Current Opinion in Critical Care最新文献

Purpose of review: Despite the pivotal role of randomized controlled trials (RCTs) in critical care research, many have failed to demonstrate significant benefits, particularly in nutrition interventions. This review highlights how patient heterogeneity affects trial outcomes and explores how artificial intelligence and machine learning can address this issue by identifying subgroups with distinct treatment responses, improving trial design, and enhancing the precision of nutritional interventions.

Recent findings: RCTs estimate the average treatment effect, which can obscure heterogeneous treatment effects, where some patients benefit while others experience no effect or harm. Recent studies highlight that artificial intelligence techniques such as clustering, predictive modeling, causal artificial intelligence, and reinforcement learning have the potential to individualize treatments and decrease heterogeneity in trials. Digital twins and artificial intelligence-driven adaptive trial designs further enable personalized interventions, optimizing study populations and improving treatment precision.

Summary: The integration of artificial intelligence and machine learning into clinical trials offers a powerful strategy to refine patient selection, reduce variability, and enhance the detection of meaningful treatment effects. These advancements hold significant potential to transform critical care nutrition research, leading to more precise, personalized, and effective interventions.

Purpose of review: Cardiogenic shock continues to portend a poor prognosis. Despite ongoing efforts over the past few decades to help improve mortality, little progress has been made in improving the short-term and long-term outcomes of patients presenting with cardiogenic shock. This is especially true of those presenting with acute myocardial infarct related cardiogenic shock.

Recent findings: Cardiogenic shock should be understood as a continuum. Patients can move from one stage of shock to another and hence should be assessed on an ongoing basis. Cardiogenic shock should be assessed based on the severity, the phenotypic presentation and the concomitant processes that influence prognosis. Right ventricular cardiogenic shock and mixed cardiogenic shock have been recognized as predictors of worse overall prognosis. Incorporating detailed classification of cause of cardiogenic shock into routine clinical practice and will help with standardizing nomenclature and aid in understanding of the disease process and assist in refining interventions.

Summary: Early identification, risk stratification and understanding the nuances of presentation may help with selecting appropriate treatment strategies. Aggressive management should include multidisciplinary team-based approaches to help escalate care as needed.

Purpose of review: After more than 50 years from its invention, the intra-aortic balloon pump (IABP) is still one of the most widely used mechanical circulatory support devices to treat cardiogenic shock (CS). This review aims to describe the role of IABP in current clinical practice.

Recent findings: In recent years the better understanding of the variable hemodynamic profiles that characterize the CS condition has led to a reappraisal of the IABP role in select CS phenotypes. Combining a "mechanical" afterload reduction with an increase in mean arterial pressure, this device appears particularly suited to treat acute decompensated heart failure-CS and the mechanical complications of an acute myocardial infarction, as these conditions would greatly benefit from systemic afterload reduction. Notwithstanding the negative results of IABP support for acute myocardial infarction-related CS, this document reviews other potential established and emerging settings of application.

Summary: In this scoping review, we discuss the IABP design and hemodynamic effects, with a pathophysiology-oriented outlook to its clinical use. Different options for IABP device insertion, potential complications, and optimal device synchronization with cardiac cycle are also summarized with the aim to provide an updated, pragmatic guide to critical care physicians using these devices.

Purpose of review: The primary aim of this review is to summarize the value of nutrition therapy in reversing or altering the core pathophysiology during severe acute pancreatitis (SAP) and how it may impact short-term and long-term clinical outcomes.

Recent findings: Early, intense inflammation is ubiquitous during the acute phase of SAP, and specific nutrients like vitamins C, D, and omega-3 fatty acids may modulate inflammation. Omega-3 fatty acids supplementation shows promise in small studies, especially when given parenterally, though results from large randomized trials are pending. Moreover, SAP commonly causes gastrointestinal dysfunction, evidenced by impaired barrier function and motility. Early enteral nutrition (EN) can reduce mucosal inflammation and protect barrier function, with glutamine supplementation potentially offering additional benefits. For impaired motility, which often presents as intra-abdominal hypertension, the commencement of early EN could aid bowel movement, though careful monitoring for ischemia is needed. Long-term outcomes in SAP patients remain understudied, and the impact of nutritional therapy on postdischarge physical function and quality of life warrants further research.

