Current Opinion in Critical Care最新文献

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: 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.

Purpose of review: Acute kidney injury (AKI) is common in critically ill patients, especially among those with severe and advanced organ failure. The use of extracorporeal support (ECS) is frequently considered. Machines, filter technology and techniques for extracorporeal organ support continue to expand quickly. The aim of this review is to describe the interactions between different types of ECS techniques and kidney function.

Recent findings: There is a bidirectional relationship between AKI and ECS techniques, including renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO), hemoadsorption and cardiac support devices. Patients with AKI frequently need ECS but all devices can also potentially contribute to AKI and other complications. The main mechanisms of ECS-associated AKI include comorbidities, risk factors associated with critical illness in general, vascular complications linked to ECS, inflammation, hypoperfusion and ischemia-reperfusion injury.

Summary: The pace of technological advancement of ECS techniques is expanding quickly but outpacing research and data on both the effectiveness and risk or morbidity with these devices. More research is urgently needed.

Purpose of review: Mechanical circulatory support (MCS) is increasingly used in cardiogenic shock, yet evidence for its benefit in postcardiac arrest patients remains limited and controversial. This review discusses recent randomized trials and evolving concepts in hemodynamic phenotyping and patient selection.

Recent findings: MCS devices - such as intra-aortic balloon pump (IABP), microaxial flow pump (mAFP), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) - distinct indications, risks, and limitations. Although mAFP demonstrated improved survival in infarct-related cardiogenic shock, no MCS device has showed positive results in cardiac arrest patients. Similarly, early VA-ECMO initiation for refractory cardiac arrest has not shown a survival benefit in unselected patients and is associated with significant complications. Mixed shock states and transient myocardial dysfunction are common after cardiac arrest as well as hypoxic brain injury, complicating decision-making and highlighting the need for individualized approaches.

Summary: MCS use after cardiac arrest should not be used routinely. In selected patients with cardiogenic shock based on advanced hemodynamic phenotyping, MCS can be considered balancing the risk of postarrest severe hypoxic brain injury. Future research should focus on improving patient selection, understanding shock phenotypes, and optimizing timing and modality of support to improve outcomes in this critically ill population.

Purpose of review: To revise key components of early postoperative management in acute brain injury (ABI) patients, including transfusion strategies, oxygenation and fluid targets, hemodynamic support, noninvasive intracranial pressure (ICP) assessment, and anticoagulation management.

Recent findings: Recent large randomized trials suggested that liberal transfusion strategies (i.e. aiming at hemoglobin ≥9 g/dl) showed potential benefits in functional outcomes and reduced ischemic complications. While hypoxemia is clearly harmful in ABI, observational and meta-analytic data link hyperoxia to worse neurological and survival outcomes, supporting to maintain normoxia (i.e. PaO2 80-120 mmHg) and avoid unnecessary supplemental oxygen. Euvolemia is the goal in ABI patients; current evidence supports saline as first-line maintenance fluid, with balanced crystalloids reserved for correcting electrolyte abnormalities, given signals of increased mortality with their use in TBI. When invasive ICP monitoring is unavailable or contraindicated, multimodal noninvasive strategies may guide timely interventions and reduce the risk of unrecognized intracranial hypertension. Thrombo-prophylaxis timing and type in ABI must balance bleeding and thrombotic risks, resumption of oral anticoagulants after ischemic or hemorrhagic stroke should be individualized, and reversal of anticoagulation before urgent neurosurgery mainly relies on prothrombin complex concentrate, with the role of specific antidotes to be further demonstrated.

Summary: This review offers evidence-based guidance on key aspects of managing acute brain injury patients undergoing neurosurgical or interventional neuroradiological procedures. Current literature highlights the complexity of care in this population, emphasizing the need for ongoing clinician education and high-quality research to refine and optimize management strategies.

Purpose of review: Critically ill patients often present with multiorgan dysfunction, and the kidney plays a central role in these pathophysiologic interactions. This review aims to provide an up-to-date summary of the most relevant kidney-organ cross-talks in the ICU, including lung, heart, liver, gut, and brain interactions, with emphasis on underlying mechanisms and clinical implications.

Recent findings: Recent large-scale observational studies and meta-analyses have strengthened the evidence for bidirectional interactions between the kidneys and other organs. In acute respiratory distress syndrome, for example, acute kidney injury contributes significantly to mortality, with inflammation, hemodynamic disturbances, and mechanical ventilation as key elements. Cardiorenal syndromes have been well classified, with venous congestion, immune response and renin-angiotensin-aldosterone system dysregulation identified as the most important drivers. At the core of these organ interactions - including impairments in liver metabolism, intestinal barrier integrity, and brain function - lies systemic inflammation, predominantly mediated by pro-inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha, which activate endothelial and immune responses across organ systems and contribute to multiorgan dysfunction. Novel biomarkers and therapeutic interventions are being explored across organ systems.

Summary: Organ-kidney cross-talk is a hallmark of critical illness and significantly affects patient outcomes. Understanding these interactions is essential for early diagnosis, risk stratification, and tailored interventions. Integrating knowledge of organ-specific pathophysiology with kidney-centered management strategies holds promise for improving multiorgan recovery and reducing ICU mortality.