Journal of Intensive Care最新文献

Background: This study investigated the application of software-based data monitoring for quality control (QC) in continuous renal replacement therapy (CRRT) management.

Methods: This single-center pre-post intervention study, conducted in three ICUs of a tertiary hospital in Shanghai, compared outcomes before (Jan-Dec 2023) and after (Jan-Dec 2024) implementing the Sharesource Connect system. Data from 9 Prismaflex CRRT machines were collected retrospectively during 2023 and prospectively on a monthly basis during 2024. Alongside the software, a comprehensive quality improvement program: (1) multidisciplinary team collaboration; (2) data-driven QC; and (3) structured training. Primary outcomes-filter lifespan, downtime percentage, delivered/prescribed dose ratio, ultrafiltration volume, and vascular access alarms-were compared.

Results: A total of 798 filters from 514 patients (2023) and 717 filters from 492 patients (2024) were analyzed. Key quality metrics improved significantly following implementation (2024 vs. 2023): Filter lifespan increased significantly from 20.08 ± 4.12 h to 24.08 ± 4.27 h (P = 0.043), Kaplan-Meier analysis demonstrated improved filter survival (Log-Rank p < 0.001). Cumulative survival increased from 2023 to 2024 at key time points: 12 h (69.1%-87.2%, + 18.1%), 24 h (30.9%-34.6%, + 3.7%), and 36 h (5.6%-13.6%, + 8.0%), with consistent improvements observed. Downtime percentage decreased from 39 to 28% (P = 0.015), reducing non-effective treatment time by 11 percentage points. The delivered/prescribed dose ratio increased from 82 to 86% (P = 0.046). The mean delivered dose was 35.67 ± 4.01 mL/kg/h (prescribed: 41.33 ± 4.5 mL/kg/h). Ultrafiltration volume remained stable (3.13 ± 0.37 vs. 3.52 ± 0.44 L/treatment day, P = 0.058). There was no significant difference in vascular access alarms (3.39 ± 1.44 vs. 2.93 ± 0.73 events/day, P = 0.392).

Conclusion: The Sharesource Connect system could be used for the monitoring, collection, and analysis of CRRT data to assist in the QC management related to CRRT, so as to provide a software basis for further multi-center studies or random control trials on the intelligent management of critical patients undergoing CRRT.

Background: The Adult Sepsis Event (ASE) criteria, developed by the US. Centers for Disease Control and Prevention (CDC), utilize electronic Sequential Organ Failure Assessment (eSOFA) scores derived from structured electronic health records to retrospectively detect organ dysfunction in patients with suspected sepsis. While validated primarily in inpatient cohorts, their applicability in emergency department (ED) populations remains uncertain. Moreover, the impact of including isolated serum lactate elevation as a marker of organ dysfunction in eSOFA has not been systematically evaluated.

Methods: We retrospectively reviewed data from 698 patients (aged ≥ 19 years) with suspected infections presenting to the EDs of three institutions from September 1 to 30, 2023. Blood cultures were obtained from all patients. Patients were classified according to Sepsis-3 (≥ 2-point SOFA score increase from baseline) and ASE-defined eSOFA (organ dysfunction occurring within ± 2 days of blood culture collection). Extended eSOFA additionally included isolated lactate elevation (≥ 2.0 mmol/L). Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results: Among 698 patients, 456 (65.3%) met Sepsis-3 criteria, 251 (35.9%) met ASE-defined eSOFA, and 340 (48.7%) met extended eSOFA criteria. Mortality was highest (19.8%) among patients classified by both SOFA and eSOFA. ASE-defined eSOFA demonstrated moderate sensitivity (52.0%) and high specificity (94.2%), with a PPV of 94.4%. Extended eSOFA improved sensitivity (64.3%) but lowered specificity (80.6%). Mortality increased with the number of dysfunctional organ categories. Notably, the inclusion of isolated lactate elevations identified additional high-risk patients not captured by eSOFA.

Conclusion: ASE-defined eSOFA moderately aligns with Sepsis-3 criteria, effectively identifying high-risk ED sepsis cases. Extended eSOFA criteria with lactate enhance sensitivity but reduce specificity, suggesting tailored application based on clinical settings and available resources.