Summary: Nutrition therapy may intervene in the pathophysiology of SAP in many aspects, thereby improving both short-term and long-term outcomes. However, there is a substantial lack of high-quality evidence concerning this topic.

Purpose of review: Temporary circulatory support (TCS) devices play a crucial role in stabilizing patients with refractory cardiogenic shock. They provide essential hemodynamic support and serve as a bridge to recovery, decision-making, heart transplantation, or long-term mechanical circulatory support. However, despite their increasing use, recent trials challenge their impact on survival. This review summarizes recent findings and discusses challenges in optimizing patient selection and device use.

Recent findings: The intra-aortic balloon pump (IABP) remains the most used TCS device. However, evidence suggests it is ineffective as a standalone therapy. Its value may lie in combination strategies, such as pairing with VA-ECMO, to enhance ventricular unloading. Recent randomized trials on VA-ECMO, including ECLS-SHOCK, have been disappointing. They show no survival benefit in acute myocardial infarction-related cardiogenic shock. Even well conducted trials face limitations, including heterogeneous patient populations and challenges in endpoint selection, making definitive conclusions difficult. The Impella device showed promising results in the DanGer Shock trial, with reduced mortality compared to standard care. However, concerns persist about patient selection and the unexpectedly high mortality rate in the control group. Meanwhile, the role of temporary right ventricular assist devices is increasingly recognized, particularly in facilitating hemodynamic stability during left ventricular assist device implantation.

Summary: TCS has revolutionized the management of cardiogenic shock, but significant challenges remain. Further research is needed to refine patient selection, improve device integration, and optimize outcomes. Emerging technologies, including biocompatible materials and artificial intelligence for device monitoring, hold promise for advancing the field. Future studies should also prioritize multicenter collaborations and real-world data to address current limitations in evidence.

Purpose of review: This review aims to synthesize current evidence on the expanding role of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) beyond glycemic control, particularly in the context of critical illness. With growing recognition of their anti-inflammatory, immunomodulatory, and organ-protective properties, GLP-1RAs show promise in managing complications such as sepsis, acute respiratory distress syndrome (ARDS), acute kidney injury, and multiorgan dysfunction. This review explores their mechanisms across vital systems - including cardiovascular, pulmonary, renal, hepatic, neuropsychiatric, and gut-lung-microbiome axes - highlighting preclinical and clinical data. By consolidating emerging findings, this review aims to inform future translational research and support the integration of GLP-1RAs into critical care strategies.

Recent findings: Recent evidence highlights GLP-1RAs as promising adjuncts in critical illness due to their multiorgan protective effects. In cardiovascular systems, GLP-1RAs improve endothelial function, reduce ischemia-reperfusion injury, and modulate autonomic tone. In the CNS, they provide neuroprotection by reducing neuroinflammation and pyroptosis. In the lungs, they attenuate ARDS by decreasing cytokine production, enhancing surfactant secretion, and restoring alveolar-capillary integrity. Renally, they reduce acute injury and preserve filtration function. In the gut, GLP-1RAs modulate the microbiome, enhance barrier integrity, and lower systemic inflammation via the gut-lung axis. Additionally, they reduce hepatic inflammation and support pancreatic beta-cell survival, improving insulin sensitivity and metabolic stability in critical care.

Summary: GLP-1 receptor agonists hold promise as multiorgan protective agents in critical illness, offering benefits beyond glucose control. Their anti-inflammatory, metabolic, and vaso-protective properties may be harnessed to prevent or attenuate organ failure, support recovery, and improve long-term outcomes in critically ill patients. Further clinical trials are warranted to define their safety, efficacy, and optimal application across ICU populations.

Purpose of review: When considering "personalized nutrition therapy," particularly in the intensive care unit (ICU), the default response is indirect calorimetry (IC). However, predictive equations (PEs) remain more commonly used due to cost and logistical constraints. A recent paradigm shift in how nutrition support is viewed during the early phases of critical illness has also called into question if exact energy targets are what constitutes "personalized nutrition therapy." This review examines recent evidence comparing IC and PE based nutrition support in the ICU, highlighting practical issues around timing, patient selection, and nutrition adequacy and aims to redefine the focus of personalized nutrition therapy moving forward.

