Current Opinion in Critical Care最新文献

Purpose of review: Head and neck surgical patients can pose significant management challenges in the ICU postoperatively. In this review, we provide details on the common surgeries that present to the ICU, expected complications and management strategies to improve outcomes.

Recent findings: Vital structure involved in breathing, swallowing and neurovascular control are located in the head and neck region posing unique challenges for critical care. A delayed extubation strategy can be performed in select patients and has the advantage of reducing hospital stay, early oral intake, return of speech and decreased respiratory infections compared to a tracheostomy. Recent literature highlights critical interventions to improve outcomes and the importance of a multidisciplinary approach for the management of these patients.

Summary: These patients require close monitoring for airway compromise, bleeding, neurological deterioration and surgical complications postoperatively. A carefully planned delayed extubation, including a plan for reintubation of a difficult airway may be required in select patients. General management includes tracheostomy care, prevention of deep vein thrombosis, following enhanced recovery after surgery guidelines and maintaining a balance between adequate pain and preservation of airway reflexes. A thorough understanding of the surgery-specific complications and close interaction between the critical care, anesthesiology and surgical teams is paramount.

Purpose of review: Refractory ventricular fibrillation, which fails to respond to defibrillation, is associated with poor survival. Despite this, there are no treatments that are proven effective beyond standard defibrillation and cardiopulmonary resuscitation. Double sequential external defibrillation (DSED) has been proposed as an alternative defibrillation strategy for this patient population. In this review, we will discuss key evidence surrounding DSED, as we present two opposing arguments, 'pro' that DSED is ready for clinical practice and 'con' that more research is needed prior to implementation of this technique.

Recent findings: The Double Sequential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF) randomized clinical trial demonstrated improved patient outcomes for patients with refractory ventricular fibrillation who did not respond to standard defibrillation attempts. There remain unanswered questions with respect to the mechanism by which DSED may improve outcomes and the logistics of implementation into clinical practice.

Summary: This article discusses some of the key controversies surrounding DSED and whether this novel defibrillation strategy is ready for integration into standard practice. Further research is ongoing that may help to answer further questions related to the utility of DSED.

Purpose of review: The diuretic agents are commonly used in ICUs for various purposes. Despite the widespread utilization of diuretics, there remains substantial ambiguity regarding their indications, ICU-related changes in their pharmacodynamics and pharmacokinetics, dosing, form, and timing of administration, the differences in their utilities based on each organ failure, and their monitoring and safety issues.

Recent findings: In the recent past, there have been several clinical trials and large registries or systematic reviews with a focus on the use of diuretic agents in ICUs.

Summary: In this review article, we outline the essential changes in drug behavior during critical illnesses and organ failures, describe the indications of their use in ICUs (management of fluid overload, electrolyte imbalances, or diagnostic or prognostic tests), assess the impact of different organ failures on the utility and effectiveness of diuretics, review major recent clinical trials related to diuretic comparison, use of multiple classes of diuretics, and monitoring and safety of their use. We also provide some information regarding the safety and adverse effects of diuretic use in the ICU and outline the importance of individualizing their use during critical illnesses.

Purpose of review: Advanced radiological imaging techniques, modern minimal invasive surgical procedures and the implementation of high care postoperative care units (PACU) have resulted in a reduction of critical care unit admission following lung surgery. Diagnosis of lung cancer in earlier states, enabling defined surgery with less tissue trauma, shorter duration and reduced blood loss are reasons for this development. However, postoperative pulmonary complications (PPCs), necessitating critical care therapy, is still a major problem.

Recent findings: PPCs increase morbidity and mortality, reduce long term outcome, provoke critical care unit admission, raise costs of medical treatment and prevent timely hospital discharge. Pulmonary tissue inflammation and hypoxia represent an important underlying pathophysiological mechanism of PPCs and preventing them improves postoperative outcomes. In contrast to its relevance for outcome, evidence to guide perioperative and postoperative critical care therapy of PPCs after lung surgery is limited. It has become clear, that intertwined measures must be taken in the pre, intra- and postoperative phase to reduce PPCs and to enhance recovery after thoracic surgery.