Traumatic brain injury (TBI) affects approximately 69 million people annually, with the majority of cases being mild-to-moderate in severity. However, in severe TBI, early management is critical and includes fluid resuscitation to control intracranial pressure (ICP) and optimize cerebral perfusion pressure. The SAFE-TBI study linked hypotonic 4% albumin to higher mortality versus saline (33.2% vs. 20.4%; RR 1.63; P = 0.003), likely due to elevated ICP, prompting guidelines favoring saline. However, these recommendations are based on low-quality evidence and overlook hyperoncotic albumin. Preclinical data confirm that hypotonicity-not albumin-drives ICP elevation. Emerging data suggest that hyperoncotic albumin (20-25%) may reduce ICP and improve outcomes. This letter highlights evidence gaps and advocates re-evaluating albumin use in TBI, especially hyperoncotic formulations.

Background: Optimal mean arterial pressure (MAP) range after cardiac arrest remains uncertain. This study aimed to investigate the association between MAP and neurological outcomes during the early post-resuscitation period, with the goal of identifying optimal MAP range associated with favorable outcomes.

Methods: This retrospective observational study included 291 post-cardiac arrest patients treated at a tertiary care center. Five machine learning models to predict favorable neurological outcomes using hourly MAP measurements during the first 24 h after return of spontaneous circulation (ROSC) were compared and Random Forest model was selected due to its superior performance. Variable importance and Shapley Additive exPlanations (SHAP) were used to investigate the association between MAP and favorable neurological outcomes. SHAP dependence plots were used to identify optimal MAP ranges associated with favorable outcomes. In addition, individual-level predictions were interpreted using local interpretable model-agnostic explanations (LIME) and SHAP force plots.

Results: Machine learning analysis showed that MAP were associated with favorable neurological outcomes, with higher variable importance during the first 6 h after ROSC. SHAP analysis revealed an inverted U-shaped relationship between MAP and favorable neurological outcomes, with an optimal threshold of 79.56 mmHg (IQR: 73.70-82.54). This threshold remained consistent across both early (1-6 h: 79.26 mmHg) and later (7-24 h: 80.09 mmHg) hours. Individual-level explanations using SHAP and LIME highlighted that maintaining higher MAP during the early post-resuscitation period contributed positively to outcome predictions.

Conclusions: Machine learning analysis identified MAP as a major predictor of favorable neurological outcomes, with higher variable importance during the first 6 h after ROSC. MAP showed an inverted U-shaped relationship with favorable neurological outcomes, with an optimal threshold of approximately 80 mmHg.

Background: Post-intensive care syndrome (PICS) encompasses persistent physical, cognitive, and psychological impairments in individuals following intensive care unit (ICU) discharge. The short-term mental health impacts of PICS have been previously examined; however, long-term change pattern remain inadequately understood. In this study, we aimed to determine the prevalence of mental health disorders in individuals at 4 years post-ICU discharge, compare prevalence rates between 1 and 4 years, and identify change patterns and associated factors.

Methods: In this 4-year follow-up study of the SMAP-HoPe study (754 ICU survivors from 12 Japanese ICUs were originally examined in the SMAP-HoPe study), we included participants from seven ICUs who completed mental health assessments using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at both 1- and 4-years post-ICU discharge. Growth mixture modeling was employed to identify distinct change patterns for anxiety, depression, and post-traumatic stress disorder (PTSD).

Results: Among the 319 eligible participants, 223 (70.0%) provided responses. The prevalence of depression significantly increased from 24.7% at 1 year to 32.7% at 4 years (p = 0.021), whereas that of anxiety increased from 15.3% to 21.6% (p = 0.049). PTSD prevalence decreased from 5.1% to 2.7% (p = 0.549). Distinct change patterns were observed for anxiety-minimal (scores < 4) and decreasing, mild (scores ≥ 4) and increasing, and moderate (scores ≥ 8) and stable; for depression-minimal (scores < 4) and stable, mild (scores ≥ 4) and increasing, and moderate (scores ≥ 8) and stable; and for PTSD-minimal (scores < 4), mild (scores ≥ 4), and moderate (scores ≥ 10) symptoms that remained stable. Participants with higher education had a lower risk of exhibiting the moderate-stable depression change patterns (adjusted odds ratio: 0.25, 95% confidence interval: 0.09-0.68, p = 0.006).

Conclusions: Mental health disorders in ICU survivors persist for a long term, with the prevalence of depression increasing over 4 years. Multiple change patterns were observed for each disorder, suggesting various progression courses. Participants with high education were protected from severe depression and its change patterns. These findings highlighted the importance of extended follow-up care and individualized interventions based on the change patterns and associated predictors.

