Intensive Care Medicine最新文献

When native blood flow through the aorta from the adult heart and lungs meets retrograde blood flow from an artificial heart and lung during venoarterial extracorporeal membrane oxygenation (VA-ECMO), the result is the creation of two separate circulations on either side of the blood flow mixing point. This phenomenon is known as dual circulation and is characterized by different content of oxygen and carbon dioxide between the circulations. There is currently a lack of clarity surrounding the nomenclature to describe this physiologic phenomenon in VA-ECMO and thus we endeavor to name and define these terms to facilitate clear communication and proper clinical management of these patients.

Purpose: The optimal physiologic parameters to monitor after a session of awake prone positioning in patients with acute respiratory failure are not well understood. This study aimed to identify which early physiologic changes after the first session of awake prone positioning are linked to the need for invasive mechanical ventilation or death in patients with acute respiratory failure.

Methods: We performed a secondary analysis of a prospective cohort study of adult patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) treated with awake prone positioning. We assessed the association between relative changes in physiological variables (oxygenation, respiratory rate, pCO₂ and respiratory rate-oxygenation [ROX] index) within the first 6 h of the first awake prone positioning session with treatment failure, defined as endotracheal intubation and/or death within 7 days.

Results: 244 patients [70 female (29%), mean age 60 (standard deviation [SD] 13) years] were included. Seventy-one (29%) patients experienced awake prone positioning failure. ROX index was the main physiologic predictor. Patients with treatment failure had lower mean [SD] ROX index at baseline [5 (1.4) versus 6.6 (2.2), p < 0.0001] and within 6 h of prone positioning [5.6 (1.7) versus 8.7 (2.8), p < 0.0001]. After adjusting for baseline characteristics and severity, a relative increase of the ROX index compared to baseline was associated with lower odds of failure [odds ratio (OR) 0.37; 95% confidence interval (CI) 0.25-0.54 every 25% increase].

Conclusion: Relative changes in the ROX index within 6 h of the first awake prone positioning session along with other known predictive factors are associated with intubation and mortality at day 7.

Purpose

Whether skin disinfection of the surgical site using chlorhexidine-alcohol is superior to povidone-iodine-alcohol in reducing reoperation and surgical site infection rates after major cardiac surgery remains unclear.

Methods

CLEAN 2 was a multicenter, open-label, randomized, two-arm, assessor-blind, superiority trial conducted in eight French hospitals. We randomly assigned adult patients undergoing major heart or aortic surgery via sternotomy, with or without saphenous vein or radial artery harvesting, to have all surgical sites disinfected with either 2% chlorhexidine-alcohol or 5% povidone-iodine-alcohol. The primary outcome was any resternotomy by day 90 or any reoperation at the peripheral surgical site by day 30.

Results

Of 3242 patients (1621 in the chlorhexidine-alcohol group [median age, 69 years; 1276 (78.7%) men] and 1621 in the povidone-iodine-alcohol group [median age, 69 years; 1247 (76.9%) men], the percentage required reoperation within 90 days was similar (7.7% [125/1621] in the chlorhexidine-alcohol group vs 7.5% [121/1621] in the povidone-iodine-alcohol group; risk difference, 0.25 [95% confidence interval (CI), − 1.58–2.07], P = 0.79). The incidence of surgical site infections at the sternum or peripheral sites was similar (4% [65/1621] in the chlorhexidine-alcohol group vs 3.3% [53/1621] in the povidone-iodine-alcohol group; risk difference, 0.74 [95% CI − 0.55–2.03], P = 0.26). Length of hospital stay, intensive care unit or hospital readmission, mortality and surgical site adverse events were similar between the two groups.

Conclusion

Among patients requiring sternotomy for major heart or aortic surgery, skin disinfection at the surgical site using chlorhexidine-alcohol was not superior to povidone-iodine-alcohol for reducing reoperation and surgical site infection rates.

This review explores the current landscape and evolving understanding of sepsis, highlighting both challenges and future directions. Sepsis remains a major global health burden, with diverse clinical presentations complicating timely diagnosis and management. Existing definitions, including the Sepsis-3 criteria, emphasize the importance of organ dysfunction, yet early sepsis detection remains limited by available tools. The Sequential Organ Failure Assessment (SOFA) score, though widely used, may not fully capture early stages of infection or account for complex presentations like noncatecholamine-resistant shock. Additionally, the review underscores the pressing need for standardized terminology across sepsis and shock characterization to ensure consistency in diagnosis and treatment strategies. Accessible, resource-adapted solutions are particularly crucial in low- and middle-income countries where sepsis-related mortality rates are higher due to limited resources. Future research should focus on developing and validating integrated, multi-parameter tools that combine clinical, biochemical, and microbiological data to improve sepsis outcomes globally. Advancing sepsis care will require both technological innovation and collaborative, globally consistent guidelines to bridge disparities in healthcare delivery.