Journal of Intensive Care Medicine最新文献

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

PurposeCritical Care Echocardiography (CCE) is now a major tool in assessments of ICU patients. We aimed to evaluate its clinical impact in patients admitted to the intensive care unit for acute respiratory failure (ARF) or shock.MethodsWe conducted a single-center retrospective observational study of all patients admitted between January 1th and December 31st 2019 for ARF or shock, who received CCE in the first 12 h of admission. The primary outcome was the therapeutic impact associated with CCE. Secondary outcomes included differences in therapeutic impact between ARF and shock patients, and between trans-thoracic (TTE) and trans-esophageal (TEE) CCE.Results486 patients were potentially eligible, 109 were excluded because CCE was performed after 12 h or because of missing CCE report. 329 patients were analyzed, 31% with shock, 44% with ARF, 25% with both. TTE was performed in 71%, TEE in 29%. All TEE patients were invasively mechanically ventilated and 65% of invasively ventilated patients underwent TEE. No TEE-related complications were observed. CCE was followed with 363 therapeutic interventions in 231 (70%) patients within 2 h. The most common involved hemodynamic optimization in 193 patients (59%), including fluid expansion (129 patients, 39%), vasopressor initiation (39 patients, 12%), vasopressor dose adjustment (79 patients, 24%), inotrope initiation (15 patients, 4.5%), inotrope dose adjustment (5 patients), and others like cardioversion (4 patients) and veno-arterial ECMO implantation (3 patients). TEE patients were more likely to receive therapeutic changes, notably significantly more fluids (53% vs 34% p = 0.0014) and had more frequent vasopressor dose adjustments (64% vs 24% p < 0.001).ConclusionsCCE was followed with therapeutic interventions in nearly 70% of patients admitted for ARF or shock, emphasizing its diagnostic value. Hemodynamic optimization was the primary intervention. We have not found any complications or adverse events of TEE in our cohort.

Objectives: Early rehabilitation of critically ill patients has been reported to have benefits such as recovery of physical function at the time of discharge and increasing ventilator-free days, but there is also a risk of increasing the mortality rate. Whether early rehabilitation for patients with septic shock is associated with mobilization during their intensive care unit (ICU) stay without worsening the survival rate was investigated. Design: The Best Available Treatment for septic SHOCK (BEAT-SHOCK) registry was a multicenter, prospective, cohort study. Setting: Twenty ICUs in Japan. Patients: Patients with septic shock requiring high-dose norepinephrine (≥0.2 µg/kg/min) who were admitted to participating ICUs for more than 5 days from 2020 to 2022. Interventions: Early rehabilitation within 48 h after ICU admission for patients with septic shock. Measurements: The primary outcomes were sitting on the edge of the bed and standing within 14 days during the ICU stay, with secondary outcomes including 28-day mortality and 90-day mortality. Main Results: Of 268 patients, 156 underwent early rehabilitation. The early rehabilitation and no early rehabilitation groups had similar median ages (72 vs 73 years) and Acute Physiology And Chronic Health Evaluation II scores (28 vs 26). Early rehabilitation had a significant effect on sitting on the edge of the bed within 14 days after ICU admission (adjusted hazard ratio [aHR] 1.66; 95% confidence interval [CI] 1.15-2.39). It also had a significant effect on standing within 14 days after ICU admission (aHR 2.20; 95%CI 1.29-3.77). The 90-day mortality rate was similar between the groups (early rehabilitation group: 28%, no early rehabilitation group: 23%, P=0.51), with an aHR of 1.27 (95%CI 0.78-2.08). Conclusion: Early rehabilitation for patients with septic shock was associated with mobilization during their ICU stay without worsening the survival rate.[Trial registration: UMIN clinical trial registry, UMIN000038302. Registered November 1, 2019, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000043641].

ObjectiveTo evaluate the implementation of a blood culture algorithm in a mixed medical-surgical ICU at a community hospital, and examine the association with blood culture utilization rate and patient outcomes. Design: A quasi-experimental study examining pre- and post-implementation periods. Setting: A 22-bed mixed medical-surgical ICU at a community hospital. Patients: Adult ICU patients were admitted between February 2022 and October 2024, excluding those with neutropenia (<500 cells/μL) or solid organ transplants. Intervention: Introduction of a multidisciplinary-developed blood culture algorithm designed to standardize ordering practices for new clinical events and clearance of bacteremia. Measurements and Main Results: Primary outcomes included blood culture event rates. Secondary outcomes were antibiotic days of therapy, mortality, and readmissions. Interrupted time series analysis using Poisson regression models were used to examine associations between the intervention and clinical outcomes. The intervention reduced blood culture event rates by 39% (IRR 0.61, 95% 0.49, 0.75) without significantly decreasing adverse events such as 90-day death incidence (5.7% vs 7.2%, p-value 0.44) and 30-day hospital readmission (11.0% vs 8.0%, p-value 0.11). Inappropriate blood culture rates also decreased. Conclusions: Implementation of a blood culture algorithm in a community ICU setting was associated with reduced blood culture utilization without compromising patient safety. The intervention may substantially reduce unnecessary blood cultures, addressing a key gap in diagnostic stewardship in non-academic settings.

