Annals of Intensive Care最新文献

Background: Sepsis remains a major cause of morbidity and mortality. Precision therapeutics are now regarded as a novel prospective to improve outcome. This approach relies on biomarkers to identify a pathway of pathogenesis which prevails and directs the best available therapeutic option to modulate this pathway. This review provides the most recent findings on biomarkers for bacterial or viral sepsis. These biomarkers provide guidance for prompt diagnosis and management tailored to specific needs.

Main body: Keywords relative to sepsis management (early recognition, antibiotic administration, selection of fluids, vasopressors and immunotherapy) were searched across PubMed database. Published evidence the last five years exists for heparin-binding protein (HBP), monocyte distribution width (MDW), interleukin-10 (IL-10), presepsin, procalcitonin and C-reactive protein (CRP) for early sepsis diagnosis; procalcitonin is the most well-studied biomarker for antibiotic guidance. Endothelial and cardiac biomarkers have been explored as tools to tailor circulatory support in sepsis, including fluid therapy, and the targeted use of vasopressors for vascular tone optimization.

Conclusion: This review explored how biomarkers can optimize immunomodulatory therapies, guide vasopressor initiation, inform antibiotic stewardship, and aid in fluid resuscitation decisions, ultimately improving patient outcomes.

Background: Although largely used, the place of extracorporeal renal replacement therapy (RRT) in acute kidney injury (AKI) in intensive care unit (ICU) patients has yet to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Pediatric Group of Intensive Care and Emergency (Groupe Francophone de Réanimation et d'Urgence Pédiatrique, GFRUP) organized a consensus conference in November 2024.

Methods: A committee, without any conflict of interest (CoI) on the subject, defined seven generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Eighteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 14 critical-care medicine physicians and a nurse) and the public. The jury then met for 48 h to write out and vote on its recommendations.

Results: The panel provided 45 statements addressing seven questions. In patients, adults or children, admitted to the ICU with AKI (1) What are the indications for RRT, when should it be initiated, and within what timeframe? (2) What are the advantages/disadvantages of the different RRT modalities in ICU, and based on what criteria should they be chosen? (3) Which dose of dialysis should be prescribed for ICU patients? (4) How to prescribe, adjust and monitor each RRT technique? (5) Which vascular access technique should be preferred (insertion site, catheter type and length)? (6) How to prevent circuit thrombosis? (7) What are the criteria to consider weaning from RRT and how can it be achieved?

Conclusions: These recommendations should optimize the prescription and use of RRT during AKI in ICUs for both adult and pediatric patients.

Background: Central nervous system (CNS) infections carry a severe prognosis and often require intensive care unit (ICU) admission. This study evaluated the prognostic value of neuroimaging in patients with all-type CNS infections.

Methods: Using a predefined strategy, we first conducted a systematic search of PubMed/MEDLINE, PubMed Central, Embase, Cochrane and Google Scholar. Eligible studies published between January 1st, 2000, and June 1st, 2023, were included. We considered randomized controlled trials, non-randomized trials, cohort studies, excluding abstracts, cost-effectiveness analyses, letters, conference proceedings, systematic reviews, and meta-analyses. Two authors independently screened publications and extracted data. The meta-analysis was performed using a random-effects model. The main outcomes were (1) unfavorable outcome, defined as severe functional disability or death, and (2) mortality. Pooled odds ratios (OR) and 95% confidence intervals (95%CI) were calculated for each neuroimaging feature. We performed prespecified subgroup analyses depending on type of CNS infection (bacterial meningitis, CNS tuberculosis, CNS cryptococcosis, viral encephalitis, and brain abscess), country income, and ICU admission status.

Results: Of 7,864 studies identified, 83 met the inclusion criteria, with 48 studies (6,434 patients) included in the meta-analysis. Abnormal MRI (OR: 3.55; 95%CI: 1.81-6.96; I²=0%), brain ischemia (OR: 4.65; 95%CI: 3.14-6.88; I²=28.5%), and hydrocephalus (OR: 4.56; 95%CI: 2.49-8.36; I²=61.5%) were significantly associated with unfavorable outcome. Hydrocephalus (OR, 3.99; 95%CI 1.83-8.70; I²=61%) and brain ischemia (OR, 3.51; 95%CI, 2.22-5.54; I²=16.4%) were associated with mortality. These associations remained consistent in patients with bacterial meningitis and in patients with CNS tuberculosis, but not in other CNS infections. Subgroup analyses depending on country income and ICU admission status revealed similar findings.

