Annals of Intensive Care最新文献

Background: Critically ill immunocompromised patients are particularly susceptible to acute kidney injury (AKI) due to various underlying mechanisms. Although invasive mechanical ventilation has been associated with an increased risk of AKI, its specific impact on immunocompromised patients with acute respiratory failure has not been explored. This study aims to describe the prevalence of AKI in this patient population and evaluate the potential risk associated with invasive mechanical ventilation, using causal inference models adjusted for the likelihood of requiring ventilation.

Results: We conducted a post-hoc analysis of 734 immunocompromised patients from the HIGH clinical trial. Of these, 302 (41%) required invasive mechanical ventilation, and 542 (74%) developed AKI. Notably, AKI frequently occurred before the initiation of invasive mechanical ventilation, with the median day of peak KDIGO stage being 2 days (IQR 1-4 days), compared to 3 days (IQR 2-4 days) for initiation of mechanical ventilation. While univariate analysis showed a significant association between invasive mechanical ventilation and AKI (OR = 1.08, 95% CI = 1.02-1.16, p = 0.014), this association was not significant in the multivariate model (OR = 1.05, 95% CI = 0.98-1.13, p = 0.185). Similar findings were observed after adjusting for the risk of invasive mechanical ventilation using overlap weighting and in a competing risk model. Among patients who received mechanical ventilation, 59 (19%) developed AKI after initiation of mechanical ventilation.

Conclusion: Immunocompromised patients with acute respiratory failure face a significant risk of developing AKI, driven by a combination of factors such as their underlying conditions and disease severity. In contrast, the direct impact of invasive mechanical ventilation appears to be limited, suggesting that mechanical ventilation may not be a primary driver of AKI in this vulnerable patient population.

Background: High positive end-expiratory pressure (PEEP) may improve ventilation-perfusion (V/Q) mismatch in acute respiratory distress syndrome (ARDS) patients with high recruitability in supine position. However, impacts of PEEP on V/Q mismatch in prone position relative to supine position remain poorly understood. We aimed to compare PEEP effects between positions, and evaluate its relationship with lung recruitability.

Methods: A total of 50 patients with moderate-to-severe ARDS were consecutively enrolled. Recruitment-to-inflation (R/I) ratio was used to measure baseline lung recruitability. V/Q mismatch, gas exchange, and respiratory mechanics were evaluated at PEEP 5 cm H₂O and PEEP 15 cm H₂O in supine position, followed by PEEP 5 cm H₂O and PEEP 15 cm H₂O in prone position.

Results: Median R/I ratio was 0.60 [0.38, 0.72], separating patients with higher and lower R/I ratio. In patients with higher R/I ratio, PEEP 15 cm H₂O (compared to PEEP 5 cm H₂O) reduced shunt without significantly increasing dead space in both supine and prone positions, thereby improving V/Q mismatch (supine: 30.7 [28.6, 36.8]% at PEEP 15 cm H₂O vs.38.0 [34.9, 45.4]% at PEEP 5 cm H₂O, P < 0.001; prone: 25.7 [21.4, 30.4]% at PEEP 15 cm H₂O vs. 32.8 [27.5, 36.7]% at PEEP 5 cm H₂O, P < 0.001). However, in patients with lower R/I ratio, PEEP 15 cm H₂O (compared to PEEP 5 cm H₂O) in supine position did not improve V/Q mismatch (37.8 [34.7, 42.1]% at PEEP 15 cm H₂O vs. 41.3 [34.8, 45.4]% at PEEP 5 cm H₂O, P = 0.078), as the reduction in shunt was accompanied by a significant increase in dead space; in prone position, PEEP 15 cm H₂O significantly worsened V/Q mismatch (35.9 [28.3, 43.4]% at PEEP 15 cm H₂O vs. 31.7 [24.3, 37.6]% at PEEP 5 cm H₂O, P < 0.001), as it failed to reduce shunt while significantly increasing dead space.

Conclusions: In patients with higher R/I ratio, PEEP 15 cm H₂O improved V/Q mismatch in both supine and positions. In patients with lower R/I ratio, PEEP 15 cm H₂O did not impact V/Q mismatch in supine position but significantly worsened it in prone position.

Objectives: To evaluate the efficacy and safety of Ilaprazole in preventing stress ulcer-associated upper gastrointestinal bleeding in critically ill patients.

Design: A Randomized, Double-Blind, non-inferiority Phase 3 Trial.

Setting: 70 hospitals across China from July 16, 2021, to April 28, 2022.

Patients: 441 Patients (mean age 59 years; 150 female) at high risk for stress ulcer bleeding requiring invasive mechanical ventilation were enrolled.

