Current Opinion in Critical Care最新文献

Purpose of review: Acute mesenteric ischaemia is an uncommon but often fatal condition frequently requiring intensive care management. This review discusses the multidisciplinary management of subtypes of acute mesenteric ischaemia, emphasizing the specific challenges of nonocclusive mesenteric ischaemia (NOMI) in the ICU.

Recent findings: While multidisciplinary approach and early revascularisation have improved outcomes in arterial occlusive acute mesenteric ischaemia, diagnostic and therapeutic strategies for NOMI remain challenging. Similarities and differences in diagnosis and management of patients with NOMI and of occlusive subtypes of acute mesenteric ischaemia are outlined. In the absence of evidence, we suggest that optimizing hemodynamic stability, with a focus on achieving euvolemia, maintaining adequate cardiac output and ensuring adequate vascular tone, may help prevent or limit nonocclusive bowel ischemia. Equally important is treating the underlying cause of hemodynamic instability (such as sepsis, cardiac dysfunction or hypovolemia). In patients admitted to ICU after revascularisation and/or bowel resection, limitation of progression of intestinal damage is the target, while addressing progression of bowel necrosis when it occurs, requires well established multidisciplinary teamwork.

Summary: Managing acute mesenteric ischaemia in the ICU extends beyond restoring mesenteric blood flow, it requires simultaneous correction of the systemic insult driving and/or driven by ischemia, and timely surgical intervention both when bowel viability is salvageable or already lost. Different subtypes of acute mesenteric ischaemia have some differences in diagnosis and management.

Purpose of review: To summarize the emerging paradigm of acute coronary occlusion myocardial infarction (OMI), with a practical overview of clinical assessment, ECG advances, and the role of bedside echocardiography and troponin.

Recent findings: ST-elevation MI (STEMI) millimeter criteria are a poor surrogate marker for OMI, with high rates of false positives (STE without OMI) and false negatives (OMI without STE). The OMI paradigm shift maximizes the capabilities of the ECG while putting these findings into clinical context. OMI is a clinical diagnosis that starts with assessment for anginal symptoms, whether they are continuous or resolved, and whether the patient is stable or unstable. Evidence-based ECG advances have addressed multiple diagnostic dilemmas in the STEMI paradigm to identify false positive and subtle occlusions. OMI ECG signs double the sensitivity of STEMI criteria, maintain high specificity, and can be learned by AI. Regional wall motion abnormalities on bedside ultrasound can complement clinical and ECG signs. The initial troponin has limited sensitivity and predictive value in OMI.

Summary: The OMI paradigm shift uses clinical features, ECG/POCUS findings and judicious use of troponin to identify patients in need of emergent reperfusion.

Purpose of review: Acute heart failure (AHF) is a frequent, high-risk emergency department presentation in which early diagnostic and therapeutic decisions strongly influence outcomes. This review is timely as new evidence is reshaping the first hours of care, requiring emergency department clinicians to integrate updated diagnostic tools and early guideline-directed treatments.

Recent findings: Key diagnostic advances include broader use of cardiopulmonary ultrasound and emerging biomarker-based, machine-learning tools. Noninvasive ventilation remains preferred for severe respiratory distress, while high-flow nasal cannula is widely used despite neutral comparative data. Diuretic strategies are evolving, with natriuresis-guided protocols and combination regimens enhancing decongestion. Vasodilators retain a role in hypertensive AHF. In cardiogenic shock, early inotrope initiation may improve survival, and new agents such as istaroxime show promising hemodynamic effects. Additional emergency department strategies include midazolam for agitation, intravenous iron for iron deficiency, and cautious anti-inflammatory use. Avoiding iatrogenesis - particularly urinary catheterization and prolonged boarding - is crucial, especially in frail patients. Very early initiation of guideline-directed medical therapy, including SGLT2 inhibitors, is increasingly supported. Risk-based disposition using tools such as EHMRG or MEESSI-AHF, combined with structured follow-up, can improve postdischarge outcomes.

Summary: Integrating these advances may optimize early emergency department management, personalize care, and improve outcomes in AHF.