Summary: This review gives an overview on recent advances of the perioperative and critical care prevention and therapy of postoperative pulmonary complications in patients with lung surgery.

Purpose of review: This narrative review aims to present the latest findings on physiological targets for postresuscitation management of cardiac arrest and to discuss the recent treatment recommendations from the International Liaison Committee on Resuscitation (ILCOR).

Recent findings: Evidence supports targeting normal physiological ranges. ILCOR recommends maximal oxygen until reliable O 2 saturation (O 2 Sat) is achieved, then titrate to 94-98%. Avoid hypoxia (O 2 Sat < 90%), even transient hypoxia is associated with worse outcomes. Pulse oximetry may be less accurate in patients with darker skin, potentially masking hypoxemia. For end-tidal carbon dioxide (ETCO 2 ), aim for the upper end of normal (ETCO 2 35-45 mmHg) to account for alveolar dead space. Avoid hypotension; target systolic blood pressure (SBP) >100 mmHg or mean arterial pressure (MAP) >60-65 mmHg. NIBP may overestimate SBP and MAP, especially in hypotensive or shocked patients-higher targets may be needed.

Summary: Hemodynamic stabilization and effective airway and ventilation management to prevent deviations from normal ranges are critical postresuscitation priorities in the prehospital setting, essential for preventing re-arrest and optimizing patient outcomes. Prehospital clinicians should be aware of the limitations of their monitoring equipment.

Purpose of review: This review synthesizes recent advancements in understanding intracranial compliance (ICC) pathophysiology, explores novel monitoring techniques, and discusses their evolving clinical implications. We highlight how a shift from static intracranial pressure (ICP) thresholds to dynamic ICC assessment is transforming the management of acute brain injury.

Recent findings: ICC is the brain's ability to accommodate volume changes without significant ICP elevation, is a critical determinant of outcome in neurocritical care. The paradigm in ICC is evolving from a focus on absolute ICP values to a dynamic, continuous assessment of the brain's compensatory capacity. Emerging concepts extend the classical Monro-Kellie doctrine, incorporating the dynamic roles of cerebrospinal fluid circulation, including the glymphatic system, in maintaining intracranial homeostasis. Integrating new pathophysiological insights with advanced monitoring tools holds immense potential to refine clinical decision-making, enabling more proactive and personalized interventions, ultimately improving outcomes for patients with acute brain injury.

Summary: To achieve such goal, both invasive and noninvasive advanced monitoring techniques now provide real-time insights into ICC status. ICP waveform analysis offers granular information on compensatory reserve and cerebral autoregulation. Noninvasive methods, such as cranial micro-deformation sensors and transcranial Doppler-derived parameters offer accessible bedside assessment. These tools, alongside others such as optic nerve sheath ultrasound and pupillometry, facilitate earlier detection of decompensation, guide individualized therapy and improve prognostication.

Purpose of review: Invasive mechanical ventilation (IMV) is a cornerstone in the management of acute respiratory failure (ARF) and acute respiratory distress syndrome (ARDS); however, positive pressure ventilation (PPV) and injurious IMV can contribute to renal dysfunction. This review aims to summarize current evidence on kidney-ventilator interactions and explore strategies for kidney-protective ventilation.

Recent findings: The relationship between ARF/ARDS and acute kidney injury (AKI) is a major contributor to morbidity, mortality, and adverse outcomes among critically ill patients. PPV can induce hemodynamic and neurohormonal changes that may impair kidney function. Additionally, injurious IMV can exacerbate these effects and promote biotrauma, triggering inflammatory responses that further compromise kidney function. Conversely, AKI can exert both inflammatory and non-inflammatory effects, impairing pulmonary function. Lung-protective ventilation (LPV) using low tidal volume and conservative fluid management are strategies that may mitigate AKI. Extracorporeal organ support, including renal replacement therapy and extracorporeal membrane oxygenation, may facilitate LPV and be associated with improved outcomes in patients with IMV-associated AKI.