Interventions: Patients were randomly assigned to receive either Ilaprazole (10 mg once daily, first dose doubled; 220 patients) or esomeprazole (40 mg twice daily; 221 patients).

Measurements and main results: 441 patients (mean age 59 years; 150 female) were enrolled: 220 received Ilaprazole and 221 received esomeprazole. In FAS set, the primary endpoint occurred in 213 (96.80%) patients in the Ilaprazole and 215 (97.30%) in esomeprazole arms (Absolute Risk Difference: -0.47, 95% CI: -4.02, 3.03, p = 0.772). Secondary outcomes showed comparable incidences of clinically insignificant UGI bleeding, any gastrointestinal bleeding, 28-day mortality, ICU mortality, and pneumonitis. Adverse events were similar between groups, but Ilaprazole had a significantly lower incidence of hepatobiliary disorders (0.9% vs. 5%, p = 0.012).

Conclusions: Ilaprazole demonstrated non-inferiority to esomeprazole in preventing UGI bleeding in critically ill patients at high risk of stress ulcer.

Background: Encephalopathy is a frequent complication of circulatory shock and is associated with adverse outcomes. Whether encephalopathy is driven primarily by systemic inflammation, endothelial activation or cerebral hypoperfusion remains uncertain.

Methods: We retrospectively studied 198 intensive care unit (ICU) patients with circulatory shock (95 septic shock, 103 non-septic shock). Encephalopathy (coma and delirium) was assessed using the Glasgow Coma Scale, Richmond Agitation-Sedation Scale, and Confusion Assessment Method for the ICU. Neuroinflammation or blood-brain barrier (BBB) dysfunction was evaluated using serum S100B protein. Systemic inflammation and endothelial activation were assessed using serum C-reactive protein (CRP), Matrix metalloproteinase-9 (MMP-9), Intercellular Adhesion Molecule -1 (ICAM-1) and Vascular Endothelial Growth Factor (VEGF). Severe hypotension was defined a priori as mean arterial pressure (MAP) <50 mmHg sustained ≥1 min; we also quantified the number of episodes and cumulative duration of MAP <60 and <50 mmHg across the first 72 h. Multivariable logistic regression and mixed-effect models examined associations with encephalopathy and ICU outcomes.

Results: Encephalopathy developed in 140 patients (71%): 31 (23%) with coma and 99 (71%) with delirium. Severe hypotension (OR: 2.56 (1.18, 4.75), p = 0.022), longer sedation duration (OR: 1.09 (1.02, 1.18), p = 0.017), ICU-acquired infections (OR: 1.61(0.73, 3.54), p = 0.021), and elevated S100B (OR: 1.72 (0.66, 3.65), p = 0.03) were associated with encephalopathy. In contrast, systemic inflammation (CRP, MMP-9) and endothelial activation (ICAM-1, VEGF) were not associated with encephalopathy. Despite higher systemic inflammation in septic shock, the prevalence of encephalopathy and structural brain injury was similar to non-septic shock.

Conclusions: In circulatory shock, encephalopathy is most strongly associated with recurrent/severe hypotension (MAP <50 mmHg) and markers of neuroinflammation, not systemic inflammation or endothelial activation.

Background: Target-controlled infusion (TCI) is widely used for total intravenous anesthesia; however, its role in the intensive care unit (ICU) for analgesia and sedation remains insufficiently defined. We performed a scoping review to describe the existing evidence on the applications of TCI in critically ill adults.

Methods: In accordance with a registered protocol (Open Science Framework, April 3, 2025), we systematically searched major databases for randomized and non-randomized studies evaluating TCI in the ICU. Eight independent reviewers conducted study screening, data extraction, and risk of bias assessment.

Results: Thirty-three articles comprising 1,273 patients met the inclusion criteria, 1,142 1 patients receiving TCI-based analgosedation and 106 receiving conventional strategies. Reported indications for TCI-based analgosedation included postoperative ventilation, postoperative pain control, and procedures associated with discomfort and pain. Only four studies directly compared TCI-based to conventional analgosedation strategies. Overall, TCI was feasible, safe, and allowed precise titration of analgesia and sedation. Most studies were judged to have a moderate risk of bias.

Conclusions: Available data suggest that TCI-based analgosedation in the ICU is feasible and safe in the short term. Most available data are descriptive or exploratory and robust comparative clinical benefit has not yet been demonstrated. Further high-quality research is therefore needed to validate existing pharmacological models for prolonged infusions and to compare TCI with standard analgosedation practices regarding safety and patient-centered outcomes.

Background: The traditional Venous Excess Ultrasound (VExUS) scoring system relies on inferior vena cava (IVC) diameter measurements, which are affected by multiple confounding factors. The Shape Change Index (SCI) of IVC, defined as the ratio of short-axis diameter to long-axis diameter, may provide a more stable morphological indicator of venous filling.

