Journal of Intensive Care Medicine最新文献

BackgroundNecrotizing lung infections (NLI) are rare yet severe complications of lower respiratory tract infections with high mortality. Due to their scarcity and varying severity, there are no specific guidelines on managing these entities. Incidence and outcomes of NLI in patients on VV-ECMO remains largely unknown.MethodsThis observational cohort study retrospectively analyzed data from a prospective ECMO registry at University Medical Centre Ljubljana. Consecutive adult VV-ECMO patients hospitalized between 2010 and 2023 were screened. Patients with NLI, defined as computed tomography (CT) documented necrotising pneumonia, lung abscess or necrotizing cavitation were identified and included in the analysis.ResultsOut of 125 VV-ECMO patients with severe respiratory failure due to lung infections, 38 (30.4%) had NLI. Majority of patients (71%) initially presented with viral pneumonia with secondary bacterial superinfection and most had multi-lobar involvement (73.7%). There was considerable overlap of all necrotizing entities. Duration of hospitalization prior to ECMO initiation was the only significant factor determining patient outcome (2 days in survivors vs 8 days in non-survivors, p = 0.04), while duration of mechanical ventilation prior to cannulation had no significant effect on patient outcome. Although not statistically significant, survival rates were considerably higher in patients who primarily presented with community-aquired pneumonia compared to those with hospital-aquired pneumonia (38% vs 14%). Patients with additional complications like empyema or bronchopulmonary fistula had poor outcomes, with only 5% survival. Surgical lobectomy was performed in 5 (13%) patients, all patients died. Nine (24%) patients survived to ICU and hospital discharge and were still alive at 1-year follow-up.ConclusionsIncidence of NLI in VV ECMO patients is higher than reported in non-ECMO population. Surgical interventions were not successful in this cohort. Considering the combination of severe respiratory failure and necrotising complications, overall survival rate of respiratory ECMO patients with NLI is still reasonable.

The unprimed right ventricle is exquisitely sensitive to acute elevations in afterload. High pulmonary vascular tone incurred with acute pulmonary embolism has the potential to induce obstructive shock and circulatory collapse. While emergent pulmonary reperfusion is essential in severe circumstances, an important subset of pulmonary embolism patients may exhibit a less extreme presentation posing a management dilemma. As intensive care therapies have the potential to both salvage and harm the failing right ventricle, a keen understanding of the pathophysiology is requisite in the care of the contemporary patient with hemodynamically significant pulmonary embolism. Here, we review right ventricular pathophysiology, an approach to risk stratification, and offer guidance on the medical and mechanical supportive and therapeutic strategies for the critically ill patient with acute pulmonary embolism.

Medical device-related pressure injuries (MDRPIs) represent a growing and often overlooked complication in critical care environments. These injuries, result from prolonged contact with essential therapeutic equipment such as endotracheal tubes, catheters, and monitoring devices, posing a significant threat to patient safety and recovery.This systematic review synthesizes current research on the incidence and prevalence of MDRPIs in intensive care units, highlighting key risk factors including immobility, impaired perfusion, and the complexity of care in critically ill populations. Attention is drawn to the variability in reporting standards and methodological inconsistencies across studies, which obscure the true burden of MDRPIs globally. In examining evidence from diverse healthcare systems, this review emphasizes the urgent need for standardized protocols, early detection strategies, and multidisciplinary approaches to prevent device-related tissue damage. Addressing this silent threat is vital not only to improve patient outcomes but also to reduce healthcare-associated costs and strengthen the culture of safety in critical care settings.

