Current Opinion in Critical Care最新文献

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.

Purpose of review: This review explores the intricacies of withdrawal of life-sustaining therapy (WLST) after resuscitation from cardiac arrest, focusing on its key motivators and broader implication for knowledge generation.

Recent findings: When approaching WLST, it is important to balance objective prognostic data with ethical principles and cultural norms to ensure delivery of personalized, patient-centered care. Because evidence guiding prognostication after cardiac arrest remains limited, ethical frameworks are not prescriptive, and cultural norms are variable, WLST is inconsistently applied. This contributes to pervasive biases in research and clinical decision making.

Summary: WLST following cardiac arrest is a complex decision. Evidence-based approaches to prognostication have notable limitations and are inconsistently utilized by clinicians. We must account for the effect of WLST to avoid perpetuating biased interpretations of outcome data.

Purpose of review: The aim of this review is to provide an update on some key aspects of the perioperative management of patients undergoing hepatopancreatobiliary (HPB) surgery.

Recent findings: Recent studies underline the importance of performing these surgeries in specialized centers to improve outcomes. In these centers of excellence, the high volume of HPB-performed surgery, the existence of enhanced recovery after surgery (ERAS) programs, and the use of minimally invasive surgery techniques all help to improve patient outcomes. In liver surgery, the main evolving challenges remaining are intraoperative bleeding control, and postoperative complications, mainly represented by the risk of posthepatectomy liver dysfunction, for which intraoperative and postoperative strategies have recently been evaluated and could improve patient prognosis. In pancreatic surgery, the main issues raised in the review are the prevention and treatment of pancreatic fistula, and the risk and prevention of surgical site infection.

Summary: This review highlights recent developments in perioperative care for HPB surgery. This highlights the importance of specialized centers equipped to prevent and manage the specific complications associated with these procedures. Further studies are needed to clarify which intraoperative and postoperative strategies are most beneficial for postoperative outcome.

Purpose of review: Evidence regarding various aspects of prehospital emergency anaesthesia (PHEA) - including techniques and outcomes - is mixed. The heterogeneity of systems, providers, and procedures complicates interpretation of data on individual interventions. This review aims to identify recent literature that offers strategies to improve the quality and safety of PHEA.

Recent findings: Current literature supports a broader perspective on PHEA, moving beyond rapid sequence intubation alone. The adoption of videolaryngoscopy and bougies has improved intubation success, shifting focus toward maintaining physiological stability. Invasive blood pressure monitoring and arterial blood gas analysis have proven both feasible and beneficial in the prehospital setting. Consensus-based quality indicators now facilitate more consistent evaluation and comparison of practices.

Summary: PHEA is a complex and high-risk intervention. Recent evidence supports standardizing the process, including methods to optimize first-pass success and enhance physiological stability. Robust clinical governance is essential to ensure safety.

Purpose of review: Acute kidney injury (AKI) is among the most common organ failures encountered in critically ill patients, contributing to both short-term and long-term morbidity and mortality. No targeted therapy currently prevents or treats AKI. This review highlights recent advances in its prevention and treatment within critical care.

Recent findings: Increased attention to AKI heterogeneity and subphenotypes, coupled with biomarker-driven research, has deepened understanding of its pathophysiology. Several clinical trials have shown no benefit or were stopped early for futility, yet others report promising therapeutic effects or identify potential interventions. These findings need confirmation in larger prospective studies, and their clinical relevance remains to be established. Continued investigation is required to delineate AKI subphenotypes and develop targeted therapies.

Summary: Several trials already demonstrate encouraging results in specific AKI subphenotypes, supported by growing insight into its complex pathophysiology. Although candidate interventions are still under evaluation, recent progress offers hope for improved preventive and therapeutic strategies in critically ill patients.