Background: Prolonged mechanical ventilation is associated with an increased incidence of complications and higher mortality rates. Therefore, it is crucial to wean patients from mechanical ventilation as soon as possible. Recently, diaphragmatic ultrasound has been used in this decision-making process. This systematic review evaluated the effectiveness of diaphragmatic ultrasound to improve ventilator liberation outcomes.

Methods: We searched three databases - MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. We included randomized control trials that compared the use of diaphragmatic ultrasound to standard care in adult patients on mechanical ventilation via tracheal intubation. We assessed risk of bias for included trials with the Cochrane Risk of Bias Tool and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation tool. For dichotomous outcomes, we reported risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we reported mean differences (MD) with 95% CIs if all retrieved records provide data on the same scale. The primary outcome was incidence of reintubation within 48 h of extubation and the secondary outcomes included duration of mechanical ventilation, incidence of reintubation rate after 48 h, ICU length of stay, and adverse events.

Results: We found five relevant randomized controlled trials involving a total of 508 participants on mechanical ventilation in ICU following respiratory failure or surgery. Three studies (268 participants) provided data on the incidence of reintubation within 48 h of extubation. Using diaphragmatic ultrasound to guide extubation decisions led to a significant reduction in the risk of reintubation within 48 h (RR 0.62, 95% CI 0.41 to 0.95, low certainty of evidence). No significant differences were found in the duration of mechanical ventilation (MD - 1.39 h, 95% CI - 17.5 to 14.71 h, three studies, 268 participants, very low certainty of evidence) or reintubation after 48 h (RR 0.38, 95% CI 0.11-1.29, two studies, 240 participants, moderate certainty of evidence). However, ICU length of stay was significantly reduced in the diaphragmatic ultrasound group (MD - 1.0 days, 95% CI - 1.74 to - 0.26 days, one study, 130 participants, low certainty of evidence).

Conclusion: Using diaphragmatic ultrasound in addition to standard clinical criteria to guide decisions around ventilator use and liberation resulted in a reduced risk of reintubation within 48 h of extubation when compared to standard clinical criteria alone.

Systematic review registration: This systematic review was registered with the Open Science Framework: https://osf.io/cn8xf .

Background: Corticosteroids improve the outcomes of severe pneumonia; however, the most effective type remains unknown. In this study, we compared the mortality rates of patients with severe pneumonia who were treated with methylprednisolone versus those treated with hydrocortisone.

Methods: In this retrospective observational study, we utilized a nationwide Japanese Diagnosis Procedure Combination inpatient database to include adult patients with severe pneumonia who were admitted to hospitals between April 2017 and March 2022 and received either methylprednisolone or hydrocortisone. Propensity score matching was used to adjust for measured confounders, with in-hospital mortality as the primary outcome.

Results: Among the 5,084 eligible patients, 623 matched pairs were analyzed. In-hospital mortality rates were 23.9% in the hydrocortisone group and 19.4% in the methylprednisolone group (risk difference [RD], 4.5%; 95% confidence interval [CI] -0.082 to 9.1; p = 0.054). Subgroup analysis of patients with shock demonstrated significantly higher mortality in the hydrocortisone group than in the methylprednisolone group (44.7% versus 30.1%; RD, 14.6%; 95% CI 1.4-27.8; p = 0.031).

Conclusion: No significant difference in in-hospital mortality was observed between patients with severe pneumonia treated with methylprednisolone and those treated with hydrocortisone. Nevertheless, patients experiencing severe pneumonia-induced septic shock may derive benefits from methylprednisolone treatment.

Background: Given the conflicting results regarding the clinical outcomes of venoarterial extracorporeal membrane oxygenation (VA-ECMO) based on etiology, its benefit for patients with cardiogenic shock (CS) remains controversial. This study aimed to report the real-world clinical outcomes of VA-ECMO treatment for patients with CS, based on the presence of acute myocardial infarction (AMI).

Methods: Patients treated with peripheral VA-ECMO between 2008 and 2023 at a tertiary cardiovascular center were included and classified into two groups based on CS etiology (AMI-CS and non-AMI-CS). Logistic regression models were used to compare in-hospital mortality and to identify prognostic predictors.

