP frequency in support of organ recovery and transplantation. There is no single repository for NRP technical and outcome data to support practice refinement - a key aspect given practice variation between centers and countries.

Summary: NRP-based organ recovery presents ethical and legal challenges to be addressed by organ donation and transplantation clinicians and organizations in conjunction with public representatives. Additional inquiry into the determination of donor circulatory death, family information needs for authorization, and coordinated regulation of NRP practice is needed to ensure that ethical and legal concerns are appropriately addressed. Public engagement is essential to bolster and preserve trust.

Purpose of review: This review will explore acute rib fracture management focusing on indications and timing for acute surgical stabilization of rib fractures (SSRF).

Recent findings: SSRF is a well tolerated and effective approach for a variety of rib fracture patterns and is most commonly used to correct either clinical flail chest or multiple displaced fractures. Objective tools that assess for deranged pulmonary dynamics may identify patients with other fracture patterns who will also benefit from SSRF. Multimodal analgesia approaches are essential regardless of whether SSRF is pursued; intractable pain may also prompt SSRF. Hemodynamic instability precludes acute SSRF. Otherwise, SSRF should occur within 72 h of injury. Preoperative planning includes thoracic computed tomography scanning, and a preanesthetic evaluation, especially in the geriatric patient based on the presence of comorbidities. Preoperative coordination with other services that also need to address acute injuries helps condense anesthesia exposures. Acute SSRF reduces pain and in particular pulmonary complications in those with acute rib fractures.

Summary: SSRF is a well tolerated and effectively acutely deployed operative technique to address specific rib fracture injury patterns. It is ideally embraced as a structured program to facilitate collaboration, coordination, and program performance evaluation.

Purpose review: To discuss the hemodynamic monitoring techniques to quantify cardiac output, to assess the adequacy of perfusion, and to evaluate cardiac as well as pump preload and fluid responsiveness in patients supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Echocardiography is essential in the hemodynamic assessment of VA-ECMO patients. However, intermittent echocardiography should be complemented by continuous, potentially nurse driven, monitoring techniques. We will focus on invasive and noninvasive hemodynamic monitoring methods beyond echocardiography.

Recent findings: Despite the importance of comprehensive hemodynamic monitoring in the provision of safe, adequate, and well balanced VA-ECMO support, limited data are currently available in this specific patient population. While some measurements (intravascular pressures, oxygen saturation) remain valid and provide important information on the hemodynamic state, measurements of cardiac output are invalid with many of the hemodynamic monitoring methods. Many of the routinely used monitoring methods must be interpreted with caution during VA-ECMO support.

Summary: A thorough understanding of the various hemodynamic monitoring methods and the physiological interactions between VA-ECMO and patients is essential for selecting the optimal hemodynamic monitoring strategy and correctly interpreting the resulting hemodynamic measurements.

Purpose of review: This review aims to provide a perspective on fluid resuscitation strategies and emerging trends in deresuscitation, with a particular emphasis on fluid stewardship, monitoring, and personalized fluid management.

Recent findings: Recent studies underscore a paradigm shift in resuscitation strategies. Notably, aggressive plasma volume expansion has been linked to higher morbidity and mortality, favoring conservative fluid resuscitation. Dynamic parameters, such as pulse pressure variation (PPV) and stroke volume variation (SVV) outperform static markers like central venous pressure (CVP) in predicting preload responsiveness. Advances in hemodynamic monitoring and automated closed-loop fluid administration demonstrate efficacy in optimizing resuscitation. Fluid stewardship, supported by machine learning, is reshaping deresuscitation practices, and promoting negative fluid balance to reduce complications. Moreover, next-generation closed-loop systems and fluid management personalization as part of precision medicine are emerging as future directions.

Summary: Advances in fluid resuscitation challenge traditional practices, with evidence favoring personalized and goal-directed strategies. Technological innovations in hemodynamic monitoring, automated fluid control, and machine learning are driving precision fluid management. Fluid stewardship and deresuscitation aim to mitigate fluid accumulation syndrome and improve patient outcomes.

Purpose of review: Venovenous extracorporeal membrane oxygenation (VV-ECMO) provides gas exchange for patients with advanced respiratory failure who cannot maintain adequate oxygenation or carbon dioxide (CO 2 ) clearance through conventional mechanical ventilation. This review examines clinical applications of VV-ECMO with a focus on optimizing oxygen delivery and CO 2 removal.

Recent findings: Over the past two decades, VV-ECMO utilization has expanded, now serving as a bridge to recovery in cases of severe hypoxemic and hypercapnic respiratory failure, as procedural support, and as a bridge to lung transplantation. Recent data have corroborated the role of VV-ECMO in managing acute respiratory distress syndrome (ARDS), and guidelines from the American Thoracic Society (ATS) and the European Society of Intensive Care Medicine (ESICM) now recommend it be considered for severe ARDS.

Summary: This review aims to provide insights into the evolving role of VV-ECMO in the management of critical respiratory failure. Key determinants of oxygenation are discussed, particularly optimizing the ratio of VV-ECMO blood flow to cardiac output (CO). We analyze factors influencing CO 2 clearance and review available VV-ECMO configurations and their effects on gas exchange. We discuss practical targets for oxygenation and CO 2 removal in VV-ECMO, along with adjunctive techniques for refractory hypoxemia and hypercapnia.