Current Opinion in Critical Care最新文献

Purpose of review: To review the current knowledge on mechanical ventilation after cardiac arrest, carefully balancing the protection of both the brain and the lungs.

Recent findings: Although lung-protective ventilation (LPV) strategies are often considered in the general population and widely studied in acute respiratory distress syndrome (ARDS) patients, current knowledge focused on patients after cardiac arrest is unclear. Mechanical ventilation in this unique population should prevent potential brain injury while also avoiding ventilation-induced lung injury. This includes optimizing ventilation parameters, such as tidal volume ( VT ), positive end-expiratory pressure (PEEP), and gas exchange targets, while also considering the impact on cerebral perfusion and intracranial pressure. The role of LPV in patients without ARDS and after cardiac arrest is still uncertain.

Summary: In this review, we updated the strategy to optimize mechanical ventilation after cardiac arrest with the primary aim of protecting the lungs and brain, improving the patients' outcomes.

Purpose of review: This review addresses the critical care challenges encountered after gastrointestinal surgery, emphasizing the high incidence of postoperative complications and the pivotal role of early recognition and management in improving patient outcomes.

Recent findings: Despite advances in minimally invasive surgery, postoperative morbidity following major gastrointestinal procedures remains substantial. Anastomotic leaks, particularly after esophagectomy and colorectal resections, are among the most feared complications, with significant clinical and economic consequences. Infectious complications, such as pneumonia and intra-abdominal sepsis, continue to drive ICU admissions and prolong recovery. General complications including acute kidney injury and postoperative delirium are prevalent, especially among frail and sarcopenic patients. Predictive models and early warning tool, including machine learning algorithms, are emerging to assist clinicians in anticipating complications. Enhanced Recovery After Surgery (ERAS) protocols, laparoscopic approaches, and multimodal analgesia have shown efficacy in reducing morbidity and hospital length of stay.

Summary: Postoperative critical care in gastrointestinal surgery must integrate risk stratification, vigilant monitoring, and evidence-based interventions. Optimizing perioperative pathways through ERAS protocols, tailored nutrition, and modern analgesic techniques can improve outcomes. Ongoing research into predictive models and individualized care strategies will further enhance the safety and effectiveness of gastrointestinal surgical care.

Purpose of review: Acute kidney injury (AKI) is a common but complex clinical syndrome, especially among critically ill patients. Current consensus definitions for AKI rely only on changes in serum creatinine and urine output, which limits timely detection of renal injury and recovery. This review summarizes the recent literature on AKI biomarkers and digital tools investigated to optimize AKI care.

Recent findings: There is a growing body of literature on the use of biochemical, imaging, and functional biomarkers to detect AKI prior to changes in creatinine and urine output, ideally to provide a window for potential intervention and prevention of worsening renal injury. Biomarkers have also been shown to help prognosticate progression, need for dialysis, or recovery. Additionally, machine learning models have been developed and studied with similar goals. This review summarizes various biomarkers and machine learning models investigated to predict and prognosticate AKI in several critical care populations. Furthermore, this review discusses other digital tools such as electronic alerts and remote monitoring programs implemented to optimize AKI care.

Summary: The studies included in this review provide optimism for an abundance of novel resources to improve AKI care. Further validation is needed prior to utilization in clinical practice.

Purpose of review: To examine the key elements of the management of patients with severe trauma in intensive care units (ICUs), including fluids, vasopressors, transfusion and coagulation, respiratory function management, and rhabdomyolysis.

Recent findings: The management of patients with severe trauma requires perfect coordination between prehospital care, hospital care in the trauma bay, and ICU care. ICU management must ensure that bleeding and coagulopathy are controlled and that organ dysfunction are treated. Severe trauma Patients admitted to ICU at high risk of requiring surgery or angiography-embolization, and ultrasound is essential for assessing the progression of traumatic injuries. Fluid and vasopressor management must be individualized based on hemodynamic monitoring. Maintaining an Hb level ≥9 g/dl may be neuroprotective. While norepinephrine remains the vasopressor of choice, vasopressin may have nephroprotective effects and enhance coagulation. Severe rhabdomyolysis associated with hemorrhagic shock is associated with increased mortality. Compartment syndrome is one of the most frequent complications particularly in patients with severe trauma with long bone fractures and abdominal-pelvic trauma. Regional anesthesia is essential to provide targeted analgesia.

Summary: This review presents several key elements of postinterventional care for severe trauma patients admitted to the ICU. Improving the management of these patients requires trauma centers and high-quality research.

Purpose of review: This review aims to explore the distinct clinical characteristics, epidemiology, treatment approaches, and research needs concerning cardiac arrest in the intensive care unit (ICU-CA), a specific subset of in-hospital cardiac arrest (IHCA). While IHCA remains a major cause of mortality, recent data indicate improved outcomes, with a notable variation in incidence and survival depending on the location, particularly within the ICU setting.

Recent findings: Recent studies underscore that ICU-CA differs significantly from general IHCA in etiology, monitoring, and treatment environment. Although incidence rates vary widely (4-78 per 1000 ICU admissions), recent data suggest a stabilization. Causes of ICU-CA often involve noncardiac factors such as septic shock and respiratory failure. Treatment is typically guided by general advanced life support (ALS) protocols, but ICU-specific resources such as real-time monitoring, invasive pressure measurements, transesophageal echocardiography, and the potential for extracorporeal cardiopulmonary resuscitation offer unique advantages. The COVID-19 pandemic highlighted the vulnerability of ICU patients, with respiratory causes dominating and extremely poor outcomes reported.

Summary: In summary, ICU-CA represents a distinct clinical entity requiring tailored research. Future directions should prioritize international registries, validation of predictive models using artificial intelligence, and clarification of do-not-resuscitate practices to improve outcomes and resource allocation in this critically ill population.

Purpose of review: Cardiac arrest centers (CAC) are specialized certified hospitals for patients with an out-of-hospital cardiac arrest (OHCA). The certification is gaining recognition in international guidelines, and with low survival rates in many regions, the need for specialized postresuscitation care has become increasingly urgent.

Recent findings: Current PubMed literature highlights key themes like the role of CAC in improving survival and neurological recovery after OHCA, the importance of multidisciplinary teams and evidence-based protocols.

Summary: The growing evidence of CAC significantly improving survival and neurological outcomes in patients with OHCA supports the need for global implementation. For clinical practice this underscores the importance of directing OHCA patients to designate CAC whenever possible, and it highlights the need to further expand CAC certifications as a main component of postresuscitation systems.

Purpose of review: Vascular surgical patients represent one of the most complex populations in the intensive care unit, due to a combination of extensive comorbidities and high perioperative risk. Postoperative complications such as major adverse cardiovascular events, acute kidney injury, neurological complications, thromboembolism and coagulopathy are common and often intersect. We present the latest evidence on complications most encountered in critically ill patients exposed to vascular surgery and best practices for their management.

Recent findings: Although short-term mortality rates for vascular surgical procedures are decreasing, complications continue to be challenging with some procedures incurring higher long-term complication rates. Major adverse cardiovascular events, kidney injury, infections, bleeding, thrombosis and mesenteric ischaemia are some of the most common complications requiring critical care. Optimal management requires early recognition of complications, personalized organ support, and multidisciplinary coordination.

Summary: We present an updated, evidence-based overview of management strategies for critically ill vascular surgical patients, with a focus on optimizing perioperative outcomes in this high-risk population. The review highlights best practices in hemodynamic monitoring and addresses the prevention and management of common postoperative complications encountered in critical care.

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.