PurposeTo characterize post-intensive care syndrome (PICS) in critical patients who survived COVID-19 during the first pandemic wave and to follow PICS symptoms during one year.Material and methodsProspective, observational, multicenter cohort study conducted in 11 Spanish ICUs. Critically ill adult patients who survived SARS-CoV-2 infection and met risk criteria for PICS were included. In-person follow-up was conducted at 3, 6, and 12 months after hospital discharge, assessing physical, cognitive, psychological, and nutritional aspects, quality of life and return to daily activities.ResultsA total of 227 patients were included, of which 120 (52.9%) completed the 3 follow-up visits. Hand dynamometry showed muscle weakness in 40.9% of patients at 3 months, with improvement over time. Anxiety, depression, post-traumatic stress disorder (PTSD) and cognitive impairment were observed in 32.9%, 24.3%, 13.8% and 46.1% of patients, respectively, at 3 months. While anxiety, depression and cognitive impairment slightly decreased over time, PTSD did not. Nutritional risk was significant at 3 months (42.4%), with gradually recovering (3.9% at 1 year). Patients' autonomy, and perception of physical and mental quality of life, improved over the months. At 3 months, 35% of patients had returned to work, and 58.3% at one year. A significant percentage of patients required assistance from physical therapy and mental health professionals after discharge.ConclusionSignificant impairment was observed in all areas of PICS in critically ill patients with COVID-19, with progressive improvement over one year of follow-up, with the adoption of physical, mental, cognitive, and nutritional support measures.

BackgroundTraumatic brain injury (TBI) is a leading cause of death and permanent disability, with the burden being higher in low- and middle-income countries (LMICs). Effective management during the acute phase is critical for improving survival and long-term outcomes. For this reason, evidence-based decision-making is essential to delivering consistent, high-quality care. The objective of this review is to assess the safety and effectiveness of standardized care in adults with moderate or severe TBI in LMICs.Materials and MethodsA literature search was conducted in MEDLINE/PubMed, Embase, CENTRAL, LILACS, ClinicalTrials.gov and WHO-ICTRP. Conference proceedings from NCS, SCCM, and ESICM were searched for unpublished studies. Randomized controlled trials (RCTs) and non-randomized (NRSs) controlled studies comparing protocolized with non-protocolized care for patients 14 years or older with acute moderate or severe TBI in LMICs were included. Studies were independently assessed for inclusion, data extraction, and risk of bias. Study flaws were assessed using the Cochrane risk of bias tool, and quality-of-evidence using the GRADE approach.ResultsSeven studies were included, involving a total of 1821 participants. Five of these employed a quasi-experimental before-and-after design, while two used a quasi-experimental design with a non-equivalent control group. NRS recruited participants from Cuba, Argentina, Bolivia, Ecuador, Venezuela, Uruguay, Colombia, Brazil, Egypt, and Thailand. All included studies were deemed to have a high risk of bias. Very low to low-quality evidence suggests that protocolized care may provide benefits for adults with moderate to severe TBI in LMICs, including reduced mortality, improved cognitive outcomes, decreased hospitalization-related complications, and increased satisfaction with the care process. However, there appears to be little or no effect on quality-of-life scores and length of hospital stay. The impact of standardized care on functionality, language processing abilities, and ICU stay remains uncertain.ConclusionsVery low-quality evidence suggests that protocolized care may provide benefits for adults with moderate to severe TBI in LMICs. Higher-quality research is imperative to rigorously assess the safety and effectiveness of this intervention.PROSPERO registration numberCRD 420251074998.