Conclusion: Neuroimaging provides essential prognostic information in patients with CNS infections. Abnormal MRI findings, cerebral ischemia, and hydrocephalus are associated with unfavorable outcome, particularly in bacterial meningitis and CNS tuberculosis. These neuroimaging features should be considered when discussing prognosis in affected patients.

The objective of this work was to develop guidelines for nutritional support in critically ill adults and children (excluding neonates and burn patients) unable to maintain an adequate oral intake. We aimed to provide up-to-date recommendations based on high-level evidence including the results of recent landmark randomized controlled trials. Experts from the French Intensive Care Society (SRLF), the French Society of Clinical Nutrition and Metabolism (SFNCM), and the French-Speaking Group of Pediatric Emergency Physicians and Intensivists (GFRUP) used the GRADE methodology to develop the guidelines. Twenty-four Patient Intervention Comparator Outcome (PICO) questions were identified, resulting in 34 adult and 29 pediatric recommendations. Of the 34 recommendations for adults, three were based on high-level evidence, 12 on moderate-level evidence, and 19 on expert opinion. The corresponding numbers for the 29 pediatric recommendations were one, five, and 23. All recommendations achieved strong agreement among the experts. These guidelines emphasize the importance of individualized nutritional support strategies that incorporate recent high-quality evidence to optimize the outcomes of critically ill patients.

Background: While dexamethasone has been shown to improve survival in COVID-19, its dose-response relationship with plasma glucose (PG) levels and insulin requirements is poorly understood. This study investigated the impact of 12 mg (higher dose) versus 6 mg (standard dose) of dexamethasone on hyper- or hypoglycemic events and the use of insulin.

Methods: A secondary analysis of a subpopulation of the COVID STEROID 2 trial. Glycemic outcomes were assessed by time-to-event analysis of a hyperglycemic (two PG measurements ≥ 11.1 mmol/L), severe hyperglycemic (PG > 20 mmol/L), hypoglycemic (< 3.8 mmol/L) event or use of insulin, adjusted for age, diabetes status, hospital site, and mechanical ventilation. PG levels were compared before and after treatment allocation with linear mixed models to estimate changes in average PG levels over time.

Results: Of 321 participants, 170 were allocated to the higher dose and 151 to the standard dose of dexamethasone. Time to a hyperglycemic event did not differ between groups, whereas severe hyperglycemic events were more frequent in the higher dose group (36%) than in the standard dose group (31%) with an adjusted subdistributional hazard ratio of 1.76 (95% CI [1.22-2.54], p = 0.003). Insulin use and hypoglycemic events did not differ between groups. The higher vs. standard dose group had an average PG increase of 0.5 mmol/L (95% CI [- 0.2 to 1.4], p = 0.149).

Conclusion: Higher vs. standard doses of dexamethasone were associated with a higher incidence of severe hyperglycemia in patients with COVID-19 and severe hypoxemia, but the average increase in PG was similar between groups.

Background: Myasthenic crisis often requires prolonged mechanical ventilation and complex weaning, yet data remain scarce. The objective of this study was to describe the weaning characteristics in patients with myasthenic crisis using the WEAN Safe classification. Secondary aims included assessment of long-term outcome and comparison between early- and late-onset (< 65 years) versus very-late-onset MG (≥ 65 years) myasthenia gravis.

Methods: This single-center retrospective study included patients admitted for myasthenic crisis to a tertiary neuro-intensive care unit between January 2008 and December 2023. Clinical characteristics, ventilatory support parameters, timing of weaning events, complications, and outcomes were recorded. Weaning was classified according to WEAN Safe definitions: no separation attempt, short wean (successful weaning within 1 day), intermediate wean (2-6 days), prolonged wean (≥ 7 days), or failed wean (persistent invasive ventilation at discharge or death).

Results: Among 698 ICU hospitalizations (405 patients) for myasthenia gravis, 131 (120 patients) received invasive mechanical ventilation. Fifty hospitalizations (39 patients) were excluded due to non-MC-related intubation, insufficient weaning data or patients with multiple ICU admissions. The final analysis included 81 patients (median age 70 years [54-81]; 43% female; 64% with very-late-onset myasthenia gravis (≥ 65 years). The median duration of mechanical ventilation was 20 days [11-38], and the median time from the first separation attempt to successful weaning was 7 days [3-19]. According to the WEAN Safe classification, 3% had a short wean, 40% intermediate, 55% prolonged, and 3% failed weaning. Four patients (5%) required reintubation within 48 h. Ventilator-associated pneumonia occurred in 15% of patients before the first separation attempt. In multivariate analysis, the presence of thymoma (OR 3.02, 95% CI 1.01-9.07) and absence of MG-specific immunosuppressive treatment at ICU admission (OR 3.70, 95% CI 1.22-11.23) were independently associated with prolonged weaning. Intensive care unit mortality was 7%, and 12-month mortality was 19%. The median myasthenic muscle score at 1 year was 94/100 [80-100]. No significant differences in weaning parameters nor outcome were found between early- and late-onset versus very-late-onset MG, despite more comorbidities in the very-late-onset group.

