Journal of Intensive Care Medicine最新文献

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.

ObjectivesHistorically, patients with hematologic malignancies were often declined ICU admission due to anticipated poor outcomes. However, recent publications describe significant improvements in ICU and in-hospital mortality for critically ill patients with hematologic malignancies. It is unclear whether clinicians' perceptions of outcomes in this patient population have changed, or whether there is consensus on management. This study evaluated intensivist and hematologist perceptions of prognosis in critically ill patients with hematologic malignancies and identified factors that inform their decision-making.DesignWe conducted an electronic cross-sectional survey of Canadian intensivists and hematologists. The survey included 19 questions and a case-based scenario with variations in clinical factors. The survey data were summarized using frequency with percent. Data was compared between intensivists and hematologists using χ² tests for categorical data. A post-hoc analysis of secondary variables was also conducted using χ² tests.ResultsA total of 180 clinicians responded to the survey - 63% were intensivists, 36% hematologists and 1% dually trained. Most clinicians reported using a variety of cancer-, patient- and critical illness-related factors for prognostication, and most demonstrated awareness of factors associated with worse prognosis in this patient population. When presented with a hypothetical case, survey results revealed consensus on admitting the patient to ICU but variability in limitations to treatment and goals of care. Additionally, we found wide variability in predicted patient outcomes. There was significant variability in decision-making around withdrawal of life sustaining therapies, but minimal between-group differences between intensivist and hematologist responses.ConclusionsThis study found significant variation among clinicians in predicting prognosis for critically ill patients with hematologic malignancies, although concordance between intensivists and hematologists overall. Further study examining factors affecting prognosis and long-term outcomes for this patient population will help guide clinicians and better inform decisions about medical care.

PurposeDespite the need for advanced hemodynamic monitoring, the role of the pulmonary artery catheter (PAC) in cardiogenic shock (CS) remains controversial due to conflicting evidence from previous studies.Material and MethodsThis single-center retrospective study utilized the MIMIC-IV database to assess the impact of PAC use on 30-day in-hospital mortality and clinical outcomes in CS patients admitted between 2008 and 2019. Propensity score matching (PS) and inverse propensity treatment weighting (IPTW) were employed to adjust for baseline differences. The primary outcome was 30-day in-hospital mortality; secondary outcomes included hospital and ICU length of stay and complications. Cox proportional hazard ratio analyses were performed to evaluate the association between PAC use and mortality outcomes.ResultsThe final cohort consisted of 1940 adult CS patients, with 134 receiving PAC and 1806 not. PAC use significantly reduced 30-day in-hospital mortality (PS-matched HR 0.57, 95% CI: 0.39-0.83; IPTW HR 0.58, 95% CI: 0.35-0.96) but was associated with longer hospital stays (16.47 vs 12.37 days) and ICU stays (9.26 vs 7.52 days).ConclusionPAC use in CS patients was associated with improved short-term survival but also with longer hospitalization and potential complications, underscoring the need for careful patient selection and further research.

BackgroundTo investigate the association between Charlson comorbidity index (CCI) and Intensive care unit (ICU) admission in subgroup aortic aneurysm (AA) patients with different comorbidities.MethodsPatient data (N = 996) was collected from the MIMIC-IV database. The relationship between CCI and ICU admission was analyzed by logistic regression analysis. The receiver operating characteristic curve (ROC) and decision curve analysis (DCA) were used to analyze the prediction efficacy and clinical benefits of CCI. CCI-based models were also established to assess the improvement.ResultsThere were significant differences in age, AA types, rupture, surgery, obesity, and smoking between patients with and without admitting to ICU (all P < 0.05). Among 18 comorbidities, CCI was independently associated with ICU admission mainly reflected in patients with comorbidities of hypertension, coronary heart disease, hyperlipidemia, and congestive heart failure (all P < 0.05). However, singe CCI had limited prediction performance (AUC all less than 0.7) and clinical net benefit in any comorbidities. Combining with other independent factors of ICU admission in 4 key comorbidities specifically, CCI-based models significantly improved the prediction performance and increased clinical net benefit than single CCI. Especially, CCI-based model had the best predictive performance in patients with comorbidity of hypertension (AUC = 0.752).ConclusionsCCI is independently associated with ICU admission in AA patients, with enhanced predictive value when combined with other clinical factors, particularly in those with hypertension.

BackgroundPatients with malignant neoplasms exhibit an elevated risk of sepsis and associated mortality. For septic patients with hemodynamic instability, early albumin administration is recommended, yet its specific impact in cancer-related sepsis remains unclear. This study aims to explore the relationship between early albumin administration and prognostic outcomes in patients with solid malignant neoplasms complicated by sepsis.MethodsThis study employed a retrospective cohort analysis, utilizing data obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV v3.1) database. Patients were categorized into two groups: no-albumin and albumin. Within the albumin group, patients were further subclassified into early-albumin (infusion within 24 h of ICU admission) and late-albumin (infusion more than 24 h after ICU admission but before discharge). The primary endpoint was 28-day in-hospital mortality, while secondary endpoints including in-hospital mortality, length of hospital stay (Los_hospital), and length of ICU stay (Los_ICU).ResultsAmong 3700 eligible patients (2596 no-albumin; 1104 albumin), further subclassification within the albumin group revealed 736 early-albumin and 368 late-albumin patients. After propensity score matching (PSM), 312 pairs (early vs late) were analyzed. Cox regression models showed that early albumin administration significantly improved 28-day survival prospects. Compared to both no-albumin and late-albumin groups, the early-albumin group exhibited a pronounced survival advantage. Additionally, early albumin administration was associated with a shorter ICU stay. Subgroup analyses confirmed benefits across various demographics and clinical characteristics in the early-albumin group.ConclusionsEarly albumin administration within 24 h of ICU admission significantly decreases 28-day and in-hospital mortality and shortens ICU stay in septic patients with solid malignant neoplasms. Our findings suggest that early albumin administration should be integrated into personalized resuscitation strategies for this high-risk population and merit further prospective validation.