BackgroundOpioid stewardship is central to postoperative critical care, yet the prognostic value of short-term opioid dose escalation in the intensive care unit (ICU) remains unclear. In non-ICU settings, escalating opioid requirements have been associated with poorly controlled pain, postoperative complications, and increased readmission rates. Whether similar relationships exist in critically ill postoperative patients has not been established.ObjectiveTo determine whether early postoperative opioid escalation during the first 72 hours after major surgery is associated with 90-day hospital readmission among ICU patients.MethodsThis retrospective cohort study used the publicly available Medical Information Mart for Intensive Care IV (MIMIC-IV, version 3.1) database (2008-2022). Adults aged ≥ 18 years admitted to the ICU after major orthopedic, general, or neurosurgical procedures were included. Opioid escalation was defined as total morphine milligram equivalents (MME) administered during hours 48-71 exceeding twice the MME during hours 0-23 after ICU admission. The primary outcome was all-cause hospital readmission within 90 days of discharge. Multivariable logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs), controlling for age, sex, Charlson Comorbidity Index (CCI), and surgical category.ResultsOf 613 patients analyzed, mean (SD) age was 65 (15) years and 342 (55.8%) were male. Opioid escalation occurred in 126 patients (20.6%), and readmission in 229 (37.4%). In multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, and surgical category, escalation was not associated with readmission (adjusted odds ratio, 1.05; 95% CI, 0.68 to 1.63; P = .83).ConclusionsIn critically ill postoperative patients, short-term opioid escalation was not associated with 90-day readmission. These null findings suggest escalation may be a poor-quality metric in the intensive care unit due to high baseline opioid exposure and continuous monitoring. Further evaluation in non-intensive care unit settings is warranted.

BackgroundTo investigate the clinical significance of peak systolic velocity (PSV) variation of superior mesenteric artery (SMA) in predicting gastrointestinal dysfunction in septic patients.MethodsA clinical observational study was accomplished in our department. The SMA PSV values on days 1-3 after admission and the PSV variation were measured. The gastrointestinal dysfunction score (GIDS), the numbers of patients with feeding intolerance (FI) symptoms during enteral feeding, and the FI days were recorded. The clinical characteristics, inflammatory biomarkers levels, and disease severity and outcome variables were also collected.ResultsA total of 111 septic patients were enrolled during the study period. The median SMA PSV was 84.4 cm/s on admission. The PSV variation was negatively correlated with GIDS on day 3 (R² = 0.376), GIDS on day 7 (R² = 0.371), and FI days (R² = 0.266) at a moderate strength, whereas was positively correlated with the ICU-free days (R² = 0.116) at a weak strength. Moreover, the PSV variation had a notable value to predict the development of GIDS >2, feeding intolerance, and 28-day mortality. We divided patients into three groups on basis of PSV variation values: -30% < variation ≤ -10% (Group A), -10% < variation ≤ 10% (Group B), and 10% < variation ≤ 30% (Group C). Patients in Group A had increased severity scores, serum levels of procalcitonin, interleukin (IL)-6, IL-10, C-reactive protein, and white blood cell counts compared to those in Group B and C (P < .01). The Group A had increased GIDS, FI incidence, FI days, and 28-day mortality compared to the other two groups (P < .001). The days free of mechanical ventilation and continuous renal replacement therapy in Group A were also lower than those in Group B and C (P < .001).ConclusionThe SMA PSV variation may be correlated with gastrointestinal function in sepsis.

IntroductionElevated serum cortisol levels at the onset of septic shock have been linked to increased mortality. However, their relationship with hemodynamic recovery, particularly shock reversal, has not been well studied.MethodsWe conducted a prospective cohort study at Srinagarind Hospital, Thailand, between June 2019 and December 2021, enrolling adult patients diagnosed with septic shock in the emergency department. Serum cortisol levels and illness severity (SOFA and APACHE III scores) were assessed at diagnosis. Shock reversal was defined as vasopressor discontinuation with sustained mean arterial pressure ≥ 65 mm Hg for 24 h.ResultsOf 81 enrolled patients, 58 (71.6%) achieved shock reversal within 72 h. Higher serum cortisol levels were independently associated with a lower probability of shock reversal at 72 h (HR per 1 µg/dL increase: 0.95, 95% CI: 0.92-0.97) and with reduced likelihood of early shock control at 6 h (HR: 0.96, 95% CI: 0.93-0.99). Compared with cortisol < 18 µg/dL, levels of 18-30 µg/dL and > 30 µg/dL were associated with substantially lower probabilities of 72-h shock reversal (HR: 0.31, 95% CI: 0.15-0.64; HR: 0.17, 95% CI: 0.08-0.37, respectively). Each 10 µg/dL increase in cortisol corresponded to a 0.64-point increase in SOFA score at 72 h (95% CI: 0.28-1.0). No significant association was observed with 28-day mortality.ConclusionElevated serum cortisol at the onset of septic shock independently predicted delayed shock reversal and a lower likelihood of early shock control, but was not associated with 28-day mortality.