Conclusions: In this retrospective study from a single expert center, most patients with myasthenic crisis underwent intermediate or prolonged weaning, but extubation failure rate was very low. Thymoma and lack of MG-specific immunosuppressive treatment at ICU admission are associated with prolonged weaning, while age alone is not. Despite initial challenges, long-term outcomes are generally favorable, highlighting the reversibility of myasthenic crisis with expert care.

Background: Advance directives (ADs) are legally binding documents outlining individual preferences for medical care in the event of incapacitation. Evidence regarding their significance and implementation in critical care is scarce. Thus, this retrospective cohort study assesses sex differences in ADs' frequency, content, clinical translation, and associated outcomes in critically ill adults. The study was performed in two interdisciplinary tertiary Swiss intensive care units (ICUs). It included patients with ADs treated in the ICUs for > 48 h. The primary endpoint was the frequency of ADs. Secondary endpoints included the content of ADs, sex differences in baseline and treatment characteristics, the clinical implementation of ADs, and in-hospital outcomes.

Results: 5242 patients were treated for > 48 h in the ICUs, of which 313 (6.0%) had ADs (124 females [6.8% of 1813 females] and 189 males [5.5% of 3429 males], p = 0.054). No sex-related differences were observed regarding baseline characteristics except that females with ADs were more frequently single, divorced, or widowed (57% vs. 37%, p = 0.001), more frequently had acute stroke as main diagnosis (13% vs. 3%, p = 0.001), and more often refused cardiopulmonary resuscitation (CPR) (42% vs. 25%, p = 0.002) than males with ADs. In multivariable analyses, female sex was associated with refusing CPR independent of relationship status. Compared to males, females' ADs were more frequently violated (24% vs. 10%, p < 0.001), primarily by receiving unwanted treatments (24% vs. 8%, p < 0.001) and/or undesired ICU admission (10.5% vs 2.1%, p = 0.002). Despite these differences, treatment adaptations during intensive care, in-hospital outcomes, and discharge destinations did not differ between sexes.

Conclusions: This study revealed sex disparities in the content and translation of ADs between females and males admitted to ICUs. Females' ADs were more frequently violated, indicating a potential sex bias in the interpretation and translation of ADs in critical care. Clinicians must remain vigilant against violations of ADs and strive to deliver equitable care. Further prospective research is needed to investigate the causes of disparities in ICU end-of-life decision-making, integrating both qualitative and quantitative measures, to ensure equal treatment for all patients, regardless of sex or gender.

Sepsis-related acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is associated with considerable morbidity and mortality, yet the efficacy of current treatments is limited. Previous studies have predominantly focused on the lung itself as an isolated organ, whereas the role of organ crosstalk in the pathogenesis of sepsis-related ALI/ARDS cannot be overlooked. Meanwhile, neglecting the discussion of heterogeneity in sepsis caused by different sources of infection may be another important obstacle to translating previous studies into clinical efficacy. In this review, we initially delineated the distinctions in pathogenesis between pulmonary and extrapulmonary sepsis-related ALI/ARDS in microbial species, pathogenesis, host response, and clinical manifestations. Additionally, systemic organ crosstalk mechanisms are summarized, including the commonality and specificity of systemic inflammation, lung and gut microbiome, as well as cascade cell injury and death in distant organs. Subsequently, organ crosstalk between lung and extrapulmonary in pulmonary sepsis and extrapulmonary sepsis-related ALI/ARDS are discussed by organs, including immunity, neuroendocrine, metabolism, and so forth. Furthermore, extracellular vesicles represent a promising avenue of research as potential players and targets in organ-lung crosstalk in sepsis. While the complexity of multi-organ interactions and the heterogeneity of septic patients present significant challenges, these issues are expected to be addressed by the emergence of organ-on-a-chip platforms, 3D organoid cultures, and multi-omics techniques.