BackgroundStatins have well-established pleiotropic effects by interrupting delirium pathogenesis through their anti-inflammatory, immunomodulatory, and antithrombotic properties. The literature presents conflicting findings regarding the effects of statins on critically ill patients. It remains unclear whether the pleiotropic properties of statins and their influence on delirium are influenced by their lipophilicity, agent-specific, or statin intensity. This study aims to evaluate the impact of statin intensity on the risk of delirium in critically ill patients.MethodThis is a multicenter, retrospective cohort study that included adult patients aged 18 years and older who received statin therapy and were admitted to the intensive care units (ICUs). Patients were categorized into high-intensity versus low-moderate intensity groups. The primary endpoint was the occurrence of delirium. The secondary endpoints were delirium recurrence during the same ICU admission, delirium-free days (DFDs) within 60 days, mortality, hospital and ICU length of stay. A propensity score (PS) matching procedure (SAS, Cary, NC) was used at a 1:1 ratio. Multivariable logistic regression was used to determine the adjusted p-value and odds ratio for outcomes.ResultsAfter PS matching, a total of 1054 patients were included, 527 patients in each statin group. The odds of delirium and delirium recurrence were not significantly different between the two groups (OR: 1.10, 95% CI: 0.77, 1.57, P = 0.59 and OR: 0.92, 95% CI: 0.44,1.94, P = 0.84, respectively). Moreover, there was no statistically significant difference between the two groups in terms of delirium-free days (DFDs), mortality, and ICU length of stay. In contrast, patients who received the high-intensity statin had a significantly shorter duration of hospital length of stay than the low-intermediate group (beta coefficient: -0.12, 95% CI: (-0.23, -0.01), P = 0.04).ConclusionThe use of high-intensity statins in critically ill patients admitted to ICUs was not associated with a lower risk of delirium compared to low-moderate intensity statins. Further studies are required to confirm and explore various hypotheses and deepen the understanding of this correlation.

BackgroundPersistent inflammation, immunosuppression, and catabolism syndrome (PICS) that develops following critical illness is one of the most challenging issues in critical care medicine. While corticosteroids are widely used in septic shock, their impact on PICS remains unclear. While corticosteroids may reduce inflammation, they potentially increase infection risk and affect muscle function.MethodsThis retrospective cohort study analyzed 3186 patients with septic shock from a Japanese administrative claims database, which was supplied by Medical Data Vision Co., Ltd (Tokyo, Japan). Using propensity score matching, we compared outcomes between patients who received corticosteroids within the first two days of admission (steroid group) and those who did not (control group). The primary outcome was the incidence of PICS on day 28, defined as meeting at least two of the following criteria: C-reactive protein >2.0 mg/dL, albumin <3.0 g/dL, and lymphocyte count <800/μL.ResultsA total of 4054 patients were enrolled in this retrospective cohort study. After the exclusion of 868 patients, 3186 eligible patients (906 in the steroid group and 2280 in the control group) were included in the propensity score analysis. After matching, there was no significant difference in the incidence of PICS on day 28 between the steroid and control groups (16.7% vs 13.6%; risk difference, 2.22%; 95% CI, -1.89% to 6.34%; P = 0.095). Additionally, no significant differences were observed in 28-day mortality (15.2% vs 15.2%), in-hospital mortality, PICS on day 14, the Barthel Index at discharge or the percentage of patients meeting PICS criteria for each component on day 14 and day 28.ConclusionsThe administration of corticosteroids in patients with septic shock was not associated with the incidence of PICS.

BackgroundLiving donor hepatectomy is a major surgical procedure associated with significant postoperative pain. Effective analgesia is essential to enhance recovery and ensure donor safety. Traditional approaches such as epidural analgesia are effective but may raise safety concerns due to perioperative coagulopathy. Spinal analgesia using intrathecal morphine (ITM) has emerged as a potential alternative, providing long-lasting pain relief with a favorable safety profile.MethodsThis systematic review was conducted following PRISMA guidelines and registered in PROSPERO (CRD420251149887). PubMed and EMBASE were searched from January 2000 to September 2025 for randomized and observational studies evaluating spinal analgesia in living donor hepatectomy. Outcomes included pain intensity, opioid consumption, and complications. Study quality was assessed using the Oxford Centre for Evidence-Based Medicine (OCEBM) levels and the RoB 2 tool.ResultsThe initial search revealed a total of 937 publications. After duplicate removal, 932 articles were eligible for screening from title and abstract, and 920 were excluded . The remaining 12 articles were then eligible for full-text review. Among these, 4 studies were excluded (abstract N = 1; letter to the editor or commentaries N = 1; no full text available N = 1; review N = 1). Eight studies involving 698 patients were included (seven randomized trials and one retrospective study). Spinal analgesia, mainly using 300-400 µg ITM, provided effective pain relief and reduced opioid consumption compared with intravenous patient-controlled analgesia, thoracic epidural analgesia, wound infiltration, and some fascial plane blocks. Adverse effects such as pruritus, nausea, and vomiting were common but mild and self-limiting; respiratory depression was rare.ConclusionsIntrathecal morphine provides effective and durable postoperative analgesia in living liver donors, reducing opioid use and avoiding the risks of epidural catheterization. Despite promising results, evidence remains limited by small sample sizes and study heterogeneity. High-quality multicenter trials are needed to define optimal dosing and integrate spinal analgesia into multimodal enhanced recovery protocols for donor hepatectomy.