Purpose of review: Our population is ageing and this is driving rising emergency department (ED) attendances and critical care use. Frailty, not age, is the key predictor of outcomes and brings complex, multidimensional needs. However, emergency care systems were designed around single-issue presentations. This review highlights why frailty-attuned emergency care is timely and relevant, and examines evolving approaches aimed at improving person-centred outcomes.

Recent findings: Frailty affects a substantial proportion of ED patients and is associated with poorer outcomes including mortality, longer stays, and higher admission rates. Meaningful outcomes prioritize quality rather than necessarily longevity of life. Geriatric emergency medicine promotes holistic assessment, multidisciplinary involvement, and goal-oriented care, but many centres are still being reconfigured to provide for this. Meanwhile, systems can work to implement frailty screening and attuned triage, encouraging use of person-centred and pragmatic approaches based on shared decision-making to support appropriate resource use and alignment of care with patient values.

Summary: Frailty-attuned geriatric emergency care involves cohort identification, broadened assessment, and goal-based person-centred decision-making. These principles can be integrated as the basis for meaningfully grounded quality improvement and service design.

Purpose of review: Liver dysfunction is a frequent yet underrecognized feature of critical illness, affecting up to 20-40% of ICU patients. Even mild abnormalities in liver function tests are associated with increased morbidity, prolonged ICU stay, and higher mortality. Hepatic dysfunction may be the primary reason for ICU admission or develop during the ICU stay. Its clinical presentation is broad, ranging from abnormal liver function tests due to sepsis, drug toxicity, or hypoxia during critical illness, to acute liver failure in previously healthy individuals, and acute-on-chronic liver failure in patients with preexisting liver disease.

Recent findings: Recent advances highlight the importance of dynamic liver function testing, such as indocyanine green clearance, in early detection and prognostication. Moreover, evolving concepts around acute-on-chronic liver failure (ACLF) emphasize its systemic nature and the need for timely intervention, including liver support therapies and transplantation. Understanding the interplay between hepatic dysfunction and multiorgan failure is essential for improving outcomes in this vulnerable population.

Summary: This review highlights recent advances in understanding into the mechanisms, diagnosis, and management of liver dysfunction in critically ill patients, with a particular emphasis on ACLF.

Purpose of review: The vast majority of severe traumatic brain injury (TBI) patients are managed in regions of low resources. Intracranial pressure (ICP) monitoring is, therefore, uncommon. There is insufficient literature to support evidence-based algorithm construction. We here explore current validated models for sTBI management in the absence of ICP monitoring.

Recent findings: Prospective trials in LMICs used ad hoc management algorithms for nonmonitored sTBI patients. Subsequent comparison of outcomes employing these algorithms against nonprotocolized care supported benefits from protocolization. Subsequent prospective validation testing of a consensus-based elaboration of ad hoc protocols into a comprehensive management (Consensus-Revised Imaging and Clinical Examination: CREVICE) approach demonstrated the benefits of protocolization on outcome and supported the efficacy of the CREVICE approach. Although at present the only prospectively validated sTBI management algorithm, its applicability is yet limited in generalizability due to resource requirements. Additionally, possible incorporation of noninvasive methods as potential guides for ICP care absent the currently invasive techniques remains untested.

Summary: Patients with sTBI in the aggregate can be effectively managed when ICP monitoring is not available using currently available validated algorithms. Efficacy in sTBI subgroups (e.g. established intracranial hypertension) is unexplored. Research into noninvasive ICP monitoring and further diminishing resources requirements is necessary.

Purpose of review: This article provides an overview of intestinal transplantation, focusing on perioperative management and the recognition and treatment of complications in the intensive care unit. The review aims to update intensivists with a comprehensive understanding of the care of intestinal transplant recipients.

Recent findings: Despite advances in immunosuppression, donor graft preparation, perioperative care, and the management of complications such as rejection, graft-versus-host disease, and infection, graft and patient survival rates following intestinal transplantation have not improved over the past decade and remain inferior to those of other solid organ transplants. Although surgical techniques have largely remained unchanged, some transplant centers have reported performing intestinal transplantation without a stoma and utilizing preoperative embolization in selected cases.Recent updates in maintenance immunosuppression include the expanded use of less commonly employed agents as part of multimodal regimens such as mammalian target of rapamycin inhibitors and antimetabolites as well as the introduction of therapies not traditionally used for maintenance, including costimulatory blockade, interleukin-2 receptor blockade, and vedolizumab.