Recent findings: Systematic reviews and meta-analyses from 2020 to 2025 yield mixed results. Some suggest that IC-guided nutrition may reduce short-term mortality; others report higher mechanical ventilation days. Studies also show IC-based protocols typically deliver more calories than PE-based methods, potentially risking overfeeding if not carefully managed. Special populations - large burn cases, patients with obesity, and older adults - can show wide discrepancies between measured vs. predicted energy expenditures.

Summary: While IC can capture individual metabolic demands more accurately than PEs, especially in complex patients, logistical barriers and uncertainty about the ideal calorie target complicate its adoption. Evidence to support early use of IC in the ICU remains inconclusive. Further research into emerging patient identifiers based on phenotypic, metabolomic, or mechanistic profiles may redefine personalized critical care nutrition.

Purpose of review: The understanding of cardiogenic shock (CS) has significantly evolved over the past decades. Initially regarded as a purely mechanistic syndrome, CS is now recognized as a multifaceted condition that incorporates a complex interplay of hemodynamic compromise and a cascading inflammatory response. This review aims to describing cardiac and systemic inflammation involvement in cardiogenic shock.

Recent findings: Defining subphenotypes among CS patients is mandatory as it is no longer considered as a homogeneous entity. Accordingly, including inflammatory biomarkers in a risk-stratification approach and identifying populations who will predictably respond to tailored therapies is a major concern.

Summary: In this review, we propose a narrative review on cardiac and systemic inflammation occurring in CS, current research on inflammatory biomarkers and their implications in risk-stratification, and upcoming trials on therapies targeting inflammation.

Purpose of review: Accelerated muscle wasting in critically ill patients contributes to poor recovery outcomes. Critical care guidelines recommend delivering higher protein doses; yet, increasing evidence suggests harm from higher protein doses.

Recent findings: Definitive randomised controlled trials in critically ill adults have reported signals of harm from higher protein administration compared to lower protein doses or standard of care, with significant results pertaining to reduced health-related quality of life and worse outcomes in sub-groups of acute kidney injury and higher illness severity. Physiological data demonstrate anabolic resistance to dietary protein and elevated rates of protein degradation. Recent human studies propose novel mechanisms to explain these results, including inflammation, apoptosis, and deranged concentrations of vitamin D and intramuscular zinc. Preclinical models may elucidate mechanisms core to muscle wasting: 'micro muscles' cell culture systems can assess muscle loss in response to nutrient administration; and both rodent and large animal models allow for mechanistic interrogation of muscle metabolism in response to feeding.

Summary: Higher protein doses alone are unlikely to attenuate muscle wasting. Understanding mechanisms for anabolic resistance and increased protein degradation, employing preclinical models, will support the development of targeted strategies to prevent muscle loss during critical illness.

Purposes of review: The inflammatory response in sepsis raises circulatory levels of gaseous transmitters (gasotransmitters) nitric oxide (NO) and hydrogen sulfide (H 2 S), both of which generate and sustain septic shock. Current best practices, including early intravenous fluid, early antibiotics, and vasopressor support, do not target gasotransmitters. A single 5-g dose of intravenous hydroxocobalamin (high-dose HOC) is a safe intervention that targets circulating gasotransmitters. In this review, we provide an overview of the role of gasotransmitters in septic shock, outline the rationale for high-dose HOC in septic shock, and summarize clinical evidence for high-dose HOC in septic shock.

Recent findings: NO and H 2 S are elevated early in septic shock, activate inflammatory pathways, and higher levels correlate with greater severity of illness. Preclinical evidence demonstrates high-dose HOC improves outcomes in models of septic shock by scavenging circulating NO and H 2 S. Multiple case series and a Phase IIa trial show that high-dose HOC is a safe intervention that reduces vasopressor dose in adults with septic shock. Without high-level evidence, clinicians across the United States are using high-dose HOC for adults with septic shock.

Summary: High-dose HOC is a promising, nontoxic intervention that targets the pathophysiologic pathway of septic shock. Despite compelling observational and Phase IIa trial data, a pivotal phase III trial testing high-dose HOC in adults with septic shock is required before widespread use can be recommended.