Rituximab, a chimeric monoclonal antibody targeting CD20 on B cells, has become an important therapeutic agent in the intensive care unit (ICU) for a range of immune-mediated conditions. This review explores the current indications, pharmacological rationale, and practical considerations for rituximab use in the ICU. Key indications include autoimmune haemolytic anaemia, thrombotic thrombocytopenic purpura, haemophagocytic lymphohistiocytosis, autoimmune encephalitis, myasthenia gravis, and ANCA-associated vasculitis. In these conditions, rituximab often serves as a second-line or salvage therapy, particularly when corticosteroids or conventional treatments fail. Its role in respiratory failure related to inflammatory myopathies, such as anti-synthetase and anti-MDA-5 syndromes, is emerging. While generally well-tolerated, rituximab carries risks of infusion reactions, infectious complications, hematologic toxicity, and rare organ-specific adverse events. Given the increasing use of rituximab across diverse critically ill populations, intensivists must be familiar with its indications, benefits, and risks to optimize patient outcomes.

Liver transplantation (LT) remains the definitive treatment for end-stage liver disease, but it continues to face two major challenges: ischemia-reperfusion injury (IRI), which compromises graft function, and a critical shortage of suitable donor organs. To address the latter, the use of marginal grafts from extended criteria donors (ECD) and donation after circulatory death (DCD) has increased, although these organs are more susceptible to IRI. This review aims to evaluate the current landscape of machine perfusion (MP) technologies-hypothermic, subnormothermic, and normothermic-and their role in improving graft preservation, function, and utilization in LT. MP has emerged as a promising alternative to static cold storage (SCS), offering the potential to assess graft viability and reduce IRI. Hypothermic machine perfusion (HMP), particularly when oxygenated (HOPE), shows protective effects on the biliary system and may reduce ischemic injury, though data on improved graft survival remain limited. Subnormothermic perfusion is associated with enhanced ATP restoration and reduced cold-induced injury in preclinical models but lacks robust clinical validation. Normothermic machine perfusion (NMP) allows real-time functional assessment and supports active metabolism, with clinical trials demonstrating reduced early allograft dysfunction and increased use of marginal grafts. Recent studies suggest that combining techniques, such as HOPE followed by NMP, may offer synergistic benefits, although optimal protocols remain under investigation. Machine perfusion technologies represent a significant advancement in liver transplantation by improving preservation strategies and enabling the use of suboptimal grafts. While NMP appears most promising for functional assessment and extended preservation, HOPE shows particular value in end-ischemic reconditioning. Although MP is not yet a complete replacement for SCS, its potential to improve outcomes and expand the donor pool is increasingly supported by emerging clinical evidence. Further large-scale, randomized trials are essential to determine best practices and establish MP as a standard component of LT protocols.

BackgroundDexmedetomidine is a first-line sedative in intensive care unit (ICU) patients. Dexmedetomidine has a high hepatic extraction ratio, where clearance is primarily determined by hepatic blood flow. In cirrhosis, hepatic blood flow is reduced, and reduced dexmedetomidine clearance may confer increased susceptibility to cardiovascular adverse effects. Drug-induced hypotension can complicate diagnosis and treatment for the ICU-based clinician. This study's objective was to evaluate clinically significant cardiovascular adverse drug reactions (CS CV-ADRs) according to liver disease severity, stratified by the Albumin-Bilirubin (ALBI) grade, in patients with cirrhosis.MethodsThis retrospective, observational, case-control study using inverse probability of treatment weighting with the propensity score assessed adults at an academic medical center in Detroit, Michigan, from July 2018 through June 2023. Critically ill patients with cirrhosis receiving intravenous dexmedetomidine in an ICU were included. Patients experiencing a CS CV-ADR within 24 h of dexmedetomidine initiation were cases and those without a CS CV-ADR were controls. The primary outcome was incidence of CS CV-ADRs stratified by liver disease severity. A CS CV-ADR included a hemodynamic event and clinically relevant intervention each within 60 minutes. A multivariable regression was used to identify predictors of CS CV-ADRs.ResultsA total of 95 cases and 95 controls were included. The median (IQR) time to CS CV-ADR was 2.4 h (1.3-9.8). Liver disease severity was stratified using the ALBI Grade, ranging from ALBI Grade 1 (least severe) to Grade 3 (most severe) disease. ALBI Grade 3 was significantly associated with increased odds of CS CV-ADRs (Adjusted OR 2.25; 95% CI [1.47-3.46]).ConclusionsIncreasing liver disease severity according to ALBI Grade was associated with greater odds of CS CV-ADRs in critically ill patients with cirrhosis receiving dexmedetomidine. ALBI Grade may be an objective tool for predicting adverse effects of dexmedetomidine or development of dose adjustments for liver dysfunction.