Summary: In recipients of intestinal transplants, prompt identification of infections and complications such as rejection, posttransplant lymphoproliferative disorder, and graft-versus-host disease is essential. Early recognition and intervention are critical to preserving graft function and improving overall survival. Effective management of these perioperative challenges requires a multidisciplinary team approach, with intensivists playing a central role in achieving optimal outcomes.

Purpose: Portopulmonary hypertension (PoPH) and hepatopulmonary syndrome (HPS) are two pulmonary vascular diseases, that occur in the context of liver disease, with high morbidity and mortality. The mechanistic link between liver and lung that drives disease pathogenesis in these conditions is not well understood, and although liver transplantation offers benefit for both PoPH and HPS, posttransplant consequences can be severe and result in critical illness.

Recent findings: Though the mechanisms of PoPH are still obscure, recent work has identified a deficiency of bone morphogenetic protein type 9 as a key characteristic that may drive pulmonary vascular remodeling in HPS. Although it is well established that liver transplantation is beneficial in select PoPH patients, the new ILTS guidelines specify updated pulmonary hemodynamic criteria to determine suitability for transplantation in PoPH.

Summary: Targeted pulmonary hypertension therapy is still the cornerstone of management in PoPH. In lieu of liver transplantation in HPS, supplemental oxygen remains the only therapy with proven clinical benefit. Posttransplant critical illness can occur in both PoPH and HPS, through mechanisms that are incompletely understood, with severe consequences for patient survival. Further work understanding PoPH and HPS is necessary to meaningfully improve patient outcomes in these devastating conditions.

Purpose of review: To discuss the optimal renal care for critically ill patients.

Recent findings: For hemodynamic optimization, balanced crystalloids are generally preferred over normal saline, except in patients with traumatic brain injury. A restrictive fluid management strategy may be considered in patients with advanced chronic kidney disease or those on dialysis. Norepinephrine is generally the first-line vasopressor, while the roles of vasopressin and angiotensin II are under investigation. The timing of dialysis initiation should be personalized, balancing the benefits of renal support with the risks of dialytrauma. Continuous renal replacement therapy may be preferred over conventional hemodialysis in patients with hemodynamic instability or intracranial hypertension. Optimal UFNET rates range between 1.0 and 1.5 ml/kg/h. Liberation from dialysis should be actively considered in patients showing signs of renal recovery. The risk of drug-induced acute kidney injury may be mitigated through nephrotoxin stewardship. Multidisciplinary collaboration and clinical decision support systems are key approaches. Integrating novel biomarkers and artificial intelligence into patient care is a promising strategy for achieving precision medicine.

Summary: Optimal renal care in critically ill patients is a holistic approach that considers hemodynamics, fluid therapy, administration of vasoactive agents, kidney replacement therapy, medication stewardship, and innovative advances.

Purpose of review: Acute kidney injury (AKI) remains a major challenge in critical care, with high morbidity and mortality. This review aims to highlight existing and upcoming tools to integrate macrocirculatory and microcirculatory perspectives to better understand and prevent AKI.

Recent findings: Hemodynamic optimization after initial resuscitation is currently based on central hemodynamic measurement of arterial/venous pressure and cardiac output, although they do not correlate well with kidney hemodynamics. Bedside ultrasound techniques, particularly contrast-enhanced ultrasound (CEUS), have uncovered impaired renal perfusion even when systemic flow appears adequate. Emerging high-frame-rate and super-resolution ultrasound methods promise to visualize renal microvessels at micrometer scales enabling true assessment of the microcirculation. Furthermore, urinary partial oxygen pressure monitoring provides continuous insight into medullary hypoxia. These diagnostics can be combined with biological phenotyping to define treatable AKI sub-phenotypes.

Summary: The integration of multimodal hemodynamic monitoring holds promise for identifying actionable AKI sub-phenotypes and guiding precision therapies. Future clinical trials should incorporate mechanistic endpoints from both the macrocirculatory and microcirculatory domains to improve our understanding of treatment effects, optimize trial design, and ultimately enhance patient outcomes in this high-risk population.