Current Opinion in Critical Care最新文献

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 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: To examine the role of echocardiography in managing patients with refractory cardiogenic shock supported by temporary mechanical circulatory support (t-MCS) and provide practical recommendations to improve clinical practice.

Recent findings: t-MCS devices are increasingly used to stabilize patients with refractory cardiogenic shock. Echocardiography, due to its accessibility and ability to assess both structural and functional aspects of heart failure, is ideally suited for daily bedside evaluation of cardiac function and t-MCS-myocardial interactions.

Summary: From t-MCS initiation to liberation, echocardiography is essential to guide clinical decision-making. It aids in selecting the most appropriate t-MCS device, ensuring optimal positioning, and fine-tuning flow parameters in real-time based on native cardiac function and patient needs. Additionally, echocardiography is critical for identifying intracardiac complications and directing unloading strategies in venoarterial extracorporeal membrane oxygenation, particularly with very low residual ejection or aortic valve closure. Finally, the weaning process should be informed by comprehensive echocardiographic evaluations, aligned with international guidelines. These steps are outlined in this review, accompanied by clear and practical recommendations to enhance clinical practice.

Purpose of review: This review is both timely and relevant as the open abdomen approach to manage injury, emergency general surgery (EGS) conditions, as well as secondary intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) remain prevalent throughout ICUs.

Recent findings: IAH is not limited to those with injury or EGS conditions, as it is increasingly recognized following cardiac surgery as well as cardiac transplantation. IAH monitoring techniques benefit from technological advances including noninvasive devices. Time to primary fascial closure (PFC) is a key determinant of patient-centered outcomes, with worse outcomes in those with delayed or failed closure attempts. Visceral edema avoidance or mitigation techniques remain controversial. Nutrition support and its impact on the gastrointestinal microbiome appear to influence infection risk and anastomotic integrity. Team-based approaches to successful as well as failed open abdomen management help optimize outcomes.

Summary: These findings bear broad implications for intensive care medicine clinicians who care for open abdomen patients, as they address resuscitation, intra-abdominal pressure monitoring, and nutrition support all of which influence the likelihood of achieving PFC - a key goal regardless of whether the abdomen was initially left open after injury, EGS, or intestinal ischemia management.

Purpose of review: This review highlights brain-gut neuroimmune interactions in the context of critical illness. Neural regulation of inflammation, gut innervation, and the brain-gut axis in critical illness are discussed.

Recent findings: Recent studies indicate that the brain-gut axis and the enteric nervous system are integral to the regulation of local and systemic inflammation. Experimental evidence suggests that neural reflexes control immune responses, and specific neural signals promote gastrointestinal homeostasis. The understanding of these interactions in the clinical context remains limited, necessitating further investigation. Notably, therapeutic interventions targeting neuro-immune pathways have shown promise in preclinical models, suggesting that a better understanding of the neuro-immune crosstalk in the critically ill may potentially identify novel therapeutic targets.

Summary: Critical illness involves complex organ dysfunction, not least in the gastrointestinal system. A multitude of neuroimmune interactions between the intestinal wall, immune cells, peripheral nerves and the central nervous system regulate inflammation. While experimental evidence supports the role of neural reflexes in controlling immune responses, clinical validation is lacking in the context of critical care. Future research needs to explore whether specific neural signals or mechanisms of neuro-immune crosstalk can be harnessed to restore and support gastrointestinal homeostasis in the critically ill.

Purpose of review: To review the time dependent nature of postcardiac arrest brain injury (PCABI) while contextualizing clinical trial evidence.

Recent findings: PCABI represents a dynamic entity with respect to its pathophysiology. Intuitively, PCABI pathophysiology has been characterized focusing on mechanisms associated with cerebral ischemia. Interventions that augment cerebral oxygen delivery, such as increasing mean arterial pressure, have garnered interest. Regrettably, these trials have not demonstrated improved outcomes. At the core of this conundrum is the time dependent nature of PCABI pathophysiology with trials employing interventions approximately 4-6 h after return of spontaneous circulation (ROSC). This therapeutic window is likely far past the efficacy period of resumption of oxygen delivery to the ischemic brain. Thus, we suggest compartmentalizing PCABI into four phases: circulatory arrest; intra-arrest physiology; immediate reperfusion; and delayed reperfusion. Culprit mechanisms are discussed for each phase with contextualization of recent trial results.