Summary: IMV influences lung-kidney interactions in a bidirectional manner. Evidence suggests the use of LPV, and extracorporeal organ support may mitigate dual organ injury. A thorough understanding of this interplay is essential to optimizing outcomes in critically ill patients receiving IMV.

Purpose of review: To highlight the unintended consequences of microbiological test results in driving inappropriate antimicrobial prescriptions, and to evaluate strategies - particularly from the perspective of diagnostic stewardship - that may mitigate this issue.

Recent findings: Despite the critical role of microbiological data in guiding appropriate antimicrobial therapy, several studies have demonstrated that misinterpretation of such results frequently leads to unnecessary treatments. Common pitfalls include overinterpretation of positive cultures from poorly collected or clinically unwarranted samples, misclassification of colonization vs. infection, and excessive reliance on test results in the absence of supporting clinical evidence. Emerging diagnostic stewardship interventions - ranging from restricting sample processing and modifying test reporting to implementing decision support tools - have shown promising outcomes in reducing overtreatment without compromising patient safety. Specific examples include urine and wound cultures, respiratory specimens, and the diagnosis of Clostridioides difficile infection. Furthermore, educational and system-level strategies such as the BLADDER score or selective result reporting can improve decision-making at various stages of the diagnostic process.

Summary: Microbiology laboratories play a pivotal role in antimicrobial stewardship and must actively support clinicians in avoiding diagnostic and therapeutic errors. While evidence supports multiple approaches to mitigate inappropriate prescriptions driven by microbiology results, their successful implementation requires interdisciplinary collaboration, tailored interventions, and ongoing evaluation of clinical impact. Diagnostic stewardship, when aligned with clinician education and robust reporting practices, is a crucial component in enhancing the accuracy of infection diagnosis and reducing antimicrobial overuse.

Purpose of review: To synthesize current evidence on prognostic factors, tools, and strategies influencing functional outcomes in patients with traumatic brain injury (TBI), with a focus on the acute and postacute phases of care.

Recent findings: Key early predictors such as Glasgow Coma Scale (GCS) scores, pupillary reactivity, and computed tomography (CT) imaging findings remain fundamental in guiding clinical decision-making. Prognostic models like IMPACT and CRASH enhance early risk stratification, while outcome measures such as the Glasgow Outcome Scale-Extended (GOS-E) provide structured long-term assessments. Despite their utility, heterogeneity in assessment approaches and treatment protocols continues to limit consistency in outcome predictions. Recent advancements highlight the value of fluid biomarkers like neurofilament light chain (NFL) and glial fibrillary acidic protein (GFAP), which offer promising avenues for improved accuracy. Additionally, artificial intelligence models are emerging as powerful tools to integrate complex datasets and refine individualized outcome forecasting.

Summary: Neurological prognostication after TBI is evolving through the integration of clinical, radiological, molecular, and computational data. Although standardized models and scales remain foundational, emerging technologies and therapies - such as biomarkers, machine learning, and neurostimulants - represent a shift toward more personalized and actionable strategies to optimize recovery and long-term function.

Purpose of review: Gastrointestinal (GI) dysfunction significantly impacts patient outcomes in septic shock, complicating clinical management due to its central role in systemic inflammation, barrier integrity, and nutrient assimilation. This review summarizes the evolving understanding of GI dysfunction during septic shock and provides an updated framework for clinical management.

Recent findings: New insights from recent studies focus on individualized nutritional strategies over standardized calorie-driven targets, highlighting risks associated with aggressive enteral nutrition, such as exacerbation of gut ischemia and bowel distension, and microbial dysbiosis. Maintaining splanchnic perfusion, monitoring GI dysfunction with standardized tools, and advancing nutritional support progressively based on patient-specific gastrointestinal tolerance are current strategies. Novel adjunctive therapies targeting gut permeability and microbiome restoration have been proposed, yet robust clinical data remain limited.

Summary: Clinical management should prioritize hemodynamic stabilization and organ support rather than immediately targeting any nutritional goals. Monitoring GI function systematically and tailoring nutritional interventions may prevent complications and support recovery. Future research should validate monitoring tools, refine individual patient assessment, and evaluate novel therapeutic interventions to improve patient-centered outcomes in septic shock.