Results: Among the 667 patients included, 264 (39.6%) were classified as having AMI-CS. The rate of cardiac arrest before VA-ECMO initiation was higher in the AMI-CS group than in the non-AMI-CS group (69.7% vs. 55.8%; P < 0.001). Patients in the AMI-CS group were older (66 vs. 61 years; P < 0.001), more likely to be male (82.6% vs. 57.3%; P < 0.001), and had a lower left ventricular (LV) ejection fraction (20% vs. 25%; P < 0.001) than those in the non-AMI-CS group. The AMI-CS group had a lower in-hospital mortality rate (58.6% vs. 69.7%; odds ratio, 0.46; 95% confidence interval, 0.29-0.75; P = 0.002) compared with the non-AMI-CS group. The independent predictors of favorable clinical outcomes after VA-ECMO included younger age, shorter cardiac arrest duration, absence of severe LV dysfunction, absence of renal replacement therapy, higher hemoglobin levels, higher arterial pH, and lower lactate levels. The association between in-hospital mortality and AMI-CS was also demonstrated in the propensity score matching analysis.

Conclusions: In this single-center study, AMI-CS was associated with a lower in-hospital mortality than non-AMI-CS after VA-ECMO treatment.

Despite advances in treatment and the expansion of standard care, pneumonia remains a major cause of mortality. It frequently leads to complications such as septic shock and acute respiratory distress syndrome (ARDS), both of which carry high fatality rates. Although antimicrobial therapy is the cornerstone of treatment, additional supportive care and adjunctive therapies, such as corticosteroids, are often required, especially in severe community-acquired pneumonia (CAP).Recent updates to major guidelines on CAP, sepsis, ARDS, and critical illness-related corticosteroid insufficiency generally support corticosteroid use in severe CAP. However, the REMAP-CAP randomized controlled trial, published in 2025, failed to demonstrate significant benefit, potentially influencing future recommendations. Currently, corticosteroid therapy should be individualized based on CAP severity, particularly the degree of hypoxemia and respiratory failure. In eligible patients, early initiation and flexible duration of corticosteroid use based on clinical response may be appropriate. For nonbacterial pneumonia, strong evidence supporting corticosteroid use exists only for COVID-19 and Pneumocystis jirovecii pneumonia in HIV-infected individuals. Conversely, observational data do not support corticosteroid use for influenza or fungal infections. In CAP complicated by septic shock or ARDS, corticosteroid use is endorsed by recent guidelines; however, the recommended timing, dosage, and duration vary. Although combination therapy with hydrocortisone and fludrocortisone is a potential option, further direct evidence is needed. Biomarkers such as C-reactive protein and, in the near future, insights into corticosteroid-related immune repair mechanisms in COVID-19 may aid in identifying corticosteroid-responsive phenotypes.

Background: Cardiogenic shock (CS) is a severe hemodynamic condition with high mortality. Although extremely frequent in daily practice, the impact of anemia in CS is largely unknown. This study focuses on the consequences of low hemoglobin (Hb) level on the outcomes of CS patients.

Methods: FRENSHOCK is a prospective registry including 772 CS patients from 49 centers. One-month and one-year mortalities were analyzed according to the admission level of Hb.

Results: Among 754 patients, 71.8% were male, with a mean age of 65.8 (± 14.8) years, and 361 (47.9%) presenting with anemia. Four groups were defined, depending on admission Hb levels by quartiles: Q1: Hb < 11.0 g/dL, Q2: Hb 11-12.6 g/dL, Q3: Hb > 12.6-14 g/dL, and Q4: Hb > 14.0 g/dL. Patients from the Q1 group required more frequent renal replacement therapy and norepinephrine. A significant increase in all-cause mortality was observed across Hb quartiles at 1 month (Ptrend = 0.035) and 1 year (Ptrend < 0.01). Q1 patients had 1.64 times higher mortality at 1 month (1.09-2.47, p = 0.02) and 2.53 times higher mortality at 1 year (1.84-3.49, p < 0.01) compared to Q4. The negative effect of low Hb level was confirmed in multivariate Cox regression adjusted for baseline characteristics, and was stronger in men, non-ischemic CS, patients without CKD and patients aged < 67 years.

Conclusion: Anemia is a common condition frequently intertwined with CS worsening both short- and long-term mortality. Further randomized studies are warranted to understand its mechanisms and adapt the transfusion strategy.