Methods: In this prospective study, trained operators performed bedside ultrasonography to measure IVC diameter and calculate the SCI of IVC (short-axis diameter/long-axis diameter). Hepatic, portal, and renal venous Doppler waveforms were used to grade venous congestion (Grade 0-3). Diagnostic performance of SCI and IVC diameter for detecting venous congestion was evaluated using receiver operating characteristic(ROC) analysis, with additional exploratory analyses performed to further characterize incremental diagnostic value.

Results: A total of 116 venous Doppler examinations from 84 critically ill adults were analyzed. The SCI of IVC demonstrated a stronger correlation with venous congestion grade than IVC diameter (Spearman's ρ = 0.691 vs 0.490, both p < 0.001). For detecting any venous congestion (VExUS Grade ≥1 vs Grade 0), the SCI of IVC showed significantly better diagnostic discrimination than IVC diameter, with an area under the curve of 0.864 compared with 0.767, respectively (p = 0.044). The diagnostic advantage of SCI appeared to be more evident in examinations without advanced venous congestion. Higher SCI values were associated with greater disease severity.

Conclusions: The SCI of IVC demonstrates superior diagnostic performance compared with IVC diameter for the identification of venous congestion in critically ill patients, particularly at earlier or less advanced stages. These findings support the use of SCI as a complementary screening tool within the existing VExUS framework. Further multicenter studies are required to confirm its clinical utility and generalizability.

Purpose: The population aging has a growing impact on intensive care. The admission policies for critically ill very old patients in intermediate care units (IMCUs) are unclear. This study aimed to identify clusters of very old patients hospitalized in IMCUs in France, and to compare "ICU-like" profiles among these patients with matched very old patients admitted to ICU patients, in order to better understand the factors influencing admission to an IMCU rather than an ICU.

Methods: We conducted a nationwide study and examined all hospitalisations in IMCUs in France over a two-year period. We studied the utilization of medical IMCU for all critically ill patients ≥80 y.o and reported patient characteristics, including the Charlson comorbidity index and Hospital Frailty Risk Score. Latent class analysis identified distinct IMCU phenotypes. Clusters with high-use organ support (≥5%) and high mortality (≥40%) were considered "ICU-like." Logistic regression compared "ICU-like" IMCU patients with propensity-matched ICU patients to identify factors associated with IMCU admission.

Results: Among the 202,976 very old individuals hospitalized in IMCU, seven phenotypes were identified. The "ICU-like" population accounted for 11.6% of the cohort (n = 23,508). After propensity score matching, the multivariate logistic regression identified age as the strongest determinant to IMCU admission, with very old patients being significantly more likely to be admitted to the IMCU over the ICU. Comorbidity status was also an independent predictor for admission to IMCU. Frailty status showed only a marginal effect, and no association was detectable for sex.

Conclusion: A substantial number of very old patients were admitted to IMCU despite meeting ICU-level criteria. Clearer admission criteria and objectives for IMCU care in older critically ill patients are urgently needed.

Background: Fulminant myocarditis (FM) in children can progress rapidly to cardiogenic shock, with high risk of mortality. Early recognition of prognostic markers is critical to guide timely escalation of circulatory support. This multicenter study sought to characterize clinical features and identify early predictors of in-hospital mortality in pediatric FM.

Methods: We conducted a retrospective cohort study of patients <18 years with FM admitted to eight ECMO-capable pediatric intensive care units between January 2018 and August 2023. Clinical, biochemical, electrocardiographic, and echocardiographic variables were analyzed. Logistic regression was used to identify predictors of mortality, and receiver operating characteristic (ROC) curves were generated to assess discriminatory performance.

Results: A total of 187 children were included; 157 (84.0%) required ECMO. In-hospital mortality was 16.6% (31/187). Univariate analysis identified elevated CK-MB, higher peak lactate, and ventricular tachycardia as associated with mortality. In multivariate analysis, peak lactate (AUC 0.791) and CK-MB (AUC 0.774) remained independent predictors. A combined model of peak lactate and ventricular tachycardia demonstrated moderate discrimination (AUC 0.772), whereas a composite model incorporating CK-MB, peak lactate, and ventricular tachycardia achieved the best predictive performance (AUC 0.815). Elevated lactate measured 12 h after initiation of extracorporeal membrane oxygenation or intensive conventional therapy further increased mortality risk (OR 1.219, 95% CI 1.004-1.481).

Conclusion: Peak lactate, CK-MB, and ventricular tachycardia are early independent predictors of in-hospital mortality in pediatric FM. Persistent hyperlactatemia within 12 h of advanced support provides additional prognostic value and may assist clinicians in early risk stratification.