BackgroundDisseminated intravascular coagulation (DIC) is a complex hemostatic disorder characterized by simultaneous thrombosis and bleeding and is frequently observed in sepsis. Traditional coagulation assays such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) primarily assess the initiation of clot formation but fail to capture the dynamic balance between procoagulant and anticoagulant forces. The thrombin generation (TG) assay provides a more comprehensive evaluation of coagulation, incorporating both propagation and decay phases, and may offer additional insight into sepsis-associated coagulopathy. This study investigated the diagnostic and prognostic utility of TG parameters across graded stages of DIC in septic intensive care unit (ICU) patients.MethodsIn this prospective observational study, 53 adult septic ICU patients contributed 151 plasma samples obtained longitudinally. Patients were classified as non-DIC, non-overt DIC, or overt DIC according to International Society on Thrombosis and Haemostasis criteria. Standard coagulation parameters and TG profiles were measured. Associations with DIC severity were examined using cumulative link mixed models with patient-level random effects. Sensitivity analyses explored transition-specific TG behavior. ICU mortality was evaluated using multivariable logistic regression and ROC analysis.ResultsIn univariate analyses, both conventional coagulation markers and TG parameters were associated with increasing DIC severity. In the final multivariable model, prolonged PT and aPTT, elevated D-dimer, and lower platelet count were the strongest independent predictors of DIC severity, whereas StartTail provided complementary kinetic information. Longitudinal analyses demonstrated progressive prolongation of StartTail and attenuation of reverse velocity index with advancing DIC stage and increasing SOFA scores, indicating worsening dysregulation of thrombin inactivation.ConclusionTG parameters, particularly late-phase kinetic features, reflect dynamic and stage-specific dysregulation of coagulation in sepsis-associated DIC. Although TG measures do not outperform conventional coagulation tests, they provide complementary mechanistic insight into thrombin regulation and consumptive coagulopathy. Larger multicenter studies are warranted to validate these findings.

BackgroundSepsis-associated acute kidney injury (s-AKI) is a frequent and severe complication in patients with intra-abdominal infections, however, early prediction remains challenging. This study aimed to evaluate the predictive value of the mean arterial pressure(MAP) to the renal resistive index(RRI) ratio (MAPRRI) for s-AKI in this population.MethodsIn this single-center, retrospective observational study, 530 patients with sepsis secondary to intra-abdominal infections were enrolled between January 2021 and December 2024. Participants were classified into AKI and No-AKI groups on the basis of the KDIGO criteria. Univariate and multivariate logistic regression analyses were performed to identify risk factors for AKI. Propensity score matching (PSM) was applied to reduce confounding effects. Receiver operating characteristic (ROC) curves were generated to assess the predictive performance of MAPRRI, MAP, and RRI.ResultsAmong the 530 patients, 104 (19.62%) developed AKI. Multivariate analysis revealed that the MAPRRI was an independent predictor of s-AKI (OR 0.861, 95% CI: 0.830-0.893; p < 0.001). After PSM, the MAPRRI remained significantly lower in the AKI group (84.6 vs 87.8, p < 0.001) and predicted s-AKI with an AUC value of 0.821 (95% CI: 0.760-0.881), outperforming MAP (AUC = 0.758, p = 0.003) and the RRI (AUC = 0.708, p < 0.001) alone. The optimal MAPRRI cutoff was 101.3, with 88.5% sensitivity and 68.1% specificity.ConclusionCompared with individual parameters, the MAPRRI is a strong independent predictor of s-AKI in septic patients with intra-abdominal infection and has superior predictive ability. It shows promise for early risk stratification and merits further multicenter validation.