Summary: PCABI has dynamic pathophysiology and restoration of cerebral oxygen delivery in a delayed manner from ROSC has diminished efficacy. PCABI pathophysiology must be viewed in a time dependent manner and interventions aimed at restoring cerebral oxygen delivery are likely only to be efficacious if applied immediately after ROSC.

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: To summarize the rationale and concepts for positive end-expiratory pressure (PEEP) setting with electrical impedance tomography (EIT) and the effects of EIT-based PEEP setting on cardiopulmonary function.

Recent findings: EIT allows patient-specific and regional assessment of PEEP effects on recruitability and overdistension, including its impact on ventilation-perfusion (V̇/Q) mismatch. The overdistension and collapse (OD-CL) method is the most used EIT-based approach for PEEP setting. In the RECRUIT study of 108 COVID-19 ARDS patients, the PEEP level corresponding to the OD-CL crossing point showed low overdistension and collapse (below 10% and 5%, respectively) regardless of recruitability. In a porcine model of acute respiratory distress syndrome (ARDS), it was shown that at this crossing point, respiratory mechanics (compliance, ΔP) were consistent, with adequate preload, lower right ventricular afterload, normal cardiac output, and sufficient gas exchange. A recent meta-analysis found that EIT based PEEP setting improved lung mechanics and potentially outcomes in ARDS patients. EIT thus provides critical insights beyond respiratory mechanics and oxygenation for individualized PEEP optimization. EIT-based methods for PEEP setting during assisted ventilation have also been proposed.

Summary: EIT is a valuable technique to guide individualized PEEP setting utilizing cardiopulmonary information that is not captured by respiratory mechanics and oxygenation response alone.

Purposes of review: Critically ill patients frequently require mechanical ventilation and often receive sedation to control pain, reduce anxiety, and facilitate patient-ventilator interactions. Weaning from mechanical ventilation is intertwined with sedation management. In this review, we analyze the current evidence for sedation management during ventilatory weaning, including level of sedation, timing of sedation weaning, analgesic and sedative choices, and sedation management in acute respiratory distress syndrome (ARDS).

Recent findings: Despite a large body of evidence from the past 20 years regarding the importance of light sedation and paired spontaneous awakening and spontaneous breathing trials (SATs/SBTs) to promote ventilator weaning, recent studies show that implementation of these strategies lag in practice. The recent WEAN SAFE trial highlights the delay between meeting weaning criteria and first weaning attempt, with level of sedation predicting both delays and weaning failure. Recent studies show that targeted interventions around evidence-based practices for sedation weaning improve outcomes, though long-term sustainability remains a challenge.

Summary: Light or no sedation strategies that prioritize analgesia prior to sedatives along with paired SATs/SBTs promote ventilator liberation. Dexmedetomidine may have a role in weaning for agitated patients. Further investigation is needed into optimal sedation management for patients with ARDS.

Purpose of review: Postextubation respiratory support treatment approaches, indications, and subgroups of patients with different responses to those therapies are rapidly changing. Planning optimal therapy in terms of choosing devices, timing of application and selecting settings with the goal of minimizing extubation failure is becoming a challenge. This review aims to analyze all the available evidence from a clinical point of view, trying to facilitate decision making at the bedside.

Recent findings: There is evidence for high flow nasal cannula support in patients at low risk of extubation failure. Noninvasive ventilation based strategies should be prioritized in patients at very high risk, who are obese or are hypercapnic at the end of a spontaneous breathing trial. Patients not included in the previous groups merit a tailored decision based on more variables.Optimizing the timing of therapy can include facilitation of extubation by transitioning to noninvasive respiratory support or prolonging a planned preventive therapy according to clinical condition.

Summary: Planning postextubatin respiratory support must consider the risk for failing and the presence of some clinical conditions favoring noninvasive ventilation.Extubation can be safely accelerated by modifying screening criteria and spontaneous breathing trial settings, but there is room to increase the role of postextubation noninvasive respiratory support for this indication, always keeping in mind the dangers of delaying a needed intubation.